Chapter 11 - Skin, Hair, and Nails Assessment, Chapter 12 - Head and Neck, including Lymph Nodes and Modules, Chapter 15 - Nose, Sinuses, Mouth, and Throat, Chapter 17 - Heart and Neck Vessels Assessment, Chapter 18 - Peripheral Vascular and Lymphati...

The nursing instructor is discussing assessment of the heart with students. A student states that he has a patient with a rushing vibration in the precordium that the student could feel and that it was in the area of the pulmonic valve. What should the instructor explain that the student is feeling? A) A thrill B) A thrust C) A heave D) A normal finding

A) A thrill

A 63-year-old patient hospitalized with pancreatitis is having problems performing ADLs. The nurse's aide brushes the patient's hair and tells the nurse that the patient is losing an excessive amount of hair. The hair has the hair bulb intact. What might this indicate to the nurse? A) Abnormal endocrine function B) Abnormal ovarian function C) Abnormal hepatic function D) Abnormal integumentary function

A) Abnormal endocrine function

A 79-year-old man has come to the clinic for a routine checkup. He reports general malaise and chronic fatigue, stating "I just can't get out and work in the garden anymore. I really miss it." The patient has a history of cardiomegaly with a hypertrophied left ventricle. Where would the nurse expect to find the PMI? A) Between the 4th and the 5th ICS at the MCL B) Lateral and inferior to the 4th and 5th ICS and the MCL C) Lateral and superior to the 4th and 5th ICS and the MCL D) Lower left sternal border

A) Between the 4th and the 5th ICS at the MCL

A nurse is conducting an admission assessment on a 67-year-old man with an intractable oral infection. The patient tells the nurse that he cannot smell things as well as he once could. What should the nurse do? A) Chart the information in the medical record B) Conduct olfaction tests C) Notify the physician immediately D) Verify the patient's ability to taste all flavors

A) Chart the information in the medical record

The nurse is caring for a 65-year-old patient with a feeding tube ordered by the physician. The nurse notes that the patient is not a mouth breather and having no difficulty breathing. While inserting the feeding tube, the nurse encounters difficulty getting the tube through the nares. What should the nurse suspect? A) Deviated septum C) Swollen nasal passages B) Obstructed turbinate D) Hypertrophied adenoids

A) Deviated septum

Teenagers doing community service following arrest for driving under the influence are working at the rehabilitation hospital with patients who have paraplegia. These patients have been paralyzed by drunk drivers. How would the nurses who care for these patients best use the time spent with these teenagers? A) Educating them about not drinking and driving B) Teaching them how to turn these patients every 2 hours C) Fulfilling the court requirements D) Keeping the shelves restocked

A) Educating them about not drinking and driving

What feature of a newborn shunts blood from the right atrium directly into the left atrium, bypassing the lungs? A) Foramen ovale C) Placental insufficiency B) Ductus arteriosus D) Injection fraction

A) Foramen ovale

A 35-year-old woman is recovering from sinus surgery. The patient reports that she is in "a lot" of pain. The physician has ordered morphine every 3 hours. What intervention would be most appropriate? A) Give morphine every 3 hours B) Reassess the patient before giving morphine as ordered C) Use nonpharmacologic pain relief prior to giving morphine D) Wait until the patient asks for pain medication before administering morphine

A) Give morphine every 3 hours

Across the lifespan, a nurse knows that the female heart A) Is normally smaller than the male heart B) Weighs more than a male heart C) Is normally larger than a male heart D) Normally beats slower than a male heart

A) Is normally smaller than the male heart

Students are practicing documentation of peripheral vascular and lymphatic assessment before going into the clinical setting. A student documents the following: Lower left leg cool to touch with dorsalis pedis, back knee pulse and femoral pulse palpable. How could the following charting be changed to communicate information in appropriate medical terminology? A) Left lower extremity cool to touch with femoral, posterior popliteal, and dorsalis pedis pulses palpable B) Left lower leg cool to touch with femoral, posterior popliteal, dorsalis and pedis pulses palpable C) Left extremity cool to touch with femoral, posterior popliteal, dorsalis and pedis pulses palpable D) No changes are necessary

