160 final
Unless a problem is suspected, which cranial nerve is not routinely tested? I II V XI
!
Which of the following statements made by a 72-year-old patient would indicate a normal process of aging? "My tongue feels swollen." "My tonsils are large and sore." "Food does not taste the same as it used to." "I have white and black spots under my tongue."
"Food does not taste the same as it used to."
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 is concerned this will happen to him. How would you respond? "The enlargement of your prostate is caused by hormone changes and not cancer." "The swelling in your prostate is only temporary and will go away." "We will treat you with chemotherapy so we can control the cancer." "It would be very unusual for a man your age to have cancer of the prostate."
"The enlargement of your prostate is caused by hormone changes and not cancer."
The mother of a 10-year-old boy asks you to discuss the recognition of puberty. You reply "Puberty usually begins about age 15." "The first sign of puberty is enlargement of the testes." "Penis size does not increase until about the age of 16." "The development of pubic hair precedes testicular or penis enlargement."
"The first sign of puberty is enlargement of the testes."
During the assessment of an 18-month-old, the mother expresses concern about the infant's inability to toilet train. What would be your best response? "Toilet training usually starts after 2 years of age. 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." "Some children are just more difficult to train, so I wouldn't worry about it yet." "Have you considered reading any of the mother's websites on toilet training? They can be very helpful." "This could mean there is a problem in your baby's development. We'll watch her closely for the next few months for further regression."
"Toilet training usually starts after 2 years of age. 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."
Despite repeated instruction over a period of 3 years, the mother of three young children has still not had them immunized. Which of the following questions would help the health care provider understand this situation? "When are you going to get your children immunized?" "What are your beliefs about immunization?" "We have asked you to get your children immunized. Why has this not been done?" "Don't you understand that your children may get ill without immunizations?"
"What are your beliefs about immunization?"
Ideally, for an adult the percentage of total calories coming from fat should be limited to: 10% 30% 40% 50%
30%
Amanda has been sick a lot, and advised by her health care provider to get 15% of her daily calories from protein. If she consumes a 2,000 calorie diet, how many calories of it should be protein?
300
"Normal" muscle strength is documented as grade _____ 0 1 5 10
5
When assessing a preschool child, the father states that his daughter enjoys hopping on one foot and jumping rope. Which age is his daughter most likely to be? 2 years old 3 years old 4 years old 5 years old
5 years old
A first-time mother asks the nurse when she can expect her 2 month old to begin creeping or crawling. The most appropriate response would be: 3 months 6 months 9 months 12 months
9 months
Which of the following infant reflex responses is considered normal? A. A 30-month-old baby's toes fan in response to stroking the lateral surface of the infant's sole. B. An 8-month-old infant demonstrates a positive Moro reflex when startled. C. A 2-month-old infant's fingers fan when the examiner's finger is placed in the infant's hand. D. A 4-month-old baby's toes fan in response to stroking the lateral surface of the infant's sole.
A 4-month-old baby's toes fan in response to stroking the lateral surface of the infant's sole.
Which of the following would be a normal finding of the ears in an 80-year-old patient? A high-tone frequency hearing loss Increased elasticity of the pinna A thin, translucent tympanic membrane A shiny, pink tympanic membrane
A high-tone frequency hearing loss
Involuntary movement of an eye following its uncovering during the cover/uncover test indicates that: A muscle weakness or muscle imbalance exists Nystagmus is present. Pupillary accommodation is impaired. Decreased sensitivity of the corneal blink reflex is present.
A muscle weakness or muscle imbalance exists
During inspection you note that the patient's costal angle is 85 degrees. This patient has: A normal finding Bronchiectasis Pneumonia Pmeunothorax
A normal finding
Which of the following examination findings is cause for concern in an adult? A palpable lymph node moves under the examiner's fingers A palpable lymph node is fixed in its setting A palpable lymph node is approximately 3 mm in size The lymph node is not palpable
A palpable lymph node is fixed in its setting
In the ICU, you are preparing to obtain an arterial blood gas (ABG's) specimen from a patient's right wrist. First you perform a physical examination maneuver to assess the patency of the right ulnar artery. What's the name of this test? Murphy's test obturator test Barlow's test Allen's test
Allen's test
Which of the following statements is accurate regarding extra heart sounds? An S 4 sound is normal in children. The S 3 sound is caused by filling of the atria. An S 3 sound is caused by stiff ventricles An S 4 sound can precede an S 3 sound in client's ventricular hypertrophy.
An S 4 sound is normal in children.
