HA Exam 4 Practice Questions
The nurse is assessing the cranial nerves. Match the cranial nerve with its related function. Cranial Nerves: 1. XII Hypoglossal 2. V Trigeminal 3. VI Adducens 4. IV Trochlear 5. X Vagus Cranial Nerve Function: a. Motor innervation to the muscles of the jaw b. Lateral movement of the eyeballs c. Sensation of the pharynx d. Downward, inward eye movements e. Position of the tongue
1e, 2a, 3b, 4d, 5c
3. During a visit for a school physical, the 13-year-old girl being examined questions the asymmetry of her breasts. What is the nurse's best response? A) "One breast normally may grow faster than the other during development." B) "I will give you a referral for a mammogram." C) "You will probably have fibrocystic disease when you are older." D) "This may be an indication of hormonal imalance. We will check again in 6 months."
A) "One breast normally may grow faster than the other during development."
How often should normal bowel sounds be heard in each quadrant of the abdomen? A. 5-35 times per minute B. Less than 5 times per minute C. 15-20 times per minute D. 20-40 times per minute
A) 5-35 times per minute Rationale: Normal bowel sounds should be heard 5-35 times per minute. Bowel sounds reflect peristalsis and should be heard irregularly.
13. Gynecomastia is: A) Enlargement of the male breast B) Presence of mast cells in the male breast C) Cancer of the male breast D) Presence of supernumerary breast on the male chest
A) Enlargement of the male breast
What function is associated with the oculomotor nerve? A) Eye movement and pupil constriction B) Eye movement via the lateral rectus C) Eye movement via the superior oblique D) Eyesight
A) Eye movement and pupil constriction Rationale: The oculomotor nerve (CN III) is responsible for controlling the superior rectus, inferior rectus, medial rectus, and inferior oblique muscles of the eye. It is also involved in controlling the levator palpebrae muscle for opening the eyelid. CN III is also used to control pupil constriction and accommodation.
When assessing the breasts, which of the following is considered normal? A. Long-standing, unchanging nevi B. Reddened Montgomery glands C. Peau d'orange skin texture D. Nipples that are not symmetrical
A) Long-standing, unchanging nevi Rationale: Long-standing, unchanging nevi are a normal finding when assessing the breasts. Reddened Montgomery glands are not a normal finding when assessing the breasts. Montgomery tubercles should not be tender or suppurative. Peau d'orange skin texture is not a normal finding when assessing the breasts. Nipples that are not symmetrical is not a normal finding when assessing the breasts. The nipples should point forward similarly.
What are the Snellen and Rosenbaum charts used to assess? A. Optic nerve B. Trigeminal nerve C. Abducens nerve D. Facial nerve
A) Optic nerve Rationale: The Snellen and Rosenbaum charts are used to assess the optic nerve. The Snellen chart tests distance vision, and the Rosenbaum chart tests near vision.
Inadequate oxygenation to the body will cause the radial pulse to become: A. Tachycardic B. Bradycardic C. Irregular D. Bounding
A) Tachycardic Rationale: The heart rate will increase to circulate more available oxygen to tissues. Tachycardia is more than 100 beats/minute. The heart rate will increase, not decrease. Bradycardia is less than 60 beats/minute. Heart rhythm (regular or irregular) is determined by the electrical conduction through the heart, not oxygenation. A bounding pulse indicates increased blood volume ejected against the arterial wall.
Which of the following techniques is used to assess muscle strength in a patient? A. Apply an opposing force or resistance. B. Observe the patient at rest. C. Percuss the muscle. D. Palpate the muscle.
A) applying an opposing force or resistance Rationale: Muscle strength is tested for symmetry and grade. Strength should be bilaterally symmetric with full motion against resistance. Observing the patient at rest is part of inspection but does not assess muscle strength. Percussion is not part of the musculoskeletal assessment. Palpation of a muscle does not assess strength; palpation is performed to assess symmetry, firmness, and detection of problems.
5. You are providing health promotion teaching for a 40-year-old woman. What is the current recommendation for women 40 years of age and older for breast cancer screening with mammography? A) Every year B) Every 2 years C) Twice a year D) Only baseline examination needed unless the woman has symptoms
A) every year
In which position should the patient be placed in order to palpate the popliteal pulse? A. Have the patient lie prone with the knee flexed. B. Have the patient lie prone with the leg straight. C. Have the patient lie supine with the knee flexed. D. Have the patient lie supine with the leg straight.