A) Left lower extremity cool to touch with femoral, posterior popliteal, and dorsalis pedis pulses palpable

When assessing the extremities of a patient, the nurse notes muscle atrophy. What does the nurse know may be the cause? A) PAD C) Venous insufficiency B) Chronic lymphedema D) Arterial aneurysm

A) PAD

A patient has been admitted to the cardiac unit and test results are available. The nurse is writing a plan of care for this patient. On what would the nurse base interventions? A) Patterns of subjective and objective data B) Patterns of test results C) Areas for care planning D) Areas that the patient requests

A) Patterns of subjective and objective data

What pulse is located in the groove between the medial malleolus and the Achilles tendon? A) Posterior tibial B) Dorsalis pedis C) Popliteal D) Femoral

A) Posterior tibial

The ICU nurse is caring for a trauma victim whose status is critical. On assessment, the nurse notes uremic frost along the patient's hairline. What would this indicate to the nurse? A) Renal failure B) Cardiovascular failure C) Hepatic failure D) Respiratory failure

A) Renal failure

A patient comes to the emergency department reporting a sudden onset of dyspnea. What finding is a manifestation of dyspnea? A) Shortness of breath C) Rapid breathing B) Painful breathing D) Inability to breathe

A) Shortness of breath

The nurse is caring for a patient with a nursing diagnosis of impaired skin integrity related to a stage III decubitus ulcer. What would be the most important outcome for this patient? A) The patient exhibits no signs or symptoms of infection B) The patient changes position every 2 hours

A) The patient exhibits no signs or symptoms of infection

A 43-year-old woman presents with overwhelming fatigue, reporting "It seems like I sleep all the time and yet I am still tired" and "I never seem to have the energy to clean my house or cook dinner." Diagnostic studies show a TSH of 6.2 mU/L and a T3 of 65 ng/dL. What outcome might the nurse identify for this patient? A) The patient verbalizes increased energy B) The patient participates in activities with no change in vital signs C) The patient verbalizes desire to participate in physical activities D) The patient sleeps 12 hours daily

A) The patient verbalizes increased energy

A student nurse is taking an anatomy test and is asked a question about the columella. What is the best description of the term columella? A) The structure that divides the nares B) The lining of the nares C) The lining of lymphatic ducts D) The mound of tissue just posterior to the eustachian tube

A) The structure that divides the nares

A nurse is providing information to a high school health class about drinking during pregnancy. What descriptors would the nurse use when talking about fetal alcohol syndrome? (Select all that apply.) A) Microcephaly B) Small eyes C) Flattened upper lip D) Prominent cheekbones E) Macrocephaly

A, B, C

When assessing for acute arterial occlusion, what would the nurse include? (Mark all that apply.) A) Pain B) Paralysis C) Pallor D) Paresthesia E) Presence

A, B, C, D

To increase the proportion of adults who engage in vigorous physical activity that promotes the development and maintenance of cardiorespiratory fitness, what would the nurse teach a patient? (Mark all that apply.) A) The importance of physical activity B) To exercise vigorously 3 or more days a week C) To "cool down" after exercise so as not to strain muscles D) To exercise for 20 or more minutes E) To swim, which is the best exercise

A, B, D

When inspecting the hair, what would the nurse note? (Select all that apply.) A) Color B) Condition of hair shaft C) Length of hair D) Hair breakage of more than 6 hairs E) Hair shafts that are shiny

A, B, E

A nursing instructor is discussing areas of health promotion related to the nose, sinuses, mouth, and throat. What topics would the instructor be most likely to cite? (Select all that apply.) A) Tobacco use B) Risks for chronic obstructive pulmonary disease (COPD) C) Obstructive sleep apnea D) Alcohol use E) Oral health

