FINAL: Exam 3 (CH 20-30)

Which phase of the nursing process is most foundational for delivery of care? A.Assessment B.Planning C.Diagnosis D.Evaluation

A. Assessment. Rationale: This assessment determines which diagnoses will be the focus of care, the interventions that will be initiated, and those that will be reevaluated. In this way, the assessments drive care, and the reassessments loop back into further assessments and revision of care planning.

Which question(s) should you ask to assess medication use in the older adult living in the community? Select all that apply. A."What medications are you taking?" B."What is the schedule for your medications?" C."Tell me why you are taking all of your medications." D."What is the dose of the medication that you take?"

A. "What medications are you taking?"; B. "What is the schedule for your medications?"; C. "Tell me why you are taking all of your medications."; D. "What is the dose of the medication that you take?" Rationale: All of the above. It is best to have the patient demonstrate how he or she takes medications. The nurse can see which medications that the patient is taking correctly, those that he or she might be skipping, and those that he or she might be taking too much.

Children are usually brought for health care visits by a parent. At about what age should you begin to question the child, rather than the parent, regarding presenting symptoms? A.5 years of age B.7 years of age C.9 years of age D.11 years of age

A. 5 years of age. Rationale: The nurse should begin to ask the child direct questions early to encourage self-care and to assist in establishing rapport. Of course, the information received from a child of any of the listed ages would be confirmed, refined, or denied by the parent.

Which of the following patients should the nurse see first? A.A patient with unilateral changes in vision B.A patient with ectropion of the lower lid C.A patient with presbyopia D.A patient with senile ptosis

A. A patient with unilateral changes in vision. Rationale: Unilateral changes in vision might indicate a stroke, which should be treated as an acute situation.

A patient reports that a previous right hip replacement is suddenly painful. Which hip assessment technique should you omit? A.Adduction B.Hyperextension C.Extension D.Circumduction

A. Adduction. Rationale: Adduction of the hip may cause the artificial hip to dislocate. The other activities are not restricted.

The nurse enters a patient's room and initiates a rapid response call based on which of the following assessments? Select all that apply. A.An acute change in oxygen saturation less than 90% despite oxygen administration B.An acute change in systolic blood pressure to less than 90 mm Hg or a sustained increase in diastolic blood pressure greater than 110 mm Hg C.New-onset chest pain D.An acutely cold, cyanotic, or pulseless extremity E.An acute change in pupillary response

A. An acute change in oxygen saturation less than 90% despite oxygen administration; B. An acute change in systolic blood pressure to less than 90 mm Hg or a sustained increase in diastolic blood pressure greater than 110 mm Hg; C. New-onset chest pain; D. An acutely cold, cyanotic, or pulseless extremity; E. An acute change in pupillary response. Rationale: All of these are emergency situations and the nurse may need additional assistance to provide immediate interventions. Additional situations include unexplained lethargy, new seizure, temperature greater than 39.0°C (102.2°F), uncontrolled pain, acute change in urine output less than 50 ml (about 1¾ oz) over 4 hours and acute bleeding.

A 70-year-old man presents with the following symptoms: straining to void, nocturia, dribbling, and hesitancy when voiding. These signs are consistent with what condition? A.Benign prostatic hypertrophy (BPH) B.Prostatitis C.Testicular cancer D.Phimosis

A. Benign prostatic hypertrophy (BPH). Rationale: As men age, fibromuscular structures of the prostate gland atrophy and are gradually replaced by collagen, which enlarges the gland. Consequences include nocturia, dribbling, and hesitancy when voiding.

One of the guests at a health promotion fair asks the nurse, "What is the greatest killer of women?" The nurse knows by current evidence that it is A.cardiovascular disease. B.lung cancer. C.breast cancer. D.osteoporosis.

A. Cardiovascular disease. Rationale: Heart disease is the number one killer of women.

A Pap smear is recommended to screen for what condition? A.Cervical cancer B.Ovarian cancer C.Endometrial cancer D.Vaginal cancer

A. Cervical cancer. Rationale: A Pap smear is a screening tool for detecting precancerous or cancerous cells of the cervix.

The patient with a head injury and increasing ICP is likely to have which assessment findings? A.Decreased LOC and sluggish pupil B.Left-sided weakness and facial droop C.Right ptosis and right-sided loss of vision D.Dilated left pupil and receptive aphasia

A. Decreased LOC and sluggish pupil. Rationale: Because increasing intracranial pressure is a global process, the findings are more general and less specific. Findings localized to the left or right side are more commonly associated with specific areas of the brain, as with a stroke.

A patient is anxious, dyspneic, and pale and uses accessory muscles to breathe. Vital signs are temperature 37°C (98.6°F), pulse 126 beats/min, respirations 40 breaths/min, and BP 122/74 mm Hg. The type of assessment that the nurse would perform is a(n) A.emergent assessment. B.general survey. C.health history. D.objective assessment.

A. Emergent assessment. Rationale: An emergent assessment focuses on data related to the problem, so that interventions can be implemented early and the problem can be resolved. Both subjective and objective data are gathered in the acute assessment.

When documenting a finding over the stomach, the nurse most accurately identifies the region as A.epigastric. B.hypogastric. C.RUQ. D.LUQ.

A. Epigastric. Rationale: The epigastric region is located above the umbilicus and straddles the midline between the right and left upper quadrants.

The most common format for the comprehensive admitting assessment in the hospitalized adult is the A.head to toe. B.body systems. C.functional framework. D.systems framework.

A. Head to toe. Rationale: This format is efficient and comfortable for the patient. Focused assessments are usually integrated.

Which of the following assessment tasks can you appropriately delegate to an unlicensed care provider? A.Height, weight, and vital signs B.Active and passive ROM C.History of current complaint D.Muscle strength

A. Height, weight, and vital signs. Rationale: Nurses frequently delegate the taking of height, weight, and vital signs to unlicensed care providers. The other items are parts of assessment that cannot be delegated to unlicensed personnel.

A 26-year-old man was in a motor vehicle accident and suffered a complete spinal cord injury to L3. The nurse assesses the patient for loss of motor function in the: A.legs B.abdomen C.chest D.arms

A. Legs. Rationale: The level of injury in the spinal cord correlates with innervation on the skin according to the level of the dermatome. Innervation of the arm roughly correlates with C5 to T1. Innervation of the chest correlates with T1 to T8. Innervation of the abdomen corresponds to T9 to T12. Innervation of the legs corresponds to L1 to S1.

When percussing the abdomen, the nurse notices a dullness at the anterior right costal margin at the right midclavicular line. Which organ is most likely involved? A.Liver B.Spleen C.Sigmoid colon D.Kidney

A. Liver. Rationale: The spleen is normally found in the 9th to 11th left intercostal space (ICS) in the left midaxillary line (MAL). The colon is in the lower quadrants of the abdomen. The kidney is located in the posterior flank, in the lower rib cage. It is percussed for tenderness and is not always palpable.

A patient with a tympanic abdomen complains of pain in the RUQ. Which sign would the nurse expect to be positive? A.Murphy sign B.Psoas sign C.Rovsing sign D.Obturator sign

A. Murphy sign. Rationale: The Murphy sign tests for gallbladder pain. The other signs test for peritoneal irritation in the lower quadrants.