A 55 year old construction worker reports pain in both legs when walking. The pain eases after about 10 minutes of rest. He has smoked 2 packs of cigarettes daily since he was 16. On physical exam you note that his dorsalis pedis pulses are decreased bilaterally in comparison with his femoral pulses. His feet are cool to the touch compared to his upper legs. The skin on the lower legs is shiny, pink, and tight with hair loss. Based on your assessment, what would you suspect? Deep vein thrombosis Arterial insufficiency Venous insufficiency peripheral neuropathy
Arterial insufficiency
Which of the following techniques is incorrect and affects the accuracy of auscultation? placing the stethoscope firmly on the surface to be auscultated. Auscultating through clothing. Isolating one sound at a time during auscultation. Listening for sound characteristics.
Auscultating through clothing.
You question a patient about alcohol consumption. What acronym for an alcoholism screening tool might be used? HOLMES DASH CAGE BECK's
CAGE
A 30 year old patient complains of flank pain, dysuria, nausea and fever. On physical exam, what finding would you assess for? psoas sign Murphy's sign CVA tenderness Rovsing's sign
CVA tenderness
When assessing a 75-year-old patient, which finding should be reported immediately to the patient's provider? Pulse of 62 beats/minute, regular Blood pressure of 120/82 Capillary refill of less than 3 seconds Detection of an S3
Detection of an S3
Which type of health history would you perform on this patient who has been at your clinic three times in the past year and is returning for a hypertension check-up? Comprehensive health history Episodic health history Screening assessment Emergency health history
Episodic health history
Which is a gerontological variation that occurs to the gastrointestinal system? Abdominal musculature strengthens. Gastric acid secretion decreases. Liver size increases. Fat deposition in the abdominal area decreases.
Gastric acid secretion decreases.
What assessment tool should be used to evaluate the level of consciousness of a patient with head trauma? Mini-Mental Status Exam (MMSE) Perceptual distortion assessment Glasgow Coma Scale Gordon's Functional assessment
Glasgow Coma Scale
A 72-year-old male presents to the office with shortness of breath and coarse cough. He is barrel chested with an A/P diameter greater than 1:2. You see he has had COPD for many years. You would expect his nail angle to be: Greater than 90 degrees Less than 80 degrees Less than 140 degrees Greater than 160 degrees
Greater than 160 degrees
You are preparing to examine the external genitalia of a school-age girl. Which of the following positions would be most appropriate in this situation? In the parent's lap In a frog-leg position on the examining table In the lithotomy position with the feet in stirrups Lying flat on the examining table with legs extended
In a frog-leg position on the examining table
For a patient with burns covering a significant portion of the body, what would be the appropriate dietary recommendations? Increased sodium and glucose (sugars) in the diet to increase metabolism Eat twice as many fruits and vegetables than before the burn injury to increase vitamin absorption. Limit fluids and decrease potassium-rich foods to avoid stressing the kidneys. Increase daily calorie intake and increased protein consumption to assist with tissue repair.
Increase daily calorie intake and increased protein consumption to assist with tissue repair.
The bell of the stethoscope is used to assess what characteristic? High-pitched sounds High-amplitude sounds Low-pitched sounds Low-amplitude sounds
Low-pitched sounds
A 40 year old female complains of right upper abdominal pain that gets worse after she eats, especially if the meal is spicy or high in fat. Based on the symptoms, you suspect cholecystitis. Which sign, on examination increases your suspicion? psoas sign Rovsing's sign Murphy's sign CVA tenderness
Murphy's sign
Which of the following correctly describes the method to assess pupillary accommodation? Shine a light into the pupil; note constriction in that eye and the opposite eye Note pupil constriction as gaze shifts from across the room to an object 6 inches away. Note ocular movement as patient follows an object through the six cardinal fields. Cover one eye of patient with card, then remove the card; note any deviation from a fixed gaze.
Note pupil constriction as gaze shifts from across the room to an object 6 inches away.
The preoperative nurse comforts the anxious patient awaiting surgery. You overhear the nurse tell the patient, "Don't worry. Everything will turn out fine. You're in good hands." This exemplifies which nontherapeutic interviewing technique? Requesting an explanation Probing Offering false reassurance Advising
Offering false reassurance
A 15 year old high school student complains pain, nausea, and anorexia. He describes the pain as generalized yesterday, but today it's localized to the right lower quadrant. When you palpate the left lower quadrant, the patient has pain in the left lower quadrant. What is the name of this sign? psoas sign Rovsing's sign Murphy's sign Brudzinski's sign
Rovsing's sign
While palpating a patient's abdominal LUQ, you visualize the underlying organs that include: Stomach, spleen, body of pancreas, splenic flexure of colon Body of pancreas, gallbladder, spleen Splenic flexure of colon, duodenum, cecum Appendix, pylorus, hepatic flexure of colon, spleen
Stomach, spleen, body of pancreas, splenic flexure of colon
As a mandatory reporter of elder abuse, which of the following must be present before you notify the authorities? Statements from the victim. Statements from witnesses. Proof of abuse and/or neglect. Suspicion of elder abuse and/or neglect.