A, C, E

The lymphatic system functions to? (Mark all that apply.) A) Maintain protein balance B) Drain lymph from the bloodstream C) Fight infection D) Hydrate the thymus E) Maintain fluid balance

A, C, E

A burn victim of a house fire is brought to the emergency department. The burn is classified as dermal. The nurse knows that the structures destroyed by the burn are what? (Select all that apply.) A) Lymphatic vessels B) Connective tissue C) Vernix D) Blood vessels E) Sweat glands

A, D, E

A nurse is preparing a teaching plan for a patient newly diagnosed with peripheral arterial disease. The nurse knows to address in this teaching plan the most modifiable risk factors. What risk factors would the nurse include? (Mark all that apply.) A) High-fat diet B) Low-protein diet C) Anaerobic exercise D) Smoking E) Activity level

A, D, E

Research has found that there is a dramatic increase in the incidence of PAD during what time period in a person's life? A) 6th decade B) 7th and 8th decades C) 8th and 9th decades D) 9th decade

B) 7th and 8th decades

A 72-year-old man is brought to the emergency department by his son. The patient reports pain in his back and abdomen and shortness of breath. What might the nurse suspect is wrong? A) Iliac vein obstruction B) Aortic aneurysm C) Lymphadenopathy D) Renal lymph obstruction

B) Aortic aneurysm

An 81-year-old man presents at the clinic with a painful ulcer on the left big toe. The patient states that the ulcer is very painful and never seems to heal. An assessment of the ulcer shows a lesion with well-defined wound edges. When dependent, the base of the lesion is ruddy in appearance and exhibits signs of infection. What would the nurse suspect? A) Infected spider bite B) Arterial ulcer C) Infected tick bite D) Venous ulcer

B) Arterial ulcer

The physiology instructor is discussing the function of sebaceous glands in the body. What would the teacher explain as the purpose of sebum to the students? A) Assists in keeping the skin intact B) Assists in friction protection C) Assists in protection from infection D) Assists in keeping skin dry

B) Assists in friction protection

An 83-year-old woman presents at the office of her primary care physician with fatigue, heart palpitations, and a "wet" cough. What might the nurse suspect in this patient? A) Heart failure B) Atrial fibrillation C) Atrial hypertrophy D) Ventricular arrhythmia

B) Atrial fibrillation

A nurse is caring for a patient with chronic lymphedema. In preparing a teaching plan for this patient, what would be essential for the nurse to address? A) Exercise plan B) Body image C) Treatment D) Pathophysiology

B) Body image

An obese 34-year-old man is undergoing a preoperative examination prior to having bariatric surgery. The patient tells the nurse that he has a red sore in his groin area that appears to be spreading. The nurse assesses the lesion and finds a macular erythematous lesion with satellite pustules. What would the nurse suspect? A) Roseola B) Candida C) Pityriasis rosea D) Herpes simplex

B) Candida

A patient presents at the urgent care clinic with severe pain and pressure around the eyes. The APRN suspects a sinus infection. What is considered the gold standard diagnostic technique in evaluating sinus disease? A) Transillumination B) Computed tomography (CT) scanning C) Percussion of the sinus cavities D) Magnetic resonance imaging

B) Computed tomography (CT) scanning

A 64-year-old patient is admitted to the hospital with severe diarrhea. When assessing the patient, the nurse notes a round "moon" face, a buffalo hump at the nape of the neck, and a velvety discoloration around the neck. What are these signs indicative of? A) Myxedema B) Cushing's syndrome C) Scleroderma D) Bell's palsy

B) Cushing's syndrome

A patient, newly admitted, has given her health history and undergone her physical assessment. Laboratory data and diagnostic study results are on the chart. What is the nurse's next step in caring for the patient? A) Notify the physician of laboratory results B) Develop a plan of care C) Inform the patient and family of diagnostic study results D) Start giving medication