The nurse gathers subjective data related to the history of the present problem. The following items are included: A.Onset, location, duration, character, aggravating/associated factors, relieving factors, temporal factors, severity B.Asymmetry, borders, color, diameter C.Heart rate, respiratory effort, response, color D.Eye opening, verbal response, motor response

A. Onset, location, duration, character, aggravating/associated factors, relieving factors, temporal factors, severity. Rationale: The OLDCARTS mnemonic may be used to describe history of the present problem. B is the warning signs for skin cancer; C is elements of the Apgar score; D is elements in the Glasgow Coma Scale.

A 50-year-old patient is seen in the clinic for an annual physical examination and screening. The patient has no known health problems. This type of care is referred to as A.primary prevention. B.promotion prevention. C.tertiary prevention. D.healthy prevention.

A. Primary prevention. Rationale: Primary prevention is screening and teaching that occur before disease. Secondary prevention focuses on preventing problems once disease is detected. Tertiary prevention addresses reducing complications from known disease.

A patient develops a sudden onset of acute chest pain. In addition to a complete description of the symptoms, what objective assessment is a priority? A.Pulse, blood pressure, peripheral pulses B.Heart sounds, rate, and rhythm C.Circulation, sensation, and movement D.Murmurs, rubs, and gallops

A. Pulse, blood pressure, peripheral pulses. Rationale: The primary concern is the effect of cardiac ischemia on the patient. To know how well the heart is circulating blood, the nurse assesses blood pressure and peripheral pulses. Findings provide information about cardiac output. B and C provide data about the heart, but not about its effectiveness; D is assessment of the periphery only.

The nurse is assessing a 2-month-old infant whose mother brought her to the emergency department because the baby wasn't eating well and she "just looks sick." Which of the following assessment findings is most worrisome? A.Stiff neck with an arched back B.Circumoral cyanosis noted when crying C.PMI not palpable, anterior fontanel bulges slightly when crying D.Temperature 36.4°C (97.5°F), heart rate (HR) 160 beats/min, respiratory rate (RR) 38 breaths/min

A. Stiff neck with an arched back. Rationale: A stiff neck and arched back describe opisthotonos, which occurs with meningeal irritation. Meningitis will need to be ruled out.

A young male presents for a sports physical examination. In addition to examining for hernias, it would be appropriate for you to do which of the following? A.Teach testicular self-examination. B.Evaluate for urinary retention. C.Examine for prostate cancer. D.Draw blood to measure prostatic surface antigen

A. Teach testicular self-examination. Rationale: This age group is at high risk for testicular cancer; prostate cancer usually occurs later in life.

A 20-year-old male patient presents with scrotal pain. A suspected diagnosis that requires immediate referral is A.testicular torsion. B.hydrocele. C.epididymitis. D.inguinal hernia.

A. Testicular torsion. Rationale: Testicular torsion requires immediate surgical intervention to prevent strangulation of the testicle.

The nurse assesses for geriatric syndromes, which are A.the interaction of multiple diagnoses that contribute to problems in the older adult. B.the exacerbation of chronic conditions, such as congestive heart failure or chronic obstructive pulmonary disease. C.conditions in which older adults may not mount an immune response. D.decreases in growth hormones and steroids that reduce functional status.

A. The interaction of multiple diagnoses that contribute to problems in the older adult. Rationale: Although no agreement exists on which clusters of symptoms are geriatric syndromes, agreement exists that they are syndromes that involve multiple systems and diagnoses.

Which of the following symptoms is NOT an indicator of preeclampsia? A.Uncontrolled vomiting B.Headache C.Epigastric pain D.Hyperreflexia

A. Uncontrolled vomiting. Rationale: Headache, epigastric pain, and hyperreflexia are typical symptoms of preeclampsia. Uncontrolled vomiting is the defining characteristic of hyperemesis gravidarum.

Which of the following interventions is a priority for patient safety during care? A.Use two patient identifiers such as name and date of birth. B.Provide documentation, medical terminology, and SBAR for verbal communication. C.Use alarms safely, especially to prevent harm to patients at risk for falls. D.Proceed with surgeries immediately with no time-out.

A. Use two patient identifiers such as name and date of birth. B. Provide documentation, medical terminology, and SBAR for verbal communication. C. Use alarms safely, especially to prevent harm to patients at risk for falls. Rationale: All surgeries must have a "time-out" period to avoid wrong site surgeries and other complications.

A normal fetal heart rate as auscultated with a Doppler sonometer is A.90 beats/min. B.120 beats/min. C.100 beats/min. D.180 beats/min.

B. 120 beats/min. Rationale: Normal fetal heart rate is 110 to 160 beats/min, using any method (Doppler, electronic fetal monitor, or fetoscope).

You evaluate all the following children one morning in the clinic. Which should you refer for further assessment? A.A 6-week-old boy whose parents recently immigrated from Thailand; his head lags when pulled up by his arms; he has several dark spots that look like bruises on his lower back and buttocks. B.A 4-week-old African American girl whose liver margins are barely palpable along the right costal margin; her kidneys are easily palpable: her ears look "funny." C.A 4-month-old Caucasian boy with loud breath sounds throughout the lung fields; auscultation of the heart reveals a split S2. D.A 9-month-old Latina who is fussy; her tympanic membrane is pearly gray and moves during pneumatic otoscopy.

B. A 4-week-old African American girl whose liver margins are barely palpable along the right costal margin; her kidneys are easily palpable: her ears look "funny." Rationale: Palpable kidneys mean they are enlarged. In addition, "funny-looking" ears could be another sign of kidney problems.

You are triaging infants who have presented to the emergency department on a Friday night. Which infant should you take in for treatment first? A.A 2-week-old infant whose mother reports, "She just won't stop crying. I'm so worried." The cry is medium pitch; temperature 37°C (99°F), HR 160 beats/min, RR 50 breaths/min; abdomen moves with each breath. B.A 6-week-old infant whose father reports, "He's vomited several times and he won't take his bottle." Temperature 36°C (96.8°F), HR 70 beats/min, RR 20 breaths/min. His lips are white. He is limp. C.A 5-month-old infant with a stuffy nose who has been unusually fussy and has had three loose stools in the past 8 hours. Temperature 37.6°C (99.8°F), HR 140 beats/min, RR 45 breaths/min while crying. D.An 8-month-old infant whose parents report he choked on a bean at dinner. The bean came out after five back pats. He turns blue around his mouth when he cries. Temperature 37°C (98.6°F), HR 130 beats/min, RR 30 breaths/min.

B. A 6-week-old infant whose father reports, "He's vomited several times and he won't take his bottle." Temperature 36°C (96.8°F), HR 70 beats/min, RR 20 breaths/min. His lips are white. He is limp. Rationale: This infant's vital signs are low; he is pale and limp. All these signs are very worrisome. Typically, heart and respiratory rates increase when an infant is stressed. By the time they start to fall, the infant is decompensating. Because he is pale (white lips), it is difficult to tell if he is cyanotic. The nurse needs to check his oxygen saturation.

The nurse practitioner is assessing a patient with frequent candidiasis. The test that the nurse will order for this patient is A.cultures for chlamydia. B.a blood test for glucose. C.a blood test for syphilis. D.a vaginal ultrasound.