A. Have the patient lie prone with the knee flexed. Rationale: The best way to palpate the popliteal pulse is with the patient prone and the knee flexed. Pulsations of the popliteal pulse can be palpated deep in the popliteal fossa lateral to the midline. Having the patient lie prone or supine with the leg straight or supine with the knee flexed does not allow for deep palpation of the popliteal pulse.
Which of the following statements best describes the mechanism(s) by which venous blood returns to the heart? 1. Intraluminal valves ensure unidirectional flow toward the heart. 2. Contracting skeletal muscles milk blood distally toward the veins. 3. The high-pressure system of the heart helps to facilitate venous return. 4. Increased thoracic pressure and decreased abdominal pressure facilitate venous return to the heart.
ANS: 1 Blood moves through the veins by (1) contracting skeletal muscles that milk the blood proximally; (2) pressure gradients caused by breathing, in which inspiration makes the thoracic pressure decrease and the abdominal pressure increase; and (3) the intraluminal valves, which ensure unidirectional flow.
Which of the following situations best describes a person at risk for development of venous disease? 1. A woman in her fifth month of pregnancy 2. A person who has been on bed rest for 4 days 3. A person with a 30-year, 1 pack per day smoking history 4. An elderly person taking anticoagulant medication
ANS: 2 At risk for venous disease are people who undergo prolonged standing, sitting, or bed rest. Hypercoagulable states and vein wall trauma also place the person at risk for venous disease.
The nurse is examining the lymphatic system of a healthy 3-year-old child. Which finding would the nurse expect to note? 1. Excessive swelling of the lymph nodes 2. The presence of palpable lymph nodes 3. No nodes palpable because of the immature immune system of a child 4. Fewer numbers and a decrease in size of lymph nodes compared with those of an adult
ANS: 2 Lymph nodes are relatively large in children, and the superficial ones often are palpable even when the child is healthy.
Which of the following statements regarding the lymphatic system is true? 1. Lymph flow is propelled by the contraction of the heart. 2. The flow of lymph is slow compared with that of the blood. 3. One of the functions of the lymph is to absorb lipids from the biliary tract. 4. Lymph vessels have no valves, so there is a free flow of lymph fluid from the tissue spaces into the bloodstream and back again.
ANS: 2 The flow of lymph is slow compared with that of the blood.
A 35-year-old man is seen in the clinic for an "infection in my left foot." Which of the following would the nurse expect to find during an assessment of this patient? 1. Hard and fixed cervical nodes 2. Enlarged and tender inguinal nodes 3. Bilateral enlargement of the popliteal nodes 4. "Pellet-like" nodes in the supraclavicular region
ANS: 2 The inguinal nodes in the groin drain most of the lymph of the lower extremity. With local inflammation, the nodes in that area become swollen and tender.
Which of the following statements is true regarding the arterial system? 1. Arteries are large-diameter vessels. 2. The arterial system is a high-pressure system. 3. The walls of arteries are thinner than those of veins. 4. Arteries can expand greatly to accommodate a large blood volume increase.
ANS: 2 The pumping heart makes the arterial system a high-pressure system.
A 65-year-old patient is experiencing pain in his left calf when he exercises, which disappears after resting for a few minutes. The nurse recognizes that this description is most consistent with: 1. venous obstruction of the left leg. 2. claudication due to venous abnormalities in the left leg. 3. ischemia caused by partial blockage of an artery supplying the left leg. 4. ischemia caused by complete blockage of an artery supplying the left leg.
ANS: 3 Ischemia is a deficient supply of oxygenated arterial blood to a tissue. A partial blockage creates an insufficient supply, and the ischemia may be apparent only at exercise, when oxygen needs increase.
The major artery supplying the arm is the: 1. ulnar artery. 2. radial artery. 3. brachial artery. 4. deep palmar artery.
ANS: 3 The major artery supplying the arm is the brachial artery.
A 70-year-old patient is scheduled for open-heart surgery. The physicians plan to use the great saphenous vein for the coronary bypass grafts. The patient asks, "What happens to my circulation when the veins are removed?" The nurse should reply: 1. "Venous insufficiency is a common problem after this type of surgery." 2. "Oh, we have lots of veins—you won't even notice that it has been removed." 3. "You will probably experience decreased circulation after the veins are removed." 4. "Because the deeper veins in your leg are in good condition, this vein can be removed without harming your circulation."
ANS: 4 As long as the femoral and popliteal veins remain intact, the superficial veins can be excised without harming the circulation.
To assess the dorsalis pedis artery, the nurse would palpate: 1. behind the knee. 2. over the lateral malleolus. 3. in the groove behind the medial malleolus. 4. lateral to the extensor tendon of the great toe.
