Final Practice Questions

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

A

Which characteristic associated with respiratory effort should be considered when planning care for a client diagnosed with a brainstem injury? A. There is loss of involuntary respiratory control. B. The client will respond negatively to increased stimuli. C. There is an increased level of carbon dioxide in the blood. D. The client's oxygen levels in the blood will be increased.

A

When assessing an adult client experiencing diarrhea, the nurse notes a round "moon" face, a buffalo hump at the nape of the neck, and a velvety discoloration around the neck. What is the possible cause of these signs? A. Myxedema B. Cushing's syndrome C. Scleroderma D. Bell's palsy

B

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

B, C, D

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

C

The right 2nd rib space is the first location for cardiac auscultation and is also known as: A. Erb's point. B. the tricuspid area. C. the aortic area. D. the mitral area.

C

A nursing instructor is describing the peripheral nervous system to a group of students. The instructor would explain that there are how many pairs of spinal nerves? A. 8 B. 11 C. 24 D. 31

D

A school-age client has been diagnosed with genu valgum. What is the other name for this condition? A. clubfoot B. flat feet C. bowlegs D. knock-kneed

D

The nurse is preparing to assess balance in an older adult client. Which test would the nurse plan on possibly omitting from the exam? A. Romberg B. Tandem walking C. Gait D. Hop on one foot

D

When conducting a generalized assessment of a new client, what would the nurse focus upon when inspecting the neck? A. Signs of a strain B. Indications of a vertebral injury C. Lymph node enlargement D. Limitations in movement

D

A client comes to the clinic and reports a sore knee. The nurse notes popping and cracking noises when the client attempts to bend the knee. The client exhibits signs of pain by facial expression. The nurse knows that the popping and cracking noises should be charted as what? A. Crepitus B. Grating noise C. Tactile emphysema D. Popping and cracking noises

A

A client has a history of emphysema. The nurse percussing the client's chest expects to hear what characteristic sound? A. Hyperresonance B. Dullness C. Resonance D. Tympany

A

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

A

A client presents at the emergency department. During the assessment, the nurse notes the following: Client is a 22-week primipara, age 25, pulse 82, BP 110/76, temp 38.3°C (100.9°F). The client is diagnosed with pyelonephritis. What would be the treatment of choice? A Hospitalization and intravenous antibiotics B. Oral antibiotics and bed rest at home C. Hospitalization and intravenous hydration D. Home care and oral hydration and antibiotics

A

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

A

A nursing instructor is discussing the functions of the breasts. A student asks about the function of the Montgomery glands. What would be the instructor's best answer? A. "They secrete a protective lubricant during lactation." B. "They are the lactiferous ducts." C. "They aid in supporting breast tissue." D. "They are lymph nodes in the axillae."

A

A student states that a client has palpable rushing vibration in the area of the pulmonic valve. What should the instructor explain that the student is feeling? A. A thrill B. A thrust C. A heave D. A normal finding

A

An older adult client has been admitted to the unit. The client has problems with fine motor movement. What would be important to do for this client? A. Open all packages and arrange the meal tray while communicating actions to the client B. Teach the client to call for assistance when getting up to bathroom C. Evaluate for assistance devices D. Assess gross motor function

A

The Papanicolaou test is a screening tool for what? A. Cervical cancer B. Vaginal cancer C. Ovarian cancer D. Labial cancer

A

The nurse is caring for a client with a nursing diagnosis of impaired skin integrity related to a stage III pressure ulcer. What would be the most important outcome for this client? A. The client exhibits no signs or symptoms of infection B. The client changes position every 2 hours C. The client keeps the area clean and dry D. The client knows prevention measures for pressure ulcers

A

The nurse is caring for a female client with hormone disorder producing excessive testosterone. Which of the following is an expected finding when assessing this client? A. Hirsutism B. Rapid heart rate C. Sensitivity to cold D. Muscle cramps

A

The nurse is conducting a skin assessment on a client and notices the client has bilateral patches on tops of both feet with no color. The nurse should document this finding as: A. vitiligo. B. erythema. C. pallor. D. tinea corporis.

A

The nurse is reviewing the plan of care for a client with peripheral neuropathy. Which intervention by the client should the nurse be concerned about? A. Limit use of a heating pad to 15 minutes at a time. B. Inspect feet daily using a mirror. C. Test bath water temperature with the hands. D. Wear clean white cotton socks.

A

The nurse is teaching an older adult diagnosed with diabetes about the skin. Which of the following should be emphasized? A. A neuropathic ulcer can develop without feeling it. B. Skin collagen decreases with age. C. Wound healing becomes prolonged with age. D. Hydration alters skin turgor.