B. A blood test for glucose. Rationale: Frequent vaginal candidiasis can be a symptom of abnormal blood glucose levels.

Which of the following patients is at highest risk for osteoporosis? A.A young man, weight-lifter, who drinks beer three times a week, with a stable job B.A middle-age woman of lower socioeconomic status who is a heavy smoker and drinks alcohol six times a week C.A woman who works as a vice-president, takes a shot of vodka six times a week, and exercises regularly D.A retired man, non-smoker, who drinks alcohol socially

B. A middle-age woman of lower socioeconomic status who is a heavy smoker and drinks alcohol six times a week. Rationale: Women of lower socioeconomic status are more likely to report limitations in activity and arthritis, obesity, and osteoporosis. Also, smoking increases the risk of developing fractures for both men and women. Alcohol use is associated with increased risk of osteoporosis because it raises parathyroid hormone levels, which causes calcium loss from bones.

Of the following changes, which is the earliest sign of progressing brain herniation that originates in the cerebral hemispheres? A.An enlarging pupil that is sluggishly reactive to light B.Altered mentation C.Widening pulse pressure with bradycardia D.Reflex posturing of extremities

B. Altered mentation. Rationale: Mental status changes are the earliest (often initially subtle) indications of generalized hemispheric dysfunction and occur prior to the cranial nerve or brainstem compression required to produce the other listed signs.

A 47-year-old woman states she is having vertigo and some difficulty with balance. The nurse should assess: A.accommodation B.the whisper test C.shoulder strength D.soft touch

B. Balance and equilibrium are associated with cranial nerve VIII. Performing a whisper test will evaluate hearing, also associated with CN VIII. Testing for accommodation evaluates CN III. Shoulder shrug assesses CN XI and soft touch assesses CN V.

While the nurse performs formal patient assessment, assistive personnel often observe changes when obtaining vital signs or assisting patients with ADLs. When discussing care for a patient with back pain, the nurse should particularly alert the assistant to watch for: A.dizziness B.bowel/bladder incontinence C.difficulty swallowing D.arm weakness

B. Bowel/bladder incontinence. Rationale: Dizziness and difficulty swallowing are potential signs of cerebral rather than spinal cord lesions. Arm weakness from spine problems would indicate cervical injury (with associated neck rather than back pain). Bowel and bladder incontinence can occur with spinal cord injury at any level.

All the following may be symptoms of a child experiencing lead poisoning except A.irritability. B.cardiomegaly. C.headaches. D.abdominal pain.

B. Cardiomegaly. Rationale: Lead poisoning may be associated with all the symptoms except cardiomegaly. Lead is a heavy metal, a neurotoxin, and is not cardiotoxic.

Auscultation is one of the most important components of which body systems? A.Reproductive, neurological, integumentary B.Cardiovascular, pulmonary, gastrointestinal C.Pulmonary, gastrointestinal, neurological D.Gastrointestinal, neurological, reproductive

B. Cardiovascular, pulmonary, gastrointestinal. Rationale: Auscultation plays a minimal role in the reproductive, neurological, and integumentary systems. Auscultation of the heart provides information on rate, rhythm, extra sounds, and murmurs. Auscultation of the lungs provides information on the underlying sound and adventitious sounds, which relate to pathology in the alveoli and airways. Gastrointestinal sounds may be absent, hypoactive, or hyperactive.

Which of the following organisms is associated with salpingitis? A.Trichinella spiralis B.Chlamydia trachomatis C.Candida albicans D.Condyloma acuminatum

B. Chlamydia trachomatis. Rationale: The most common organisms that cause salpingitis are Chlamydia trachomatis and Neisseria gonorrhoeae.

Mr. Brown was playing soccer and hurt his right knee. It appears swollen. What is the first assessment you should make? A.Palpate for crepitus in the knee. B.Compare the swollen knee with the other knee. C.Assess active ROM in the knee. D.Feel the knee for warmth.

B. Compare the swollen knee with the other knee. Rationale: The first step is inspection. The first thing to do is to compare one knee with the other for symmetry. All the other answers are procedures for assessing joints, which may be indicated but do not represent the first step that the nurse should take.

The nurse is taking a menstrual history. What would be an appropriate question to ask? A.Do you have any history of cancer in your family? B.Do you ever skip periods? C.Do you use condoms during intercourse? D.How many sexual partners have you had?

B. Do you ever skip periods? Rationale: In a menstrual history, the nurse asks information related only to menstrual function. History of cancer in relatives is part of family history. Questions related to sex or sexually transmitted infections (STIs) are asked later in the history, after the nurse has established a trusting relationship.

Which factor places an infant at greater risk than an adult for developing otitis media? A.Introduction of solid foods B.Eustachian tubes that are more horizontal (flat) than vertical and wide C.Immature cardiac sphincter D.Feeding in a semi-Fowler position

B. Eustachian tubes that are more horizontal (flat) than vertical and wide. Rationale: Infants have horizontal (flat) and wide Eustachian tubes, which make them more prone to otitis media. Feeding in a semi-Fowler position helps decrease the risk of otitis media because the infant is not flat. Introduction of solids does not influence the incidence of otitis media. An immature cardiac sphincter causes vomiting, not otitis media.

As soon as the child can stand, begin to measure the height in the upright position. A.True. Using the scale as soon as the child can stand next to it is fine. B.False. Measure the child standing starting between ages 2 and 3 years. C.It depends on when the child can stand independently. D.False. A child should always be measured in the recumbent position.

B. False. Measure the child standing starting between ages 2 and 3 years. Rationale: The child should stand for height measurements between ages 2 to 3 years. Growth charts for children aged 2 to 20 years represent standing heights. Growth charts for children aged 0 to 3 years are recumbent heights.

The nurse performs BP screening at the local community center. As part of the health promotion intervention, the nurse also discusses the following risk factors for stroke: A.Low BP, lack of exercise, and diet high in fat B.High BP, diet high in fat, and smoking C.Diet high in fat, smoking, and walking five times weekly D.Obesity, swimming five times weekly, high BP

B. High BP, diet high in fat, and smoking. Rationale: A health history of diabetes mellitus, carotid artery disease, atrial fibrillation, and sickle cell disease places a person at risk for neurovascular disease. Additionally, the lifestyle choices of smoking, high-fat diet, obesity, and physical inactivity increase the person's risk for stroke.

Nutritional screening is an assessment of risk factors that A.indicate that the patient is at high nutritional risk. B.identify older adults who may require a more comprehensive assessment. C.calculate BMI and classify patients as obese versus malnourished. D.describe food frequency and microelements that may be lacking in the diet.

B. Identify older adults who may require a more comprehensive assessment. Rationale: Although the DETERMINE is a screening tool, it is less reliable than other methods. Thus, more comprehensive assessment should be performed, which includes a calorie count, food diary, or food frequency questionnaire.

The nurse participates in bedside handoff reports, practices hourly rounding, introduces himself or herself, addresses the patient using the name he or she prefers, and paraphrases patient responses to verify understanding. These are interventions designed to A.improve patient safety. B.increase patient satisfaction. C.improve infection rates. D.increase efficient assessments.

B. Increase patient satisfaction. Rationale: Patient satisfaction has been linked to improved outcomes, and nurses are routinely involved in assessing this.