ANS: 4 The dorsalis pedis artery is located on the dorsum of the foot. Palpate just lateral to and parallel with the extensor tendon of the big toe.
When performing an assessment of a patient, the nurse notes the presence of an enlarged right epitrochlear lymph node. What should the nurse do next? 1. Assess the patient's abdomen, noting any tenderness. 2. Carefully assess the cervical lymph nodes, checking for any enlargement. 3. Ask additional history questions regarding any recent ear infections or sore throats. 4. Examine the patient's lower arm and hand, checking for the presence of infection or lesions.
ANS: 4 The epitrochlear nodes are located in the antecubital fossa and drain the hand and lower arm.
Which of the following veins are responsible for most of the venous return in the arm? 1. Deep veins 2. Ulnar veins 3. Subclavian veins 4. Superficial veins
ANS: 4 The superficial veins of the arms are in the subcutaneous tissue and are responsible for most of the venous return.
7. A bimanual technique may be the preferred approach for a woman: A) Who is pregnant B) Who is having the first breast examination by a health care provider C) With pendulous breasts D) Who has felt a change in the breast during self-examination
C) With pendulous breasts
Hearing a bruit in an artery is a sign of which of the following conditions? A. Adequate blood flow B. A clot C. An obstruction D. A pulse deficit
C) an obstruction Rationale: Presence of a bruit is a sign of arterial obstruction.
The faith community nurse is teaching the community center women's group about breast cancer risk factors. Which factors does the nurse include? (Select all that apply.) 1) First child at the age of 26 years 2) Menopause onset at the age of 49 years 3) Family history with BRCA1 inherited gene mutation 4) Age over 40 years 5) Onset of menses before the age of 12 6) Recent use of oral contraceptives
Answer: 3, 4, 5, 6. Rationale: These are all risk factors for development of breast cancer. Onset of menopause after the age of 55, not at the age of 49, is a risk factor. First child after the age of 30, not birth of a child at 26, is a risk factor.
A patient has undergone surgery for a femoral artery bypass. The surgeon's orders include assessment of dorsalis pedis pulses. The nurse will use which of the following techniques to assess the pulses? (Select all that apply.) 1) Place the fingers behind and below the medial malleolus. 2) Have the patient slightly flex the knee with the foot resting on the bed. 3) Have the patient relax the foot while lying supine. 4) Palpate the groove lateral to the flexor tendon of the wrist. 5) Palpate along the top of the foot in a line with the groove between the extensor tendons of the great and first toes.
Answer: 3, 5. Rationale: To palpate the dorsalis pedis pulses (located in the feet), ask the patient to relax the foot, and then palpate along the top of the foot in a line with the groove between the extensor tendons of the great and first toes. Placing fingers behind the medial malleolus is a technique for assessing the posterior tibial pulse. Having a patient slightly flex the knee is a technique for assessing the popliteal artery behind the knee. Palpation of the groove lateral to the flexor tendon of the wrist is the technique to assess the radial artery.
15. During the examination of a 30-year-old woman, she asks about "the 2 large moles" that are below her left breast. After examining the area, how do you respond? A) "I think you should be examined by a dermatologist." B) "This is a normal finding of supernumerary nipples that are not developed." C) "These are Montgomery's glands, which are common." D) "Is there a possibility you are pregnant?"
B) "This is a normal finding of supernumerary nipples that are not developed."
Which cranial nerve innervates the muscles involved in shoulder shrugging and in turning the head? A) CN X B) Accessory C) Abducens D) CN XII E) CN IV
B) Accessory Rationale: the accessory nerve (CN XI) innervates the sternocleidomastoid and the trapezius muscles
14. Which is the first physical change associated with puberty in girls? A) Areolar elevation B) Breast bud development C) Height spurt D) Pubic hair development
B) Breast bud development
A 23 year old female presents complaining of hearing changes and balance issues. Which cranial nerve is most likely involved with her problems? A) CN XI B) CN VIII C) CN IX D) CN V
B) CN VIII Rationale: CN VIII is the vestibulocochlear nerve which is involved in balance and hearing.
A middle aged man expresses to you that he is concerned that he cannot taste anything on the anterior portion of his tongue. What nerve innervates this portion of the tongue? A) Glossopharyngeal nerve B) Facial nerve C) Trigeminal nerve D) Hypoglossal nerve
B) Facial nerve Rationale: The facial nerve (CN VII) senses taste from the anterior 2/3 of the tongue. The Glossopharyngeal nerve (CN IX) does the posterior 1/3, and the Vagus (CN X) nerve senses taste from the extreme posterior.