A

What causes the characteristic features of coffee-ground emesis? A. Digested blood B. Decreased peristalsis C. Active bleeding D. Irritated intestinal lining

A

What is considered a modifiable risk factor for breast cancer? A. Obesity B. Age C. Genetics D. Asthma

A

What would the nurse expect to hear when auscultating the lungs of a client diagnosed with pleuritis? A. Friction rub B. Decreased breath sounds C. Sibilant wheeze D. Stridor

A

When assessing whispered pectoriloquy, the nurse would instruct a client to do which of the following? A. Softly repeat the words "one-two-three" B. Say "ninety-nine" C. Cough each time the stethoscope is moved D. Say the letter "e"

A

When determining a client's strength, it is necessary to implement what assessment? A. Comparing one side to the other B. Assessing the extremities at the same time C. Comparing upper and lower extremities D. Assessing upper and lower extremities at the same time

A

What physical characteristics should the nurse describe when discussing the characteristics of fetal alcohol syndrome? (Select all that apply.) A. Microcephaly B. Small eyes C. Flattened upper lip D. Prominent cheekbones E. Macrocephaly

A, B, C

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

A, B, E

A nurse is teaching a client about self breast examination. What would the nurse emphasize? (Mark all that apply.) A. Inspection B. Pain C. Timing D. Palpation E. Pallor

A, C, D

A teenage girl was brought to the clinic by her mother, who reports that her daughter has a boyfriend with whom the teenager is considering becoming sexually active. What should the nurse do to make the client as comfortable as possible during the nursing assessment? (Select all that apply.) A.Reassure the client that all information is kept confidential B. Ask the client's permission to share information with her parents C. Obtain the history with the client still dressed D. Be seated at eye level or lower E. Make sure the room is private and comfortable

A, C, D, E

1. What are the functions of the lymphatic system? (Mark all that apply.) A Maintaining protein balance B. Draining lymph from the bloodstream C. Fighting infection D. Hydrating the thymus E. Maintaining fluid balance

A, C, E

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

A, D, E

As people age, several neurological changes occur. Neurons, brain size, and neurotransmitters decrease. What are some of the results of aging on the neurological system? Select all that apply. A. Slower thought processing B. Reduced response to stimuli C. Delayed reflexes D. Inability to process nutrients E. More frequent seizures

A,B,C

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

B

A nurse is preparing to assess the cranial nerves of a client. The nurse is about to test cranial nerve I. Which of the following would the nurse do? A. Use a Snellen chart to test visual acuity B. Ask the client to identify scents C. Test extraocular eye movements D. Perform the Weber's test

B

A teenage boy is embarrassed by his tender and enlarged breasts. What would be the most appropriate nursing intervention to help the teen manage this problem? A. Teaching the client that hormone therapy may be required B. Reassuring the teen that this is both normal and temporary C. Preparing the client for further genetic testing D. Encouraging the teen to seek counseling to deal with permanent body image issues

B

An adult woman presents at the clinic with a grayish vaginal discharge with a 'fishy' odor. What should the nurse suspect? A. Candidiasis B. Bacterial vaginosis C. Chlamydia D. Gonorrhea

B

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

B

An older adult client presents at the office of the primary care physician with fatigue and heart palpitations. These reports support what cardiac related diagnosis? A. Heart failure B. Atrial fibrillation C. Atrial hypertrophy D. Ventricular arrhythmia

B

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

B

The neural pathway includes what? A. Optic nerve and peripheral nervous system B. Optic chiasm and optic tracts C. Optic tracts and eyes D. Optic chiasm and cranial nerve VIII

B

The nurse in the dermatology clinic is assessing an adult who has presented at the clinic with a lesion on the left inner thigh. The client tells the nurse that the lesion was discovered one month ago and no changes in the color or size of the lesion have been noted. What would be the most appropriate teaching subject for this client? A. Skin self-examination B. Signs and symptoms of melanoma C. Recognizing different types of lesions D. Protection from sun damage

B

The nurse is caring for a client who has an elevated cholesterol level. To reduce the mean total blood cholesterol and low-density lipoprotein (LDL) cholesterol levels, what diet should the nurse discuss with the client? A. High-protein, low-fat meals B. Low-fat, low-cholesterol meals C. High-protein, low-carbohydrate meals D. Low-cholesterol, low-carbohydrate meals

B

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

B

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

B

What transfers the signals into electrical impulses for the auditory nerve? A. Cochlea В. Organ of Corti C. Labyrinth D. Oval window