To correctly document that ROM in the fingers is full and active, you would write that the patient can A.perform rotation, lateral flexion, and hyperextension. B.make a fist, spread and close fingers, and do finger-thumb opposition. C.touch finger to own nose and to examiner's finger back and forth. D.perform supination, pronation, and lateral deviation.

B. Make a fist, spread and close fingers, and do finger-thumb opposition. Rationale: Finger movements are flexion, extension, abduction, and adduction. The fingers do not perform rotation or lateral flexion. Touching the finger to the nose is part of neurological assessment, not range-of-motion (ROM) testing. The wrist performs supination, pronation, and lateral deviation.

A mother brings her 6-month-old infant to the clinic for a routine evaluation. At birth, the term infant weighed 3.5 kg (7 lb 12 oz) and was 51 cm (20 in.) long. He now weighs 4.6 kg (10 lb 2 oz). Which assessments are most important for you to do next? A.Obtain a thorough obstetrical and neonatal history and say, "I'm very worried that the baby hasn't gained more weight. What are you feeding him?" B.Measure head and chest circumference and length, then plot current weight, length, and head and chest circumferences on standardized growth charts. C.Review the immunization history, administer the Denver II assessment, and ask the mother if she has noticed any unusual patterns or behaviors. D.Screen for domestic violence and focus on the neurological, cardiac, and abdominal portions of the physical examination.

B. Measure head and chest circumference and length, then plot current weight, length, and head and chest circumferences on standardized growth charts. Rationale: First, the nurse needs to determine in what percentile the anthropometric measurements fall to compare findings with measurements from previous visits. It is important to establish the trend in the infant's physical growth pattern.

A patient with a history of cirrhosis tells the nurse that his abdomen seems to be getting larger and that he has gained 9.7 kg (20 lb) in the past 6 months. How will the nurse determine whether the abdominal enlargement is from accumulation of fluid or fat from the weight gain? A.Listen for a fluid wave B.Percuss the abdomen for shifting dullness C.Auscultate for lymph nodes D.Stroke the abdomen to elicit the abdominal reflex

B. Percuss the abdomen for shifting dullness. Rationale: Percussing elicits a change from tympany to dullness when the abdomen is in its most dependent position. Fat remains static.

A 20-year-old Caucasian man complains of a mass in his left testicle. In addition to his age and race, what else is a risk factor for testicular cancer? A.Colon cancer in his mother B.Personal history of cryptorchidism C.UTI in the previous month D.Congenital hydrocele

B. Personal history of cryptorchidism. Rationale: Cryptorchidism (undescended testicle at birth) is a risk factor for testicular cancer.

Which of the following assessments is considered a basic care activity for the NCLEX licensing examination? A.Venous access devices, IV lines, invasive monitoring B.Personal hygiene habits, mobility routines C.Responses to procedures and treatments D.Vascular perfusion, hypotension, peripheral pulses

B. Personal hygiene habits, mobility routines. Rationale: The other items are considered physiological dimensions and assessments will be included in foundations and medical surgical courses.

As part of the MMSE, you ask the patient to immediately state three words. This is a measure of which of the following? A.Orientation B.Registration C.Recall D.Attention

B. Registration. Rationale: Registration indicates that the brain has processed the information and that the patient has heard the information correctly. Recall is the ability to remember it at a later time.

A patient in a nursing home was admitted with a diagnosis of dementia. He started a fire because he was cooking at home and forgot that he left a pan on the stove. The nursing diagnosis that is highest priority is: A.ineffective brain tissue perfusion B.risk for injury C.acute confusion D.impaired memory

B. Risk for injury. Rationale: Safety assumes priority because of the risk for injury. Impaired memory is also a likely diagnosis because of his forgetfulness. No data exist about confusion, so that is an area that needs further assessment. Ineffective brain perfusion is associated more with a stroke.

The nurse enters the patient's room for the first time during the shift and directly observes the patient for breathing, airway, skin color, dyspnea, and airway secretions. This assessment is performed as part of a/an A.acute assessment. B.safety assessment. C.continuing assessment. D.comprehensive assessment.

B. Safety assessment. Rationale: Safety inspections are routinely performed when initially coming on to shift to make sure that the patient is not in acute distress and is in no immediate danger of falling or injuring himself or herself.

A patient complains of a soft, irregular mass on the left side of the scrotum he noticed while walking. The nurse palpates a mass that feels like "a bag of worms." These findings are consistent with which condition? A.Hydrocele B.Varicocele C.Spermatocele D.Epididymitis

B. Varicocele. Rationale: Varicocele is a condition caused by abnormal dilation and tortuosity of the veins along the spermatic cord, often on the left side. Upon palpation, the varicocele feels like a bag of worms.

Use of the GCS provides relatively objective assessment of LOC. The three functions assessed are: A.pupil reaction, orientation, and sensation B.verbal response, eye opening, and motor response C.eye opening, motor response, and sensation D.verbal response, pupil reaction, and motor response

B. Verbal response, eye opening, and motor response. Rationale: The Glasgow Coma Scale (GCS) does not include pupillary response and sensation. Abnormalities of pupil reaction are associated with altered consciousness but may also result from peripheral nerve injury. Sensation cannot be assessed accurately if the patient has any difficulty with communication.

The nurse is performing patient teaching about normal changes during late pregnancy. These include which of the following? A.Dark cloudy urine B.Waddling gait C.Vaginal bleeding D.Sudden edema

B. Waddling gait. Rationale: Increased levels of relaxin loosen the cartilage between the pelvic bones, resulting in the characteristic "waddling" walk of the third trimester. This is a normal change during pregnancy. Dark cloudy urine is not normal and suggests infection or renal impairment. Significant vaginal bleeding (more than scant spotting) is never normal in pregnancy before the start of labor. Sudden edema is abnormal and may indicate preeclampsia

A patient reports changes in bowel pattern. Which is the best question to determine normal bowel habits? A.How often do you have a bowel movement? B.What was your bowel pattern before you noticed the change? C.Is there a family history of irritable bowel syndrome? D.Have any of your parents or siblings had cancer of the colon?

B. What was your bowel pattern before you noticed the change? Rationale: Determining the patient's bowel pattern before symptoms began is most valid in establishing the normal pattern.

An infant has a new onset of rash but otherwise seems well. Which interview question is best when trying to pinpoint a possible cause? A."Was there a prolonged NICU stay?" B."What treatments have you given her for the rash?" C."Has anything changed lately, such as shampoos, soaps, or laundry detergent?" D."How many diapers is she wetting per day, and what is the stool pattern?"

C. "Has anything changed lately, such as shampoos, soaps, or laundry detergent?" Rationale: Because the baby is otherwise well, the condition may be allergic or irritant dermatitis. Asking about a change in shampoo, soap, or laundry detergent will focus the line of questioning toward trying to pinpoint any allergen or irritant. Although it is important to ask about treatments that have been given, this question is less likely to elicit information that will help determine the cause.

Michelle's fundal height measures 28 cm (11 in.). You expect the gestational age to be A.20 weeks. B.14 weeks. C.28 weeks. D.30 weeks.