Suspicion of elder abuse and/or neglect.
A 46-year-old woman is in the clinic for her annual gynecological examination. She voices a concern about cervical cancer because her mother and sister died of it. Which of the following is correct regarding cervical cancer? Cervical cancer is manifested by severe abdominal pain. The Pap smear detects the presence of cervical cancer. Women over age 40 should start having a thorough pelvic examination every year. Women over age 4
The Pap smear detects the presence of cervical cancer.
An 18 year-old patient is brought to the Emergency Room. His vital signs are as follows: T 97.6 F, P 56, R 8, BP 98/62. What conclusion do you make about this patient's respiratory status? The patient is experiencing apnea. The patient is experiencing bradypnea. The patient is experiencing tachypnea. The patient's respiratory status is normal.
The patient is experiencing bradypnea.
Which action would alert the nurse to the possibility that a patient may become hostile? The patient is speaking in a loud voice with clenched fists. The patient is crying and suddenly comes over to you and gives you a hug. The patient is sitting 8 feet away from the nurse, laughing hysterically. The patient is looking out the window while tapping his foot.
The patient is speaking in a loud voice with clenched fists.
A 6-month-old infant is brought to the clinic for immunizations. While examining the baby, the examiner notes that the anterior fontanel has not closed. What is the significance of this finding? This indicates a slight developmental delay. There may be a nutritional deficiency. This finding is consistent with hydrocephaly. This is a normal finding.
This is a normal finding.
After examining the tonsils of a 10-year-old child, you record your findings as "tonsils are 3+," which means that: Tonsils are nearly touching the uvula. Tonsils extend to the midline of the oropharynx Tonsils are touching the uvula Tonsils are between the pillars and the uvula
Tonsils are nearly touching the uvula.
Breast masses tend to occur most often in which quadrant? Lower outer quadrant. Lower inner quadrant Upper outer quadrant Upper inner quadrant
Upper outer quadrant
Choose the true statements about vaccines given intramuscularly (IM) SELECT ALL THAT APPLY Use a 5/8 inch 25 gauge nedle Use a 1 inch, 23 gauge needle IM vaccines are routinely given in the deltoid muscle IM vaccines are routinely given in the ventrogluteal area Aspiration is required Aspiration is not required Will cause irritation and not be absorbed correctly if given subcutaneously Will cause irritation and not be absorbed correctly if given intramuscularly
Use a 1 inch, 23 gauge needle Aspiration is not required Will cause irritation and not be absorbed correctly if given subcutaneously
While conducting an assessment of the thorax and lungs you ask the patient to flex the neck forward as you palpate the spinous process in this area. The superior process that you palpate is called the: Suprasternal notch Angle of Louis Costal angle Vertebra prominens
Vertebra prominens
Which of the following best explains why infants and toddlers are at greater risk for ear infections than are older children and adults? Poorly developed immune system. Immature tympanic membrane. Wider, shorter, and horizontal eustachian tube. Excess deposition of bone cells along the ossicle.
Wider, shorter, and horizontal eustachian tube.
During a cardiac assessment, the nurse notes that the S 2 sound is normally loudest over the areas labeled as ____________________. (Your answers should appear as letters separated by commas and spaces [e.g., a, b, c, d].)
a,b
A nurse notices that a client's meal contains 25 grams of carbohydrates, 15 grams of protein, and 8 grams of fat, and calculates that the meal contains how many calories? a.232 calories b. 267 calories c. 357 calories d. 407 calories
a.232 calories
An 80 year old woman comes to the ED complaining of palpitations and shortness of breath. An ECG reveals atrial fibrillation. The mostly likely finding upon auscultation of her heart is a rapid regular pulse an irregularly irregular rhythm a midsystolic click bigeminy
an irregularly irregular rhythm
to assess an older patient's ability to consume foods, the examiner should: assess the oral cavity for the condition of the teeth and presence of lesions. examine the back, arms, and shoulders for evidence of muscle wasting. examine the skin for dryness or elasticity. assess the abdomen for fullness, distention, and bowel sounds.
assess the oral cavity for the condition of the teeth and presence of lesions.
To successfully assess clients, a nurse: a. Collects subjective and objective data and documents the findings. b. Collects subjective and objective data and analyzes the findings. c. Places more emphasis on subjective than objective data. d. Requests that the client refrain from volunteering extraneous data.
b. Collects subjective and objective data and analyzes the findings.
Your patient is 5 years old. You would expect him to: have to be held on his mother's lap. be able to sit on the examination table. be able to stand on the floor for the examination. be able to remain alone in the examination room.
be able to sit on the examination table.