B

A client presents at the emergency room reporting "the worst headache I have ever had." What are the critical initial nursing interventions for this client? (Select all that apply.) A. Scheduling a magnetic resonance imaging (MRI) scan B. Physical examination for neurologic changes C. Scheduling a computerized tomography (CT) scan D. Conducting a focused history interview E. Scheduling an electroencephalography (EEG)

B, D

A client at 39 weeks' gestation presents at the labor and delivery suite saying that she is in labor. She reports that her water has not broken yet. Physical assessment reveals that the client is not in true labor. The nurse explains that what the client is feeling are Braxton Hicks contractions. What assessment findings would tell the nurse that these contractions are, in fact, Braxton Hicks? (Select all that apply.) A. 30 to 45 seconds in duration B. Fewer than five in 1 hour C. Not painful D. Resolve with position change E. Less than 30 seconds

B, D, E

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

B, D, E

A client brought to the emergency department after a diving accident tells the nurse, "I think I hit a rock, and now I can't feel my arms or legs." A rapid physical assessment shows no other apparent injuries. What initial nursing intervention is essential to the safety of this client? A. Send for a CT scan immediately. B. Draw a basic metabolic panel to check for infection. C. Maintain immobilization of the spine until it is cleared of injury. D. Log roll the client to remove backboard, reducing pressure on the spine.

C

A client in her third trimester comes in tor a routine prenatal visit. The nurse places her in a comfortable position and attaches the tocodynamometer and ultrasound monitor to the client's abdomen. What is the purpose of this test? A. Assesses readiness for dilation B. Assesses fetal position C. Assesses fetal well-being D. Assesses readiness for delivery

C

A client presents to the emergency department after falling off a ladder while doing some outside painting at home. The client's ankle appears swollen, out of alignment, and is painful to touch. What is the nurse's first action? A. Encourage early weight bearing and ambulation. B. Apply an ice pack to the affected extremity. C. Check for a pulse, color, temperature, and capillary refill. D. Splint and immobilize the affected extremity.

C

A client presents with a diagnosed C. albicans infection. What assessment should the nurse ask initially to determine the possible cause of the infection? A. "Are you allergic to nystatin?" B. "When did the symptoms begin?" C. Are you currently prescribed an antibiotic?" D. "Have you experienced these symptoms before?"

C

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

C

A shift report indicates that an African American client has symptoms of both jaundice and splenomegaly. Considering the client's ethnicity and diagnoses, what is the likely medical diagnosis? A. Pancreatitis B. Leukemia C. Sickle cell anemia D. Colon cancer

C

A woman and her teenager have come to the clinic. The teenager has acne lesions and says that the lesions are not well controlled. The mother asks the nurse what causes acne. What would be the nurse's best response? A. Acne is caused by the apocrine glands B. Acne is caused by decreased activity of the sebaceous glands C. Acne is caused by the impedance of sebum secretion onto the skin's surface D. Acne is caused by enlarged apocrine glands

C

An emergency department nurse is caring for a teenage client who has severe pain in the umbilical area. Documentation shows that the client exhibits "Rovsing's sign." What medical diagnosis is associated with the assessment finding? A. Gastroenteritis B. Liver disease C. Appendicitis D. Enlarged spleen

C

An older adult woman comes to the clinic for her yearly examination. What would be an appropriate question to ask the client during the nursing assessment? A. Have you had a sexually transmitted infection in the past 12 months? B. Does your genital area itch excessively? C. Are you sexually active? D. What type of contraception are you using?

C

During a neck assessment, where would the nurse focus palpation of the thyroid isthmus? A. Just above the thyroid cartilage B. Between the thyroid and the cricoid cartilages C. Just below the cricoid cartilage D. In front of the sternocleidomastoid muscle

C

The nurse enters a client's room to administer a prescribed anticoagulant for atrial fibrillation. The client exhibits new onset facial drooping and slurred speech. What is the nurse's priority action? A. Administer the PO anticoagulant immediately. B. Assess the client's bleeding time before medication administration. C. Ask the client to raise both arms in front of the client's body. D. Assess the client's vital signs and cranial nerves.