C. 28 weeks. Rationale: From 20 weeks' gestation on, the fundal height should equal the gestational age in weeks.

After receiving patient information from the previous shift nurse and gathering data from the chart, the nurse will assess a group of four patients. Which one will the nurse assess first? A.A 32-year-old man with an open wound who is receiving antibiotics B.A 66-year-old woman 2 days postoperatively following ankle surgery C.A 45-year-old man with HIV and Pneumocystis jiroveci pneumonia with dyspnea D.An 88-year-old woman with confusion who had a stroke 4 days ago

C. A 45-year-old man with HIV and Pneumocystis jiroveci pneumonia with dyspnea. Rationale: Assessments are prioritized by airway, breathing, and circulation, so the patient with shortness of breath should be seen first. The patients receiving antibiotics and 2 days postoperative are stable. The elderly female with confusion would most likely be seen second because she may be at risk for injury or falls.

Which of the following interventions are common in the hospitalized patient? Select all that apply. A.Assess pain every 8 hours and reassess 2 hours after interventions. B.Assess oxygen and vital signs every day. C.Assess Braden Scale and provide skin hygiene as needed every 8 hours. D.Perform focused assessments every shift and as needed. E.Perform safety assessments every day.

C. Assess Braden scale and provide skin hygiene as needed ever 8 hours; D. Perform focused assessments every shift and as needed. Rationale: Pain is reassessed 30 minutes after an intervention; vital signs are assessed every 4 to 8 hours routinely, and safety inspections are performed at the beginning of the shift and whenever needed.

When examining the scrotum of an adult Hispanic male, a normal finding is A.symmetrical scrotal sac with two movable testes. B.smooth, rubbery, saclike surface that is sensitive to gentle compression. C.asymmetrical sac with left side lower than right side. D.reddish colored skin that is darker than general body skin and has sebaceous cysts.

C. Asymmetrical sac with left side lower than right side. Rationale: Elevation of the affected testicle will usually lessen pain in epididymitis. All other choices usually present with testicular torsion.

The nurse assesses a patient presenting with nausea, vomiting, and diarrhea. In performing the focused assessment, the nurse uses the following techniques: A.Auscultate lungs, auscultate heart, auscultate abdomen. B.Evaluate for dehydration, assess skin turgor, auscultate lungs. C.Auscultate abdomen, palpate abdomen, evaluate for dehydration. D.Palpate abdomen, percuss abdomen, auscultate heart.

C. Auscultate abdomen, palpate abdomen, evaluate for dehydration. Rationale: With nausea, vomiting, and diarrhea, concern arises about fluid volume deficit and the potential for dehydration, which would be noted with poor skin turgor. The lungs are not grouped with the symptoms. Auscultating the heart is an option to determine heart rate, but increases in heart rate can be evaluated when vital signs are collected. The abdomen needs to be auscultated to evaluate for suspected hyperactive sounds from the increased peristalsis.

A patient comes into the clinic for a scheduled NST when the nurse notes that the FHR tracing is nonreactive. Which of the following actions would be appropriate for the nurse to do first? A.Document the findings. B.Notify the provider. C.Change the mother's position. D.Instruct the patient to return to the clinic in 1 week for reevaluation of the fetal heart rate.

C. Change the mother's position. Rationale: A reactive nonstress test is indicative of a healthy fetus. If the monitoring strip is nonreactive, the nurse may offer the mother a position change or a drink of cold water or juice to stimulate the fetus. The fetal response helps to distinguish a true nonreactive test from a normal fetal sleep cycle. If the position change is not effective, this is an indicator of fetal distress and should be reported to the provider immediately. Genuine fetal distress may indicate urgent delivery of the baby to prevent a poor outcome. Findings should be documented after the intervention is complete. It would be inappropriate to wait for 1 week to intervene or reevaluate the fetal heart rate, as there is the possibility of fetal distress.

Which of the following statements is true concerning changes in the older adult? A.The lens becomes smaller and less dense. B.The tympanic membrane becomes more flexible and retracted. C.Changes in the inner ear can interfere with sound discrimination. D.Increased pupillary responses lead to difficulty in light accommodation.

C. Changes in the inner ear can interfere with sound discrimination. Rationale: As the older adult ages, sound discrimination is altered, making it difficult to hear voices when around a lot of background noise, such as a television.

Which of the following conditions would be the highest priority to contact the health care provider about? A.Striae gravidarum B.Varicosities of the labia C.Contractions before 37 weeks D.Prominent Montgomery glands

C. Contractions before 37 weeks. Rationale: Contractions prior to 37 weeks are symptomatic of preterm labor and may lead to preterm birth and poor outcomes for the baby. Striae gravidarum, labial varicosities, and prominent Montgomery glands are all normal findings in pregnancy.

You auscultate a loud murmur in an older adult patient. You should also assess for which of the following? A.Coarse rhonchi and purulent sputum B.Irregular heartbeat and pulse deficit C.Crackles in the lungs and leg edema D.Abdominal distention and liver tenderness

C. Crackles in the lungs and leg edema. Rationale: A loud murmur indicates that there may be backflow of blood through the valve (regurgitation) or difficulty with the blood moving forward over the valve (stenosis). Either of these conditions may result in symptoms of heart failure. Right heart failure causes leg edema; left heart failure causes pulmonary congestion.

You obtain a blood pressure reading of 110/70 mm Hg (left arm) in a 5-year-old boy. What would you do about this blood pressure? A.Call the physician immediately. B.Bring the child back to the clinic two more times to ensure accuracy of the assessment. C.Determine the blood pressure percentile based on age, sex, and height percentiles. D.It is normal; nothing needs to be done.

C. Determine the blood pressure percentile based on age, sex, and height percentiles. Rationale: This blood pressure may be normal, but the nurse cannot tell until it is evaluated against the blood pressure norms for children in the same age range.

The nurse usually performs a complete physical examination with elements in the following order: A.Face, heart, legs, arms B.Head, abdomen, lungs, legs C.Eyes, heart, abdomen, legs D.Ears, back, lungs, arms

C. Eyes, heart, abdomen, legs. Rationale: Moving from head to toe is most efficient for the nurse and conserves energy for the patient. Subjective data are usually collected first. The most sensitive areas (e.g., genitals) may be deferred until last.

The nurse assesses for possible complications of pregnancy. Which of these prompts referral to a perinatal specialist? A.Gastric reflux B.Previous cesarean procedure C.Oligohydramnios D.Anemia

C. Oligohydramnios. Rationale: Oligohydramnios is an insufficient level of amniotic fluid, which can result in poor fetal prognosis and perinatal complications. Gastric reflux and anemia are common features of pregnancy, which can be managed by a nurse practitioner (NP), certified nurse midwife, or physician. A previous cesarean procedure does not increase risk significantly enough to demand the care of a specialist and can also be managed by an NP, certified nurse midwife (CNM), or MD.

Which of the following 6-month-old infants has the most markers for a possible genetic disorder? A.Has large ears, is in the 95th percentile for weight and height, babbles B.Has large scaly plaques on face and torso, red reflex is absent in one eye, posterior fontanelle has closed C.Has significant head lag, one ear is small and malformed, nipples are unusually close together D.Sits up alone, cranial sutures are palpable, back of the head is flat

C. Has significant head lag, one ear is small and malformed, nipples are unusually close together. Rationale: This is the only answer choice with three markers that point to a possible genetic disorder. Large ears on a baby whose growth is in the 95th percentile on the growth chart is not a strong sign. Large scaly plaques are associated with psoriasis. An absent red reflex in one eye is abnormal but not a strong marker of a genetic disorder. Cranial sutures should be palpable; a head that is flat in the back is most likely from positional plagiocephaly related to sleeping on the back.