B) Develop a plan of care

The nurse is caring for a patient who has an elevated cholesterol level. To reduce the mean total blood cholesterol and LDL cholesterol levels, what would be important to teach this patient? A) Eat high-protein, low-fat meals B) Eat low-fat, low-cholesterol meals C) Eat high-protein, low-carbohydrate meals D) Eat low-cholesterol, low-carbohydrate meals

B) Eat low-fat, low-cholesterol meals

The nurse is conducting a comprehensive health assessment of a 55-year-old Hispanic man. Which of the following abnormal findings would be most likely in this patient? A) Bifid uvula B) Gingivitis C) Oral cancer D) Sinus infection

B) Gingivitis

What structure is found midline in the tracheal area just beneath the mandible? A) Cricoid cartilage B) Hyoid bone C) Thyroid cartilage D) Adam's apple

B) Hyoid bone

An infant girl is born with microcephaly. The infant also has a depressed nasal bridge, low-set ears, and a protruding tongue. What nursing diagnosis would be appropriate for this patient and her parents? A) Inability to suck related to protruding tongue B) Knowledge deficit related to trisomy 21

B) Knowledge deficit related to trisomy 21

An 81-year-old man presents at the clinic with reports of a painful neck. On palpation, the nurse notes a hard, nonmovable mass, approximately 20 mm, that is painful to touch. The area seems to have several nodes matted together. How would the nurse chart this last finding? A) Nodes feel matted together on palpation B) Nodes are delimited on palpation C) Nodes appear grown together on palpation D) Nodes are demarcated on palpation

B) Nodes are delimited on palpation

When assessing the lymph system of a 52-year-old patient, the nurse notes that the epitrochlear nodes are nonpalpable. What does this indicate? A) Atherosclerosis C) Possible lymphoma B) Normal finding D) No lymphedema

B) Normal finding

A 17-year-old Hispanic teen comes to the clinic reporting excessive hair growth. She tells the nurse that she is teased a lot because of hair growing on her shoulders and back; the patient also reports that hair is growing on her upper inner thighs. What would the nurse suspect? A)Endocrine disorder C) Hepatic dysfunction B) Ovarian dysfunction D) Chronic nephrosis

B) Ovarian dysfunction

A clinic patient complains of recurring headaches that are worse when first waking in the morning and with coughing or sneezing. What would be the nurse's most appropriate action? A) Ask the doctor for an order for an MRI B) Perform a focused assessment C) Prepare the patient for a spinal tap D) Perform a generalized assessment

B) Perform a focused assessment

An oncology nurse is caring for a patient newly diagnosed with an occult nasopharyngeal malignancy. Where would the nurse expect this malignancy to be? A) Osteomeatal complex B) Rosenmuller's fossa C) Kiesselbach's plexus D) Wharton's ducts

B) Rosenmuller's fossa

The nurse in the dermatology clinic is assessing a 39-year-old woman who has presented at the clinic with a lesion on her left inner thigh. The patient tells the nurse that she discovered the lesion one month ago and has noticed no changes in the color or size of the lesion. What would be the most appropriate teaching subject for this patient? A) Skin self-examination B) Signs and symptoms of melanoma C) Recognizing different types of lesions D) Protection from sun damage

B) Signs and symptoms of melanoma

The nurse is performing a generalized assessment of a 79-year-old man who has come to the clinic for his annual physical examination. The nurse notes that the patient's skin is thin and rough with abrasions. The patient tells the nurse that it seems to take "forever" for scratches to heal, "a lot longer than when I was younger." When asked if he has any other problems, the patient says that he always seems to be cold. How would the nurse note these findings in the patient's medical record? A) The patient has abnormal thinning of skin B) The patient's integumentary system is within normal limits C) The patient states that wounds are taking longer to heal D) The patient has an abnormal inability to maintain temperature