Which of the following tips will assist with eliciting the patellar and Achilles deep tendon reflexes? A. Have the patient sit with his or her feet flat on the floor. B. Have the patient focus on pulling his or her clasped hands apart. C. Have the patient flex his or her knees at a 45-degree angle. D. Strike the knee above the patella.
B) Have the patient focus on pulling his or her clasped hands apart. Rationale: With the patient in a seated position, have him or her focus on pulling his or her clasped hands apart; this will take focus away from the test of deep tendon reflexes. The patient should sit so that the upper legs are supported and the lower legs hang loosely. The patient should flex his or her knees at a 90-degree angle. Strike the knee just below the patella.
What is the correct order for abdominal assessment? A) Inspection, palpation, auscultation, percussion B) Inspection, auscultation, percussion, palpation C) Auscultation, inspection, palpation, percussion D) Palpation, inspection, auscultation, percussion
B) Inspection, auscultation, percussion, palpation Rationale: The correct order for abdominal assessment is inspection, auscultation, percussion, palpation. Palpation is the last step in abdominal assessment. Auscultation follows assessment because percussion and palpation can alter the frequency and intensity of bowel sounds.
9. During a breast examination you detect a mass. Which of the following is most consistent with cancer rather than benign breast disease? A) Round, firm, well demarcated B) Irregular, poorly defined, fixed C) Rubbery, mobile, tender D) Lobular, clear margins, negative skin retraction
B) Irregular, poorly defined, fixed
Which cranial nerve is responsible for smell? A) Accessory B) Olfactory C) Trigeminal maxillary division D) Trochlear
B) Olfactory
What is a depression that is left after pressing a finger or thumb on swollen tissue called? A. Cyanosis B. Pitting edema C. A thrill D. A varicosity
B) Pitting edema Rationale: To assess a patient for pitting edema, press a finger or thumb over the swollen tissues of the tibia or medial malleolus where edema is present. A depression left in swollen tissue is not cyanosis; cyanosis is mottled blue color of the skin. A thrill is a soft vibratory sensation; it is not a depression caused by pressing a finger or thumb on swollen tissue. A varicosity is not determined by pressing a finger or thumb on swollen tissue; varicosities are distended veins.
What questions can you ask a patient to assess his or her state of consciousness? A. Ask the patient about his or her thoughts, feelings, and emotions. B. Ask for the date, his or her name, and the location. C. Ask the patient to repeat a series of five numbers. D. Ask the patient to write his or her name and address.
B. Ask for the date, his or her name, and the location. Rationale: Begin with asking the patient today's date, then ask the patient to state his or her name. A patient should be oriented to time, place, and person and be able to respond appropriately to questions about the environment. Thoughts, feelings, and emotions are not part of an assessment for state of consciousness. Repeating a series of numbers is not part of an assessment for state of consciousness. Having the ability to write his or her name and address is not part of an assessment for state of consciousness.
What should the nurse do if a patient displays staggering or loss of balance during the Romberg test? A. Give the patient a gentle push to further assess balance. B. Delay other balance tests. C. Have the patient stand on one foot with the eyes closed. D. Have the patient hop on one foot.
B. Delay other balance tests.
3. What are the five danger signs to watch for when assessing nipples? A. Shape, tenderness, size, inversion, and mobility B. Discharge, depression, discoloration, dermatologic changes, and deviation C. Lymph nodes, breast size, symmetry, tail of Spence, and color D. Rash, nodules, warmth, redness, and pain
B. Discharge, depression, discoloration, dermatologic changes, and deviation
When should you check the patient's blood pressure to assess for orthostatic hypotension? A. After the patient has been walking around the room B. While the patient is sitting and standing C. After bloodwork has been done D. Immediately after the initial blood pressure reading
B. While the patient is sitting and standing Rationale: If orthostatic hypotension is suspected, check the patient's blood pressure while the patient is sitting and standing. Orthostatic hypotension cannot be assessed after the patient has been walking around the room; it is assessed from a sitting to standing position.
A deep tendon reflex with a normal response is scored as: A. 0 B. 1+ C. 2+ D. 3+
C) 2+ Rationale: 2+ is considered an active or expected response for deep tendon reflex; this is a normal response. 0 indicates no response for deep tendon reflex; this is an abnormal response. 1+ indicates a sluggish or diminished response for deep tendon reflex; this is an abnormal response. 3+ is a brisker-than-expected or slightly hyperactive response; this is an abnormal response.