A client tells the nurse during the nutritional assessment that she tries to keep her fat intake at less than 10% of her total caloric intake per day, and the nurse responds: a. That is admirable; how do you accomplish fat intake that low on a daily basis? b. Eating fat is essential for good health, and you should consume about 40% of your fats as monounsaturated fat to make sure you absorb all of the B Vitamins. c. Limiting fat prevents some diseases, but your fat intake is much lower than recommended. You will not be able to absorb Vitamins A, D, E and K well. d. If you wanted to try and bring your fat intake down further, you might want to eliminate eating fast foods.
c. Limiting fat prevents some diseases, but your fat intake is much lower than recommended. You will not be able to absorb Vitamins A, D, E and K well.
Each of the following is a good source of Vitamin C (ascorbic acid) EXCEPT? chicken tomatoes broccoli potatoes
chicken
In a patient with left lower lobe pneumonia, you'd expect to hear equal bilateral breath sounds decreased lung sounds over right lung base crackles over left lung base decreased resonance over right lung base
crackles over left lung base
A nurse is teaching a client about nutrition. The client is on an 1800-calorie diet. How many grams of carbohydrates are recommended for this client each day? a. 90 to 112.5 grams b. 110 to 120 grams c. 180 to 202.5 grams d. 247.5 to 270 grams
d. 247.5 to 270 grams
After physical examination of a client, the nurse documents which finding as a symptom? The client s skin feels warm to the touch. b. The client is scratching his arm. c. The client's temperature is 100° d. The client complains of itching.
d. The client complains of itching.
When auscultating the lungs of a patient with COPD, you'd expect to hear pleural rub crackles at late inspiration delayed expiratory phase stridor
delayed expiratory phase
Your patient has denied any abuse when answering the Abuse Assessment Screen, but you have noticed some other conditions that are associated with intimate partner violence. Such conditions include: asthma. confusion. depression. frequent colds.
depression
A 62-year-old male states that his doctor told him that he has an "inguinal hernia." He asks you to explain what a hernia is. You: tell him not to worry and that most men his age develop hernias. explain that a hernia is often the result of prenatal growth abnormalities. refer him to his physician for additional consultation, since he or she made the initial diagnosis. explain that a hernia is a loop of bowel protruding through a weak spot in the abdominal muscles.
explain that a hernia is a loop of bowel protruding through a weak spot in the abdominal muscles.
A 65 year old patient who smokes complains of dyspnea that's exacerbated by exertion. He has a 100 pack year history of tobacco use. He denies fever or chills. You suspect COPD. On physical examination of the thorax, you'd expect to find increased A-P diameter decreased A-P diameter no change in A-P diameter pectus excavatum
increased A-P diameter
The most reliable indicators of true hypertension are: numerous measurements taken over a period of time any readings of blood pressure in which the systolic pressure exceeds 120 mm Hg sitting, standing, and supine readings of blood pressure taken once findings of diastolic blood pressure in excess of 80 mm Hg
numerous measurements taken over a period of time
An 18-year-old college student comes to the ED complaining that her heart is racing. You obtain blood for thyroid studies. Based on the results, you suspect hyperthyroidism. Examining her eyes, what would you expect to see? recession protrusion cloudy cornea cilliary injection
protrusion
In completing a physical assessment, the nurse recognizes that respiratory function of older adult clients normally declines because of: increased elasticity of the alveoli. flaccidity of the chest wall. reduced inspiratory and expiratory effort. decreased anteroposterior diameter due to kyphoscoliosis.
reduced inspiratory and expiratory effort.
A common mistake made by health care professionals is to: acknowledge the practice of folk or herbal remedies adapt health care concepts to meet the needs of individuals of other cultures stereotype individuals based on color or ethnic group. carefully assess the understanding and beliefs of culturally diverse individuals
stereotype individuals based on color or ethnic group.
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. You know that this is called: hematuria and usually needs to be evaluated by a urologist. stress incontinence and is usually due to muscle weakness. true urinary incontinence and may mean that she has a kidney infection. urgency incontinence and she should empty her bladder before she sneezes or coughs.
stress incontinence and is usually due to muscle weakness.
S2 is the result of pressure changes from the opening of the atrioventricular valves the beginning of systole best heard in the apex area the result of pressure changes from the closure of the aortic and pulmonic valves
the result of pressure changes from the closure of the aortic and pulmonic valves
During your examination, your patient tells you that she sometimes it feels as if objects are spinning around her. You would note that she occasionally experiences: vertigo. tinnitus. syncope. dizziness.
vertigo.
Parents of a 2 week old infant report difficulty with feeding and a strange rash in his mouth. You suspect it is thrush. What finding would you expect in his mouth? Koplik's spots white plaques erythematous plaques Epstein's pearls
white plaques