B) The patient's integumentary system is within normal limits

Parents bring a 10-year-old Hispanic boy to the emergency department after a bicycle accident. His father tells the nurse that the boy was not wearing a helmet when he ran into a curb and was thrown over the handlebars, striking his head on the sidewalk. What would be the most important information for the nurse to include in education for this patient and family? A) Where to find bike safety courses B) Use of safety equipment C) Use of hand signals when bike riding D) Measuring for the right size bicycle

B) Use of safety equipment

The veins from where drain into the superior vena cava? (Mark all that apply.) A) Lower extremities B) Upper torso C) Head D) Upper extremities E) Lower torso

B, C, D

What is considered true for varicose veins? (Mark all that apply.) A) Seen less often in obese people B) Seen more often in people older than 50 years C) More common in women D) May be familial E) Always accompanied by lymphedema

B, C, D

What is the purpose of the tongue? (Select all that apply.) A) Provides resonance to the voice B) Manipulates solids and liquids when eating and drinking C) Helps with the identification of sweet, sour, salty, and bitter tastes D) Assists in speech production E) Aides in the production of saliva

B, C, D

As a pediatric nurse, it is important to assess each child for bruising. What might be indicated by ecchymoses in various areas of the body on a toddler or preschool-aged child? (Select all that apply.) A) Osteomyelitis B) A hematologic problem C) Certain infections D) Inappropriate play companions E) A coagulopathy

B, C, E

A patient presents at the emergency room reporting "the worst headache I have ever had." What are critical nursing behaviors for this patient? (Select all that apply.) A) MRI B) Physical examination for neurologic changes C) CT scan D) Focused history E) EEG

B, D

An 84-year-old woman is admitted to the hospital with pneumonia. While performing the admission assessment, the nurse finds a reddened area on the patient's coccyx. What would the nurse include about this finding in notes? (Mark all that apply.) A) Depth B) Location C) Other lesions on body D) Size E) Texture

B, D, E

The nurse is presenting an educational event for a local civic group about the risk factors for neck cancer. What would the nurse list? (Select all that apply.) A) Female gender B) Male gender C) Age older than 40 years D) Tobacco use E) Age older than 50 years

B, D, E

The nurse performs an admission assessment on a 52-year-old woman admitted through the ED with a myocardial infarction. The nurse charts "Swooshing sound heard over right carotid artery." How should this documentation be corrected? A) "Murmur heard over right carotid artery" B) "Split sound auscultated over right carotid artery" C) "Right carotid bruit auscultated" D) Does not need to be corrected

C) "Right carotid bruit auscultated"

A first-time mother calls the clinic to talk to the nurse. The mother is very upset, saying that her newborn's fingernails dip in the middle, appearing spoon-like. What would be the nurse's best response? A) "Take the baby to the emergency room to be evaluated." B) "Bring your baby to the clinic immediately." C) "This may be normal in infants." D) "This is a sign of a nutritional deficiency. What are you feeding your infant?"

C) "This may be normal in infants."

A group of nursing students is making an oral presentation on the upper respiratory system. What would the group identify as the age when the frontal and sphenoid sinuses emerge in a child? A) 6 years B) 5 years C) 4 years D) 3 years

C) 4 years

A woman and her 14-year-old boy have come to the clinic. The boy has acne lesions and says that he cannot control them. The mother asks the nurse what causes acne. What would be the nurse's best response? A) Acne is caused by the apocrine glands B) Acne is caused by decreased activity of the sebaceous glands C) Acne is caused by the impedance of sebum secretion onto the skin's surface D) Acne is caused by enlarged epocrine glands

C) Acne is caused by the impedance of sebum secretion onto the skin's surface

A nurse is preparing an educational event for the parents of children with respiratory disorders. What would the nurse tell the parents about allergy? A) If a parent has allergies, the child has a 25% chance of developing them as well B) Children will outgrow their allergies C) Allergy can affect any target organ in the body D) There are few effective treatments for allergies