11. Which woman should not be referred to a physician for further evaluation? A) A 26-year-old with multiple nodules palpated in each breast B) A 48-year-old who has a 6-month history of reddened and sore left nipple and areolar area C) A 25-year-old with asymmetric breasts and inversion of nipples since adolescence D) A 64-year-old with ulcerated area at tip of right nipple; no masses, tenderness, or lymph nodes palpated
C) A 25-year-old with asymmetric breasts and inversion of nipples since adolescence
A patient presents with concerns about his vision. He states that he is experiencing double vision. Upon evaluation you conclude that he has lateral rectus palsy. Which cranial nerve is most likely lesioned in this young man? A) Trigeminal B) Trochlear C) Abducens D) Oculomotor
C) Abducens Rationale: The lateral rectus muscle is innervated by CN VI (abducens nerve). Remember "LR6 SO4 the rest 3". (Lateral rectus innervated by CN VI, Superior oblique innervated by CN IV, the rest of the eye muscles are controlled by CN III)
Which of the following is an important part of performing an abdominal assessment? A. Completing the assessment as quickly as possible B. Stopping the assessment if the patient has any tenderness C. Explaining each step of the assessment to the patient D. Having the patient breathe normally at all times
C) Explaining each step of the assessment to the patient Rationale: Explaining each step of the assessment demonstrates respect for the patient and allows the patient to be informed of the assessment process. Abdominal assessment should be performed in a thorough manner, not as quickly as possible. Complaints of tenderness from the patient should be noted, and the complete abdominal assessment should be continued. For most parts of the assessment, the patient will breathe normally. There are instances when the patient will need to take a deep breath, such as when assessing the spleen and gastric air bubble.
What is an increased thoracic curvature, common in older adults, called? A. Scoliosis B. Lordosis C. Kyphosis D. Swayback
C) Kyphosis Rationale: Kyphosis is an increased thoracic curvature commonly found in older adults. In scoliosis there is lateral and compensatory curvature of the spine. In lordosis and swayback there is increased lumbar curvature of the spine.
8. During the examination of a 70-year-old man, you note gynecomastia. You would: A) Refer for a biopsy. B) Refer for a mammogram. C) Review the medications for drugs that have gynecomastia as a side effect. D) Proceed with the examination. This is a normal part of the aging process.
C) Review the medications for drugs that have gynecomastia as a side effect.
6. You are going to inspect a female patient's breasts for retraction. The best position for this part of the examination is: A) Lying supine with arms at the sides B) Leaning forward with hands outstretched C) Sitting with hand pushing onto hips D) One arm at the side, the other arm elevated
C) Sitting with hand pushing onto hips
2. What is the most important information to document if a mass is palpated in the breast or axilla? A. Color and tenderness of surrounding tissue B. Shape, tenderness, mobility, and size of the breasts C. Consistency, borders, mobility, location, size, shape, tenderness, and retraction of the mass D. Characteristics of the nipple and lymph nodes
C. Consistency, borders, mobility, location, size, shape, tenderness, and retraction of the mass
Which of the following cranial nerves is assessed by holding a scented object under the patient's nose? A. Facial nerve B. Oculomotor nerve C. Olfactory nerve D. Acoustic nerve
C. Olfactory nerve Rationale: The olfactory nerve is assessed by having a patient close his or her eyes, inhale deeply, and identifying the smell. The facial nerve is assessed by observing the patient making specific facial movements. The oculomotor nerve is assessed by inspecting the eyelids and by checking the pupils. The acoustic nerve is assessed by performing the whispered voice test.
Neck flexion and extension should be: A. 90 degrees B. 70 degrees C. 30 degrees D. 45 degrees
D) 45 degrees Rationale: Neck flexion and extension should each be 45 degrees; rotation should be 70 degrees on each side.
A nurse is palpating the breasts of a patient. Which of the following are important aspects of proper palpation of the breasts? A. Using finger pads to palpate B. Using a consistent pattern C. Making small circles at each part of the breast and gliding from place to place D. All of the above
D) All of the above
Which test or tests assess accuracy of movement? A. Finger-to-finger test B. Finger-to-nose test C. Heel-to-shin test D. All of the above
D) All of the above Rationale: All of the above tests can be used to assess accuracy of movement. The finger-to-finger test is used to assess accuracy of movement. The patient's movements should be rapid, smooth, and accurate with no past pointing. The finger-to-nose test is used to assess accuracy of movement. The patient's movements should be rapid, smooth, and accurate, even with increasing speed. The heel-to-shin test is used to assess accuracy of movement. The patient should move his heel in a straight line without deviations to the side.