A clinical nurse is assessing a patient's knowledge and understanding of bone health and maintenance. Which of the following responses of the patient indicates adequate understanding to maintain musculoskeletal health? A.I will take calcium supplementation as prescribed and eat plenty of citrus fruits. B.I will expose myself to sunlight at least 1 hour daily and eat plenty of green, leafy vegetables. C.I will take calcium supplementation and vitamin D as prescribed. D.I will exercise daily and take vitamin E as prescribed.

C. I will take calcium supplementation and vitamin D as prescribed. Rationale: Calcium is essential for bone growth and remodeling. Vitamin D is essential for calcium absorption. Eating plenty of citrus fruits or increasing vitamin C intake will not assist in calcium absorption. Exposing to sunlight for at least an hour daily is not needed and is impractical. Weight-bearing exercises help build stronger bones, but vitamin E will not assist in calcium absorption.

A patient with a history of kidney stones presents with complaints of pain, hematuria, and nausea with vomiting. What assessment technique will elicit kidney pain? A.Inspection with indirect lighting B.Iliopsoas muscle sign C.Indirect percussion for CVA tenderness D.Blumberg sign

C. Indirect percussion for CVA tenderness. Rationale: Fist percussion over the costovertebral angle (CVA) is the only technique listed that reflects a technique for assessing the kidney. The two specialty techniques are used to assess peritoneal inflammation.

When performing an abdominal assessment, what is the correct sequence? A.Inspection, palpation, percussion, auscultation B.Palpation, percussion, inspection, auscultation C.Inspection, auscultation, percussion, palpation D.Auscultation, inspection, palpation, percussion

C. Inspection, auscultation, percussion, palpation. Rationale: For the abdomen, auscultation must be performed before percussion and palpation to prevent minimizing bowel sounds.

When doing an assessment of the spine of an older adult, you can expect to see which variation? A.Lordosis B.Torticollis C.Kyphosis D.Scoliosis

C. Kyphosis. Rationale: Many older adults normally have an exaggerated forward curve of the thoracic spine, which may appear even more curved because of fat pad deposits.

Which of the following findings are considered an expected change in the skin in older adults? A.Solar lentigines (liver spots) B.Actinic keratoses C.Loss of subcutaneous fat D.Photoaging

C. Loss of subcutaneous fat. Rationale: The skin normally thins and loses subcutaneous fat with aging, making it more susceptible to tears and breakdown.

A young adult marathoner reports of right foot third metatarsal pain (6/10) and swelling for more than 4 weeks. An x-ray was ordered, and it did not show abnormal findings. Which of the following imaging might the nurse expect the physician to order? A.Repeat x-ray B.CT scan C.MRI D.Nuclear scintigraphy

C. MRI. Rationale: Systematic reviews demonstrated that MRI has the highest specificity for diagnosing stress fractures and is followed by nuclear scintigraphy. Repeat x-ray imaging is not indicated and has the lowest specificity for detecting stress fractures. A CT scan is not the most appropriate imaging for stress fractures.

Michelle says that her last normal menstrual period was June 15. Using the Nägele rule, her EDD is A.September 8. B.March 8. C.March 22. D.January 22.

C. March 22. Rationale: The Nägele rule states that to determine estimated date of delivery, subtract 3 months from the first day of the last menstrual period and add 7 days to the result.

You are evaluating the growth pattern of a 5-month-old infant born at 27 weeks' gestation. Which of the following actions will yield the most accurate assessment of growth for this infant? A.Calculate how many kilocalories per day the infant is consuming, evaluate his bowel movement pattern, plot his measurements, and compare with the last two visits. B.Determine whether he has gained at least 2.2 kg (5 lb) since birth, because infants should gain 500 g to 1 kg (1 to 2 lb) per month in the first 6 months. C.Plot the weight and length on a standardized growth chart for a 7-week-old infant and compare with birth measurements and measurements on previous visits. D.Plot the weight and length on a standardized growth chart for a 12-week-old infant and compare with birth measurements and measurements on previous visits.

C. Plot the weight and length on a standardized growth chart for a 7-week-old infant and compare with birth measurements and measurements on previous visits. Rationale: This baby was born 13 weeks prematurely. At 5 months, he is now 20 weeks old. Subtract 13 from 20 to get 7 weeks, which is his corrected age.

When auscultating the abdomen, the nurse hears a bruit to the right of the midline slightly below the umbilicus. The nurse documents this finding as a bruit of which of the following? A.Right renal artery B.Right femoral artery C.Right iliac artery D.Abdominal aorta

C. Right iliac artery. Rationale: The iliac arteries are located to the left and right of the midline of the abdomen, below the umbilicus. The aorta is midline, the renal artery is above the umbilicus, and the femoral artery is located in the groin.

The practitioner has decided to place a patient on isotretinoin for her acne problems. The nurse is preparing to counsel the patient. What is the most important information she needs to tell the patient? A.She needs to take the medication daily and avoid missing a dose. B.She should not take this medication with antibiotics. C.She needs to use two forms of birth control or abstain from sex 1 month before, during, and 1 month after taking this medication. D.She needs to take a weekly pregnancy test to make sure she has not gotten pregnant while on this medication.

C. She needs to use two forms of birth control or abstain from sex 1 month before, during, and 1 month after taking this medication. Rationale: Because of the severe teratogenic effects of this medication, anyone of childbearing age must either abstain from sex or use at least two forms of birth control during treatment and for 1 month before and 1 month after treatment.

The patient's muscle tone is hypertonic so the muscles are stiff and the movements are awkward. The nurse documents these findings as A.atony. B.tremors. C.spasticity. D.fasciculation.

C. Spasticity. Rationale: Atony is the lack of tone or strength, tremors are involuntary contractions of muscles, and fasciculation is involuntary twitching.

Which of the following would you recognize as an unexpected finding while examining the male genitalia? A.Smegma is present on the uncircumcised patient. B.Testes are palpable and firm within the scrotal sac. C.You note an impulse at the tip of your finger during hernia examination. D.The urethral meatus has a slitlike opening central to the distal tip of the glans.

C. You note an impulse at the tip of your finger during hernia examination. Rationale: Indirect inguinal hernia presents with an impulse at the tip of the nurse's finger during hernia examination. All other answers represent normal findings.

A patient calls the provider's office to schedule an appointment because a home pregnancy test was positive. The nurse knows that the test identified the presence of which of the following in the urine? A.Estrogen B.Progesterone C.hCG D.Follicle-stimulating hormone

C. hCG. Rationale: After implantation, the outer layer of the developing embryo (trophoblast) produces human chorionic gonadotropin (hCG). Pregnancy tests (both urine and blood) measure levels of this hormone, whose presence validates the existence of a pregnancy and initiates a feedback loop that preserves the corpus luteum.