C) Allergy can affect any target organ in the body

When doing a shift assessment on a newly admitted patient, the nurse notes lack of hair on the right lower extremity; thickened nails on the right lower digits; dry, flaky skin on the right lower extremity; and diminished tibial pulses bilaterally and absent pedal pulses. What nursing diagnosis should this patient receive? A) Risk for peripheral neurovascular dysfunction B) Activity intolerance related to pain and claudication with ambulation C) Altered tissue perfusion, arterial related to reduced blood flow D) Pain related to decreased blood flow and altered tissue perfusion

C) Altered tissue perfusion, arterial related to reduced blood flow

An 87-year-old woman has come to the clinic for a routine checkup. The nurse practitioner notes that the carotid artery pulse is diminished bilaterally and a systolic bruit is auscultated bilaterally. What would the NP want to have this patient assessed for by a cardiologist? A) Stenotic aortic valve B) Atherosclerotic pulmonic valve C) Atherosclerotic stenotic carotid arteries D) Congenital stenotic carotid arteries

C) Atherosclerotic stenotic carotid arteries

When doing a risk assessment of the nose, sinuses, mouth, and throat, what finding might indicate allergy? A) Low-grade fever B)History of macular rash C)Frequent childhood infections D) Family history of diabetes

C) Frequent childhood infections

The nurse is presenting a class for pregnant women. What would the nurse include related to the head and neck? A) Get regular examinations including B12 screening B) Get regular examinations including folic acid screening C) Get regular examinations including thyroid screening D) Get regular examinations including amniocentesis screening

C) Get regular examinations including thyroid screening

A patient is given a nursing diagnosis of activity intolerance related to pain and claudication with ambulation. What would be an appropriate intervention for this patient? A) Assess for pain, pulses, pallor, paresthesia, and paralysis B) Assess dorsalis pedis and posterior tibial pulse bilaterally C) Gradually increase activity D) Assess with a Doppler and notify the physician

C) Gradually increase activity

The nursing instructor is discussing the collection of subjective information when assessing a patient with arterial, venous, and lymphatic disorders. What would the instructor tell the students to include in the subjective portion of the health assessment? A) Plan for modifying risk factors B) Education on nonmodifiable risk factors C) Identification of cardiovascular risk factors D) History related to grandparents' health

C) Identification of cardiovascular risk factors

Emergency medical technicians bring a 17-year-old boy to the emergency department after a diving accident. The patient is alert and coherent. He tells the nurse, "I think I hit a rock and now I can't feel my arms or my legs." A rapid physical assessment shows no other apparent injuries. What is essential in this patient's care? A) Send for a CT scan immediately B) Draw a basic metabolic panel to check for infection C) Immobilize the spine until it is cleared of injury D) Log roll the patient to remove backboard reducing pressure on spine

C) Immobilize the spine until it is cleared of injury

A 6-year-old girl is brought to the pediatric clinic by her mother, who tells the APRN that her daughter has a sore on her leg that "just keeps getting bigger." On examination, the APRN notes an area of vesicles and bulla, some of which have ruptured and are oozing serous fluid. A honey-colored crust covers the area. What would the APRN tell the mother the lesion is? A) Varicella B) Scabies C) Impetigo D) Rubella

C) Impetigo

The nurse is caring for a 58-year-old man who presents at the clinic with reports of general malaise and fatigue. Physical assessment reveals that the patient's lips are dry and cracked. What might this indicate? A) Heat stroke B) Viral infection C) Inadequate hydration D) Allergy

C) Inadequate hydration

A normal assessment of the neck would include palpation of the thyroid isthmus. Where would the nurse find the isthmus? A) Just above the thyroid cartilage B) Between the thyroid and the cricoid cartilages C) Just below the cricoid cartilage D) In front of the sternocleidomastoid muscle