C

The nurse is performing a generalized assessment of an older adult. The nurse notes that the client's skin is thin and rough with abrasions. The client tells the nurse that it seems to take "forever" for scratches to heal, "a lot longer than when I was younger." How would the nurse note these findings in the client's medical record? A. The client has abnormal thinning of skin B. The client's integumentary system is within normal limits C. The client states that wounds are taking longer to heal D. The client has an abnormal inability to maintain temperature

C

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

C

Upon entering the examination room, a nurse observes that the client is leaning forward with arms supporting body weight. The nurse would most likely suspect the client is compensating for what pathophysiological disorder? A. Diabetes mellitus B. Heart failure Chronic obstructive pulmonary disease D. System lupus erythematous

C

What color of sputum would support the diagnosis of heart failure? A. White B. Yellow C. Pink D. Rust

C

When considering the head and neck, what screening should be included as a component of a pregnant woman's regular examinations? A. B12 B. folic acid C. Thyroid D. amniocentesis

C

When inspecting the bulbar conjunctiva, what would you expect to find? A. A pink to light red color B. Small areas of rough tissue C. Small blood vessels D. An opaque membrane

C

Which of the following tests would be most appropriate for the nurse to use when assessing motor function of the trigeminal nerve? A. Ask the client to differentiate sharp and dull sensations on the face B. Have the client smile, frown, and wrinkle the forehead C. Palpate the temporal and masseter muscles while the client clenches teeth D. Assess dilatation of pupils with direct light

C

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

D

A client has sustained an injury to the cerebellum. Which area would be the primary area for assessment? A. Vital signs B. Neurologic system C. Cardiac function D. Coordination

D

A client with a cervical spine injury reports chronic pain. What would be the most appropriate initial nursing intervention for this client? A. Work with medical team to evaluate possible surgery. B. Discuss pharmacologic interventions. C. Educate the client regarding cervical spine pain. D. Assess the client regarding characteristics of the pain.

D

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

D

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

D

An adult woman reports to the nurse that she has an area on her breast that is dimpled and "looks like the skin on an orange." These characteristics are associated with what breast disorder? A. Early cancer B. Fibroadenoma C. Fibrocystic disease D. Blocked lymph drainage

D

An emergency department nurse is assessing an adult client who is reporting chest pain. The client states that the pain gets worse with movement. What further assessment should the nurse make? A. Auscultation at the 5th intercostal space (ICS) B. Palpation at the point of maximum impulse (PMI) C. Assessment at the midclavicular line (MCL) D. Palpation of the costochondral junction

D

An older adult client reports a need to get up during the night to urinate. What assessment will provide the most relevant information concerning the management of client's nocturia? A. "What do you think is causing this need to urinate so often?" B. "Are you tired in the morning because of this?" C. "Is there a family history of this problem?" D. "Have you made any lifestyle changes because of this?"

D

During a health history, a client tells the nurse that "I can't breathe well at night when I'm lying down". The client also reports an interrupted sleep pattern caused by waking up with trouble breathing and a nagging cough. Considering the client's reports, what medical condition should the nurse's assessment be focused on? A. Pneumonia-related dyspnea B. Tuberculosis-related cough C. Bronchitis D. Heart failure induced orthopnea

D

During the Romberg test, a client is unable to stand with his feet together and demonstrates a wide-based, staggering, unsteady gait. The nurse would identify this as which of the following? A. Spastic hemiparesis B. Parkinsonian gait C. Scissors gait D. Cerebellar ataxia

D

In the clinic within an adult assisted-living complex, a 68-year-old retired detective reports his mouth is continually dry. This is problematic for him. What are the functions of saliva? A. Provides lubrication B. Protects oral mucosa C. Rinses oral cavity D. All of the above

D

The nurse practitioner auscultates both lobes of a client's enlarged thyroid gland. Identification of what sound would tend to confirm a diagnosis of a toxic goiter? A. Rush B. Gurgle C. Murmur D. Bruit

D

What should be the nurse's initial intervention when adventitious sounds are heard during auscultation of a client's lungs? A. Refer the client for further medical evaluation. B. Auscultate for egophony. C. Perform bronchophony. D. Have the client cough and then listen again.

D

When assessing cranial nerves IX and X, which of the following would the nurse consider as a normal finding? A. Stationary soft palate on phonation B. Deviation of uvula when client says "ah" C. Asymmetrical soft palate D. Uvula and soft palate rising bilaterally

D

Which anterior neck structure is found in the depression between the trachea and the sternomastoid muscle? A. Internal jugular vein B. External jugular vein C. Sternomastoid D. Carotid artery

D

While auscultating a client's abdomen, the student notes sounds that are both high-pitched and rushing. The student demonstrates an understanding of abnormal bowel sounds when proposing what to be the cause of these sounds? A. Diarrhea B. Adynamic ileus C. Intestinal fluid D Partial intestinal obstruction

D

While performing an admission assessment, the nurse auscultates a high-pitched, scratching, and grating sound at the left lower sternal border. The nurse should use what term to document the sound? A. Aortic ejection click B. Split sound C. Pericardial murmur D. Pericardial friction rub

D

Is the following statement true or false? The nurse should include teaching the patient how to correctly clean the external ear canal with a cotton-tipped swab.

False