The patient has findings of cognitive decline, minimal to no intake of nutrition, and neglect of the home environment and finances. Which of the following is the appropriate nursing diagnosis? A.Disturbed sensory perception B.Impaired individual coping C.Imbalanced nutrition, less than body requirements D.Adult failure to thrive

D. Adult failure to thrive. Rationale: These findings are some defining characteristics of adult failure to thrive. Although some data may support the other diagnoses, this is the best diagnosis based on the symptoms.

Health promotion for children should incorporate teaching about lifelong cardiovascular health, including which of the following? A.Information on good nutrition B.Information on the prevention of illnesses C.Information on exercise D.All of the above

D. All of the above. Rationale: Exercise and good nutrition with maintenance of an appropriate weight are important for cardiovascular health. By preventing illnesses with immunizations, pregnant women are not exposed to viral illnesses (e.g., rubella and rubeola) that may injure the developing fetal heart. Hand hygiene and avoidance of sick people may help decrease the spread of bacteria that could potentially injure the heart valves.

When speaking with a frail older adult, it is best to A.fill in silences to avoid discomfort. B.address all questions to the patient's family. C.rely on the patient's memory when gathering all information. D.ask questions using lay terms rather than medical terms.

D. Ask questions using lay terms rather than medical terms. Rationale: The older adult needs more time to answer questions. It is best to talk directly with the patient and use the family as a resource as needed. Information from the chart can be validated with the patient, but it is best to gather information ahead of time to avoid asking unnecessary questions and fatiguing the patient.

Which of the following are interventions the nurse makes to prevent infections? Select all that apply. A.Immediately discontinue use of medication if an adverse drug reaction is suspected. B.Prevent infection of the blood from corrupted central lines by changing daily. C.Contact provider for sepsis treatment with positive urine dipstick for leukocyte esterase and/or nitrite. D.Assess for surgical site infections for 30-90 days after an operative procedure E.Screen patients for sepsis using evidence-based care and report all patients with sepsis.

D. Assess for surgical site infections for 30-90 days after an operative procedure. Rationale: A. The provider and the pharmacist will consult on the seriousness of the reaction, whether to stop the medication and whether to add the medication to the patient's allergy list. B. Determine how long the patient has had the central line and whether its use is warranted. C. Signs and symptoms of urinary tract infection include fever (>38°C [104.8°F]), dysuria, urgency, suprapubic tenderness, frequency, costovertebral angle pain or tenderness, positive dipstick for leukocyte esterase and/or nitrite, pyuria, (urine specimen with white blood cell [WBC] count≥10/mm3), microorganisms seen on Gram stain, and positive urine culture of microorganisms (Centers for Disease Control and Prevention [CDC], 2017). Determine how long the patient has had the urinary catheter and whether there is still a need for its use.

If the great toe extends upward and the other toes fan out in response to stroking the lateral aspect of the sole of the foot, this is documented as which of the following? A.Hyporeflexia B.Normal plantar reflex C.Cushing response D.Babinski sign

D. Babinski sign. Rationale: The Babinski sign indicates pathological hyperreflexia. A normal plantar reflex would result in toes curling downward to the same stimulus. The Cushing response refers to a pattern of changes in vital signs, not reflexes.

You are teaching a parenting class, and the parents are sharing baby pictures. Which picture indicates that the parent may need additional education? A.Baby is playing peek-a-boo in his car seat, which is installed in the middle part of the rear seat. B.Daddy is brushing his son's two front teeth while baby is splashing in the bathtub C.Baby (10 months old) is in his high chair feeding himself banana cut in small pieces. D.Baby is sleeping supine in her crib, no pillow, one blanket, bottle lying beside baby and a tiny dribble of milk at the corner of her mouth.

D. Baby is sleeping supine in her crib, no pillow, one blanket, bottle lying beside baby, and a tiny dribble of milk at the corner of her mouth. Rationale: Although it is good that the baby is on her back to sleep and doesn't have excess toys and things in her crib, the bottle in the crib and little dribble of milk indicate that the baby fell asleep while drinking formula. This practice can lead to baby bottle tooth decay.

You note that an adolescent has uneven shoulder height. To differentiate functional from structural scoliosis, you ask the patient to A.stand up straight while you check the height of the iliac crest. B.flex the elbow and pull against your resistance. C.shrug both shoulders while you provide resistance. D.bend forward at the waist while you palpate the spine.

D. Bend forward at the waist while you palpate the spine. Rationale: Checking the height of the iliac crest will provide information about scoliosis but will not differentiate functional from structural. With functional scoliosis, the spine straightens with bending. This problem usually is associated with uneven leg length.

A man had a motor vehicular accident and fractured his right ankle. He was transferred from the emergency department to the orthopedic nursing unit for further observation and possible surgery in the next 12 hours. What is the priority nursing assessment of the admitting orthopedic nurse? A.Temperature B.Capillary refill proximal to the injury of the right ankle C.Capillary refill distal to the injury of the left ankle D.Capillary refill distal to the injury of the right ankle

D. Capillary refill distal to the injury of the right ankle. Rationale: Capillary refill is the priority nursing assessment to evaluate tissue perfusion for orthopedic trauma patients. Temperature is not a priority nursing assessment. Assessment of capillary refill should be distal to the injury and not proximal. The patient fractured his right ankle, and assessment of the left ankle is not the priority.

The nurse performs the first assessment on the hospitalized patient and documents it in the chart as the A.sporadic assessment. B.functional assessment. C.focused assessment. D.comprehensive assessment.

D. Comprehensive assessment. Rationale: when the patient is admitted to the hospital, a more comprehensive assessment gathers the patient history, subjective data, and objective data. Assessments follow that focus on the problems identified.

Upon inspection, the nurse sees flesh-colored lesions surrounding the anal area. These lesions most likely indicate A.hemorrhoids. B.herpes simplex virus 2. C.AIDS. D.condyloma acuminatum infection.

D. Condyloma acuminatum infection. Rationale: Condyloma present as fleshy white to gray-appearing lesions. These lesions can be individual or may cluster in groups.

During a physical assessment, using the handle of the reflex hammer, you gently stroke the inner left thigh of the patient, which causes the ipsilateral testicle to rise. What superficial reflex is demonstrated? A.Abdominal reflex B.Babinski reflex C.Brachioradialis reflex D.Cremasteric reflex

D. Cremasteric reflex. Rationale: The superficial cremasteric reflex is created by stroking the upper thigh, which causes the ipsilateral testicle to rise. Absence of this reflex is seen in association with disorders of the pyramidal tract above the level of the first vertebra.

Which of the following activities best facilitates anticipatory guidance? A.Becoming very proficient in interviewing and performing the physical examination B.Doing as much of the examination as possible with the infant in the parents' lap C.Recognizing and reporting signs of physical abuse and neglect D.Encouraging parents to make an appointment with the pediatrician before the baby is born

D. Encouraging parents to make an appointment with the pediatrician before the baby is born. Rationale: All the actions mentioned are good things to do; however, encouraging a prenatal visit to the pediatrician sets up the opportunity for parents to ask questions and for the pediatrician to help prepare the parents (anticipatory guidance) for the new baby.

The nurse assesses whether the patient outcome "Patient drinks 1 liters every shift" has been met. This is called A.assessment. B.planning. C.implementation. D.evaluation.