C) Just below the cricoid cartilage

A nurse is providing patient teaching to the parents of a 3-year-old girl who experiences chronic epistaxis. What would the nurse identify as the area where most nosebleeds originate? A) Rosenmuller's fossa B) Wharton's ducts C) Kiesselbach's plexus D) Stensen's duct

C) Kiesselbach's plexus

A woman brings her 3-year-old daughter to the pediatric clinic and tells the APRN that her child has "lumps in her neck that move around but don't hurt." On examination, the APRN notes lymph nodes that are less than 10 mm, nontender, and movable. How would the APRN describe findings in the medical record? A) Shoddy nodes B) Knotty nodes C) Shotty nodes D) Notty nodes

C) Shotty nodes

The sternal angle at the 2nd rib space is also known as what? A) Erb's point B) Manubrium C) The aortic area D) The PMI

C) The aortic area

A patient has been prescribed tetracycline for acne. What is the most important point the nurse should make in patient teaching about this medication? A) The patient may experience phototoxicity B) The medication may interfere with the menstrual cycle C) The patient may experience photosensitivity D) The medication may be inactivated by antacids

C) The patient may experience photosensitivity

A patient presents at the cardiology clinic for a checkup 6 months after MI. The patient is known to have a bundle branch block that delays activation of the right ventricle. What would the nurse expect to hear when auscultating heart sounds? A) Arrhythmia B) Extra sound C) Wide splitting D) Delayed S1

C) Wide splitting

Nursing students are learning about assessment of the head and neck. What cultural considerations would the students learn to assess in relation to this area? (Select all that apply.) A) Shape of the ears B) Shape of the chin C) Shape of the lips D) Shape of the nose E) Shape of the eyes

C, D, E

Nursing students are learning how to objectively assess venous pulses. How would the nursing instructor teach the students to optimally position the patient for this procedure? (Mark all that apply.) A) Use a bright light for better visualization B) Sit the patient up at a 90°angle C) Emphasize the shadows of the pulsations with lighting D) Place the head of the bed 30° to 45° E) Have the patient turn the head away from the side being examined

C, D, E

The autonomic nervous system innervates the salivary glands along with which cranial nerves? (Select all that apply.) A) X B) VIII C) VII D) IX E) XII

C, D, E

A patient with intermittent claudication wonders why the nurse wants to know where the patient is experiencing cramping when he walks. What would be the nurse's best answer? A) "The area of pain tells us what treatment will work best for you." B) "The area of cramping indicates whether you may have numbness and tingling also." C) "The area of pain can help us identify what risk factor is predominant." D) "The area of cramping is close to the area of arterial occlusion."

D) "The area of cramping is close to the area of arterial occlusion."

How should the nurse document a normal pulse in the medical record? A) +2/2 B) +2/3 C) +3/3 D) +3/4

D) +3/4

The area known as Erb's point is the third site for auscultation on the precordium. Where is it located? A) 4th left rib space C) 4th right rib space B) 3rd right rib space D) 3rd left rib space

D) 3rd left rib space

A 62-year-old woman states that she has to get up during the night to urinate. How would the nurse further assess this patient's nocturia? A) Ask the patient how often she thinks she should be getting up at night B) Ask the patient "Are you tired in the morning because of this?" C) Ask the patient whether siblings or parents had this problem D) Ask the patient "Have you made any changes because of this?"

D) Ask the patient "Have you made any changes because of this?"

A patient with a cervical spine injury has chronic pain. What would be the most appropriate initial nursing intervention for this patient? A) Work with medical team to evaluate possible surgery B) Discuss pharmacologic interventions C) Chronic pain related to cervical spine injury D) Assess characteristics

D) Assess characteristics

Which pulse is located at approximately the inner third of the antecubital fossa when the palm is held upward? A) Epitrochlear B) Radial C) Ulnar D) Brachial

D) Brachial

The APRN notes that the thyroid gland is enlarged and auscultates both lobes of the thyroid. For what is the APRN listening? A) Rush B) Gurgle C) Murmur D) Bruit