Moderate and deep palpation of the abdomen: A. May cause tenderness B. Should not detect masses C. May locate the margins of the liver D. All of the above
D) All of the above May cause tenderness Should not detect masses May locate the margins of the liver Rationale: The patient may report tenderness with deep palpation that was not there during light palpation. Deep palpation may cause tenderness over the cecum, sigmoid colon, aorta, and xiphoid process. In a healthy patient, deep palpation should not detect masses. Palpate with the side of your hand over the liver and spleen; these organs should bump into your hand with inspiration.
10. During the examination of the breasts of a pregnant woman, you would expect to find: A) Peau d'orange B) Nipple retraction C) Unilateral, obvious venous pattern D) Blue vascular pattern over both breasts
D) Blue vascular pattern over both breasts
Which of the following actions are part of the assessment of the glossopharyngeal and vagus nerves? A. Testing the gag reflex B. Having the patient swallow C. Touching the patient's face with dull and sharp objects D. Both A and B
D) Both A and B Rationale: -Both testing the gag reflex and having the patient swallow are part of a thorough assessment of the glossopharyngeal and vagus nerves. -When the posterior wall of the pharynx is touched, the patient should gag and the uvula should stay midline. -Having the patient swallow is part of a thorough assessment of the glossopharyngeal and vagus nerves. Have the patient drink some water while you observe her ability to swallow. -Touching the patient's face with dull and sharp instruments is not part of assessment of the glossopharyngeal and vagus nerves.
Which of the following findings in a musculoskeletal assessment would be considered abnormal? A. Nodules B. Bogginess C. Symmetry D. Both A and B
D) Both A and B Rationale: Both nodules and bogginess are considered abnormal findings. Symmetry is an expected finding in a musculoskeletal assessment. Muscles, joints, and bones should be symmetrical.
3. How would you assess sensitivity to superficial pain? A. Touch the patient with the sharp side of a broken tongue blade. B. Have the patient keep his or her eyes open. C. Allow 2 seconds between stimuli. D. Both A and C.
D) Both A and C Rationale: -Touching the patient with the sharp side of a broken tongue blade and allowing 2 seconds between stimuli are both part of a thorough assessment for superficial pain sensation. -With the patient's eyes closed, ask the patient to identify if the sensation is dull or sharp. -For assessment of superficial pain, randomly apply the sharp and dull stimuli, allowing 2 seconds between stimuli to avoid a summative effect.
Which cranial nerve is responsible for sight? A) Trochlear B) Cranial nerve four C) Oculomotor nerve D) CN II
D) CN II Rationale: CN II is the optic nerve. The optic nerve is responsible for eye sight.
What is the responsibility of the hypoglossal nerve? A) Taste of the posterior 1/3 of the tongue B) Taste of the extreme posterior portion of the tongue C) Taste of the anterior 2/3 of the tongue D) Controls tongue movement
D) Controls tongue movement Rationale: The hypoglossal nerve (CN XII) is not involved in taste, but is involved in tongue movement.
12. Any lump found in the breast should be referred for further evaluation. A benign lesion will usually have 3 of the following characteristics. Which one is characteristic of a malignant lesion? A) Soft B) Well-defined margins C) Freely movable D) Irregular shape
D) Irregular shape
What will the nurse instruct nursing assistive personal (NAP) to do when measuring an adult patient's radial pulse? A) Place the patient in the lateral (side-lying) position before measuring the pulse. B) Apply gloves with each patient before measuring the pulse. C) Document whether the patient's pulse is bounding or has diminished. D) Palpate the patient's inner wrist on the thumb side with the fingertips of your two middle fingers.
D) Palpate the patient's inner wrist on the thumb side with the fingertips of your two middle fingers. Rationale: The thumb side of the wrist easily accesses the radial artery for the radial pulse. The ulnar artery is on the little finger side of wrist. The nurse's thumb has pulsation that will interfere with accuracy; therefore the fingertips are the most sensitive parts of the hand to palpate arterial pulsation. The patient may assume a sitting or supine position before measuring the radial pulse. Gloves are not usually required to measure the radial pulse. The radial pulse site harbors normal skin flora, not pathogenic microorganisms, in the general population. Documenting whether the patient's pulse is bounding or has diminished pertains to documentation of the procedure, not to the procedure itself.