D. Evaluation. Rationale: Assessment occurs throughout different parts of the nursing process. When the intent of the assessment is to determine whether outcomes are met, this is referred to as evaluation.

A child's head circumference is a measurement that should be obtained at every well-child visit until the child is 5 years old. A.True. This measurement is indicative of brain growth. B.False. One or two measurements are the standard of care. C.True. It will provide information on the child's readiness for kindergarten. D.False. The charts for head circumference norms end at 36 months of age.

D. False. The charts for head circumference norms end at 36 months of age. Rationale: There are no reference points after 36 months; however, if concern is noted, continued measurements are appropriate.

The nurse evaluates circulation, movement, and sensation on the right leg of a patient who was admitted with a tibia/fibula fracture. This type of assessment is considered a A.head-to-toe assessment. B.comprehensive assessment. C.emergency assessment. D.focused assessment.

D. Focused assessment. Rationale: The assessment focuses on the patient's problem and is usually combined with a screening assessment for common hospital complications.

After completing a history on a 45-year-old patient, the nurse suspects the patient may have uterine fibroids. What information might have led her to this conclusion? A.History of STIs B.History of multiple births C.Vaginal discharge D.Heavier than usual menstrual periods

D. Heavier than usual menstrual periods. Rationale: Fibroids are suspected when a patient presents with heavy menstrual flow, irregular bleeding, pelvic pressure, or all of these symptoms.

Which sexually transmitted infection presents with painful red superficial vesicles along the penis or on the glans? A.Gonorrhea B.Chlamydia C.Syphilis D.Herpes simplex virus 2 (HSV-2)

D. Herpes simplex virus 2 (HSV-2). Rationale: Herpes presents with painful vesicles along the penis or on the glans.

The nurse is caring for a patient who is admitted to the hospital with a possible ectopic pregnancy. Which of the following nursing actions is the priority? A.Monitoring daily weight B.Assessing for edema C.Monitoring the temperature D.Monitoring the blood pressure

D. Monitoring the blood pressure. Rationale: A significant drop in blood pressure is an indicator of hemorrhage caused by a ruptured ectopic pregnancy. Temperature, edema, and weight are important, but hemorrhage is the life-threatening concern.

Which assessment technique best confirms splenic enlargement? A.Deep palpation under the left costal margin B.Fist percussion of the spleen with the patient in a sitting position C.Deep palpation over the RUQ with the patient lying on the right side D.Percussion along the left MAL spleen and gentle palpation

D. Percussion along the left MAL spleen and gentle palpation. Rationale: Percussion is the best technique to estimate the size of the spleen; gentle palpation is necessary to reduce the risk of splenic rupture.

Mrs. Johnson, a transcriptionist, reports pain and burning in her right hand. What assessment procedures should you perform next? A.Trendelenburg and drawer signs B.McMurray and Thomas tests C.Bulge test and ballottement D.Phalen and Tinel tests

D. Phalen and Tinel tests. Rationale: Both Phalen and Tinel signs are specific findings with carpal tunnel syndrome. Based on Mrs. Johnson's occupation, she is at risk for this problem. Bulge and ballottement tests look for effusion in the knee joint. The McMurray test assesses for meniscus tears in the knee. The Thomas test is used to identify flexion contracture of the hip. The Drawer test is for knee injury and the Trendelenberg test is for hip disease.

The nurse is preparing the patient for her genital examination. What position will the nurse assist the patient into for a comfortable genital examination? A.Semi-Fowler B.Prone with her knees bent C.Supine with her knees bent D.Semi-lithotomy

D. Semi-lithotomy. Rationale: The patient is placed in the semi-lithotomy position so that she has eye contact with the health care practitioner and can see what is going on.

You are inspecting the groin of an older adult man who lives in a long-term care facility. Which of the following is an expected finding that you will document? A.Pediculosis in hair distribution B.Hypospadias on the glans C.Yellow discharge from the meatus D.Smegma under the foreskin

D. Smegma under the foreskin. Rationale: Smegma is a thin, white, cheesy substance that may normally be present under the foreskin. Pediculosis is infestation with lice. Hypospadias occurs when the urethral meatus is on the ventral side of the penis. Yellow discharge indicates an infection.

The correct position in which to place a healthy adult male client to examine the rectum and prostate is A.the left lateral Sims position with right knee flexed and left leg extended. B.the supine position with hips and legs flexed and feet positioned on the examining table. C.the modified knee-chest position with the patient prone and knees flexed under hips. D.standing and leaning over the examination table with chest and shoulders resting on the table.

D. Standing and leaning over the examination table, chest and shoulders resting on the table. Rationale: Standing is preferred because it allows for visualization of the anus and palpation of the rectum. If the patient cannot stand, the Sims position (A) is used

What percussion sound is heard over most of the abdomen? A.Resonance B.Hyperresonance C.Dullness D.Tympany

D. Tympany. Rationale: The small intestine and colon, which are hollow organs, are predominant over most of the abdominal cavity. The result is tympany as the percussion sound.

The nurse is inspecting the urethra and the Skene glands. She knows these are a part of what area? A.Mons pubis B.Vulva C.Posterior fourchette D.Vestibule

D. Vestibule. Rationale: Within the vestibule in the upper middle area lies the urethra, with bilateral paraurethral Skene glands at the 7-o'clock and 5-o'clock positions, respectively.

The chart states that a 62-year-old woman has had a stroke in the right parietal area of the brain. The nurse expects to note which of the following? A.Tremors on the left side of the face B.Tremors on the right side of the face C.Weakness in the right arm D.Weakness in the left arm

D. Weakness in the left arm. Rationale: Weakness results from loss of motor function in the motor cortex of the brain. Tremors are associated with other diseases (e.g., Parkinson disease and multiple sclerosis). The deficit is on the opposite side of the body because the motor fibers cross, causing left-sided weakness.

Which of the following infants has the most signs that point to possible abuse? A.History of a long NICU stay for extreme prematurity; does not respond to loud clapping B.Positive Ortolani and Barlow maneuver results; one leg looks shorter than the other C.Small baby with large areas of denuded skin on his face and torso D.When baby cries, mother says, "Shut up already." Baby has a foul odor and looks dirty.

D. When baby cries, mother says, "Shut up already." Baby has a foul odor and looks dirty. Rationale: The mother's response indicates an inability or unwillingness to respond to the baby's cues. The foul odor and uncleanliness signify possible neglect. A careful physical examination, with the nurse looking for other signs of abuse, is in order.C. Has significant head lag, one ear is small and malformed, nipples are unusually close together. Rationale: This is the only answer choice with three markers that point to a possible genetic disorder. Large ears on a baby whose growth is in the 95th percentile on the growth chart is not a strong sign. Large scaly plaques are associated with psoriasis. An absent red reflex in one eye is abnormal but not a strong marker of a genetic disorder. Cranial sutures should be palpable; a head that is flat in the back is most likely from positional plagiocephaly related to sleeping on the back.

What is the best time to assess the respiratory rate of a young child? A.While the child is crying B.While the child is playing in the playroom C.Immediately after taking the child's BP D.While the child is quietly sitting on the parent's lap

D. While the child is quietly sitting on the parent's lap. Rationale: Respirations are best determined while the child is sleeping or quietly awake. When a child is playing or upset, respirations may increase from activity or crying.