D) Bruit

Which of the following anterior neck structures is found in the depression between the trachea and the sternomastoid muscle? A) Internal jugular vein B) External jugular vein C) Trachea D) Carotid artery

D) Carotid artery

A nurse caring for a patient admitted 2 days ago following a cerebral vascular accident notes that the patient is frequently coughing, has food falling from the mouth while eating, and frequently chokes. What would be the most pertinent nursing diagnosis for this patient? A) Impaired dentition B) Alteration in mobility C) Altered cerebral perfusion D) Impaired swallowing

D) Impaired swallowing

When conducting a generalized assessment of a new patient, for what would the nurse inspect the neck? A) Strain B) Vertebral injury C) Lymph node enlargement D) Limitations in movement

D) Limitations in movement

An 84-year-old woman is admitted to the hospital after a fall during which she hit her head. While performing the admission assessment, the nurse finds a large ecchymosis over the C7-T1 area. The patient reports tenderness on palpation and movement. What would be an appropriate nursing diagnosis for this patient? A) Impaired skin integrity related to bed rest B) Impaired range of motion related to injury C) Immobility related to bed rest D) Neck pain related to possible neck injury

D) Neck pain related to possible neck injury

An emergency department nurse is assessing a 62-year-old rancher who arrives at the ED with chest pain. The patient states that the pain gets worse with movement. What further assessment should the nurse make? A) Auscultation at the 5th ICS B) Palpation at the PMI C) Assessment of the precordium D) Palpation of the costochondral junction

D) Palpation of the costochondral junction

While performing an admission assessment, the nurse auscultates a high-pitched, scratching, and grating sound at the left lower sternal border. The nurse should know that this would be documented as what type of sound? A) Paradoxical sound C) Pericardial murmur B) Split sound D) Pericardial friction rub

D) Pericardial friction rub

A pediatric nurse is doing her initial shift assessments on assigned patients. One of the patient's is a toddler with pneumonia. How would the nurse assess this patient's skin turgor? A) Pinch a fold of skin on the patient's abdomen B) Pinch a fold of skin on the patient's cheek C) Pinch a fold of skin on the patient's upper thigh D) Pinch a fold of skin on the patient's forearm

D) Pinch a fold of skin on the patient's forearm

Parents bring a child to the clinic and report a "rash" on her knee. On assessment, the APRN notes the area to be a reddish-pink lesion covered with silvery scales. What would the APRN chart? A) Seborrhea B) Contact dermatitis C) Eczema D) Psoriasis

D) Psoriasis

A trauma patient reports pain in his left lower extremity. The nurse notes that the extremity has pallor. Pedal pulses are diminished, and paresthesia is present. What nursing diagnosis might the nurse use? A) Pain related to decreased blood flow and altered tissue perfusion B) Activity intolerance related to pain and claudication with ambulation C) Altered tissue perfusion, arterial related to reduced blood flow D) Risk for peripheral neurovascular dysfunction

D) Risk for peripheral neurovascular dysfunction

An APRN is conducting the physical assessment of a 5-year-old Caucasian girl. The patient's mother states that it seems like her daughter always has a strep throat. For what intervention might this indicate a need? A) Dialysis B) Removal of nasal polyps C) Sinus surgery D) Tonsillectomy

D) Tonsillectomy

A mother brings her 6-month-old son to the clinic for a follow-up assessment after antibiotic treatment for recurring otitis media. What would the nurse expect to find while assessing the patient's mouth? A) White uvula C) White patches on the buccal mucosa B) Red and white patches in the throat D) White coated tongue

D) White coated tongue

A newborn has a hemangioma on the face. What would be important for the nurse to include in patient teaching? A) Will need surgery to remove B) Will become smaller over the first year of life C) Is made of epithelial cells that form caverns and fill with blood D) Will usually resolve by age 9 years

D) Will usually resolve by age 9 years