What should you do if a patient is ticklish when you are palpating the abdomen? A. Distract the patient by talking to him or her. B. Do not palpate the abdomen in the upper quadrants. C. Do only deep palpation of all four quadrants. D. Place your hand over the patient's hand during palpation
D) Place your hand over the patient's hand during palpation Rationale: Place your hand over the patient's hand during palpation, leaving your fingers free to palpate. Palpate with a firm hand or place your hand over the patient's during palpation. All quadrants are palpated for a thorough abdominal assessment. The abdominal assessment begins with light palpation.
Normal capillary refill is less than 2 seconds and is assessed by: A. Pressing on the radial artery until a pulse is no longer felt B. Palpating all superficial veins in the legs to check for tenderness C. Palpating all of the pulses bilaterally to check that they are equal D. Pressing on the nail bed until it blanches, and observing how quickly full color returns
D) Pressing on the nail bed until it blanches, and observing how quickly full color returns
Which of the following are included in the assessment of mental status? A. Speech and language B. Emotional stability C. Physical appearance and behavior D. All of the above
D) all of the above Rationale: Speech and language, emotional stability, and physical appearance and behavior are all part of a thorough assessment of mental status.
What does a goniometer measure? A. Muscle strength B. Joint stability C. Cranial nerve function D. Angles of extension and flexion
D) angles of extension and flexion
Which of the following statements is the most complete description of the tail of Spence? A. Breast tissue that extends into the axilla B. A common place to find breast lumps C. Not included in a breast exam D. Both A and B
D. Both A and B Rationale: The tail of Spence is breast tissue that extends into the axilla. It is a common place to find breast lumps upon palpation. The tail of Spence is part of a thorough breast examination.
8. The nurse should document mild, slightly pitting edema present on the ankles of a pregnant patient? a. 1+ b. 3+ c. 4+ d. brawny edema
a. 1+
1. The two parts of the nervous system are: a. Central & Peripheral b. Motor & Sensory c. Peripheral & Autonomic d. Hypothalamus & Cerebral
a. Central & Peripheral
8. The cerebral cortex is the center for highest functions including thought, memory, reasoning and sensation a. True b. False
a. True
6. A 67- year old patient states that he recently began to have pain in his left calf when climbing the 10 stairs to his apartment. This pain is relieved by sitting for about 2 minutes; then he is able to resume his activities. The nurse interprets that this patient is most likely experiencing a. claudication b. sore muscles c. muscle cramps d. venous insufficiency
a. claudication
6. The ability that humans have to perform very skilled movements such as writing is controlled by: a. Basal ganglia b. Corticospinal tract c. Spinothalamic tract d. Extrapyramidal tract
b. Corticospinal tract
7. The medical record indicates that a person has an injury in the Wernicke's area. When you meet this person, you expect: a. Difficult speaking b. Difficulty with language comprehension c. Emotionally labile d. Visual disturbances
b. Difficulty with language comprehension
5. Which of these statements about the peripheral nervous system is correct? a. The cranial nerves enter the brain through the spinal cord b. The peripheral nerves carry input to the central nervous system by afferent fibers and away from the central nervous system by efferent fibers c. Efferent fibers carry sensory input to the central nervous system through the spinal cord d. The peripheral nerves are inside the central nervous system and carry impulses through their motor fibers
b. The peripheral nerves carry input to the central nervous system by afferent fibers and away from the central nervous system by efferent fibers
2. What is the most common site of breast tumors? a. Upper inner quadrant b. Upper outer quadrant c. Lower inner quadrant d. Lower outer quadrant
b. Upper outer quadrant
3. What is the most frequent site of breast cancer? a. Upper inner quadrant b. Upper outer quadrant c. Lower inner quadrant d. Lower outer quadrant
b. Upper outer quadrant
7. During an assessment, the nurse uses the 'profile sign' to detect a. pitting edema b. early clubbing c. symmetry of the finger d. insufficient capillary refill
b. early clubbing
2. When performing an assessment on a patient, the nurse notes the presence of an enlarged epitrochlear lymph node? What should the nurse do? a. assess the abdomen further b. examine the lower hand and arm further noting any lesions c. check the cervical lymph nodes, noting any enlargement d. ask additional history questions regarding possible ear infections or sore throats
b. examine the lower hand and arm further noting any lesions
10. During a discussion about breast self-examination with a 70 year old woman, which of these statements by the nurse is most appropriate? a. the best time to examine your breasts is during ovulation b. examine your breasts every month on the same day of the month c. examine your breasts shortly after your menstrual period each month d. the best time to examine your breasts is immediately before menstruation
b. examine your breasts every month on the same day of the month
1. The nurse must palpate the abdomen before auscultation. This stimulates the bowel sounds which produces more productive bowel sounds a. true b. false
b. false
2. You are going to assess the abdomen. The correct position would be lying down in the bed (or exam table) and having the patient raise their arms behind their head a. true b. false
b. false
4. Correct way to palpate breast tissue is to assess with your fingertips a. True b. False
b. false
9. During an assessment, the nurse notices that a patient's left arm is swollen from the shoulder down to the fingers, with nonpitting brawny edema. The right arm is normal. The patient had a left-sided mastectomy 1 year ago. The nurse suspects: a. venous stasis b. lymphedema c. arteriosclerosis d. deep vein thrombosis
b. lymphedema
6. Normal liver span over (R) MCL a. 4-8 cm b. 6-10 cm c. 6-12 cm d. 8-12 cm
c. 6-12 cm
9. A patient comes into the Emergency Department complaining of left eye blindness without obvious injury. As a nurse, you know the primary part of the brain responsible for visual reception is: a. Frontal lobe b. Parietal lobe c. Occipital lobe d. Temporal lobe
c. Occipital lobe
4. When teaching the breast self-examination, you would inform the woman that the best time to conduct breast self-examination is: a. At the onset of the menstrual period b. On the 14th day of the menstrual cycle c. On the 4th to 7th day of the cycle d. Just before the menstrual period
c. On the 4th to 7th day of the cycle
10. Three parts of the brainstem include all the following except: a. Pons b. Midbrain c. Spinal cord d. Medulla
c. Spinal cord
2. The area of the nervous system that is responsible for mediating reflexes is the: a. Medulla b. Cerebellum c. Spinal cord d. Cerebral cortex
c. Spinal cord
4. Which statement concerning the areas of the brain is true? a. The cerebellum is the center for speech and emotion b. The basal ganglia are responsible for controlling voluntary movements c. The hypothalamus controls body temperature and regulates sleep d. Motor pathways of the spinal cord and brainstem synapse in the thalamus.
c. The hypothalamus controls body temperature and regulates sleep
9. The nurse is performing percussion during an abdominal assessment. Percussion notes heard during the abdominal assessment may include: a. Flatness, resonance, and dullness b. Resonance, dullness, and tympany c. Tympany, hyperresonance, and dullness d. Resonance, hyperresonance, and flatness
c. Tympany, hyperresonance, and dullness
4. The nurse is reviewing the blood supply to the arm. The major artery supplying the arm is the ______ artery? a. ulnar b. radial c. brachial d. deep palmar
c. brachial
5. Select the sequence of examination techniques during the abdominal exam a. inspection, palpation, percussion, auscultation b. inspection, auscultation, palpation, percussion c. inspection, auscultation, percussion, palpation d. auscultation, inspection, palpation, percussion
c. inspection, auscultation, percussion, palpation
5. A 65-year old patient is experiencing pain in his left calf when he exercises that disappears after resting for a few minutes. The nurse recognizes that this description is most consistent with ______? a. venous obstruction b. claudication due to venous abnormalities c. ischemia caused by partial blockage of the artery d. ischemia caused by a complete blockage of the artery
c. ischemia caused by partial blockage of the artery
7. Which organ do you expect to be able to palpate in the normal abdomen? a. spleen b. left kidney c. right kidney
c. right kidney
10. When using a Doppler, the nurse recognizes venous blood flow when which sound is heard? a. low humming sound b. regular lub-dub pattern c. swishing-whooshing sound d. steady, even flowing sound
c. swishing-whooshing sound
3. The husband of a 70-year old woman tells you that he is concerned because he noticed a change in his wife's personality and ability to understand simple conversation. She also becomes angry easily. What part of the cerebellum is responsible for this behavior? a. Parietal b. Occipital c. Temporal d. Frontal
d. Frontal
1. The reservoirs for storing milk in the breast are: a. Lobules b. Alveoli c. Montgomery glands d. Lactiferous sinuses
d. Lactiferous sinuses
3. The nurse plans to assess an adult patient for Homan's sign. The nurse should: a. ask the patient to stand for the procedure b. place the hands on the patient's thigh muscle c. flex the patient's knee, then plantar flex the foot d. flex the patient's knee, then dorsiflex the foot
d. flex the patient's knee, then dorsiflex the foot
1. The nurse is preparing to assess the dorsalis pedis artery. Where is the correct location for palpation? a. behind the knee b. behind the lateral malleolus c. in groove behind the medial malleolus d. lateral to extensor tendon of great toe
d. lateral to extensor tendon of great toe
8. The most predominate percussion note in the abdomen is? a. dullness b. resonance c. flatness d. tympany
d. tympany
