NSG2317 Final

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The nurse is performing a health interview on a patient who has a language barrier, and no interpreter is available. Which is the best example of an appropriate question for the nurse to ask in this situation? a. Do you take medicine? b. Do you sterilize the bottles? c. Do you have nausea and vomiting? d. You have been taking your medicine, havent you?

The nurse just noted from the medical record that the patient has a lesion that is confluent in nature. On examination, the nurse expects to find: a. Lesions that run together. b. Annular lesions that have grown together. c. Lesions arranged in a line along a nerve route. d. Lesions that are grouped or clustered together.

A patient's thyroid gland is enlarged, and the nurse is preparing to auscultate the thyroid gland for the presence of bruit. A bruit is a _____ sound that is hard best with the ______ of the stethoscope. A. low gurgling; diaphragm B. loud, whooshing, blowing; bell C. soft, whooshing, pulsatile; bell D. high-pitched tinkling; diaphgragm

C. soft, whooshing, pulsatile; bell

A 52-year-old patient describes the presence of occasional floaters or spots moving in front of his eyes. The nurse should: a. Examine the retina to determine the number of floaters. b. Presume the patient has glaucoma and refer him for further testing. c. Consider these to be abnormal findings, and refer him to an ophthalmologist. d. Know that floaters are usually insignificant and are caused by condensed vitreous fibers.

The nurse is taking the history of a patient who may have a perforated eardrum. What would be an important question in this situation? a. Do you ever notice ringing or crackling in your ears? b. When was the last time you had your hearing checked? c. Have you ever been told that you have any type of hearing loss? d. Is there any relationship between the ear pain and the discharge you mentioned?

The nurse notices that a patients submental lymph nodes are enlarged. In an effort to identify the cause of the node enlargement, the nurse would assess the patients: a. Infraclavicular area. b. Supraclavicular area. c. Area distal to the enlarged node. d. Area proximal to the enlarged node.

The nurse recognizes that categories such as ethnicity, gender, and religion illustrate the concept of: a. Family. b. Cultures. c. Spirituality. d. Subcultures.

The nurse is performing a physical assessment on a newly admitted patient. An example of objective information obtained during the physical assessment includes the: a. Patients history of allergies. b. Patients use of medications at home. c. Last menstrual period 1 month ago. d. 2 5 cm scar on the right lower forearm.

When considering priority setting of problems, the nurse keeps in mind that second-level priority problems include which of these aspects? a. Low self-esteem b. Lack of knowledge c. Abnormal laboratory values d. Severely abnormal vital signs

Which mental disorder causes a gradual decrease in the patient's cognitive functioning? 1 Delirium 2 Dementia 3 Depression 4 Anxiety disorder

Which mental disorder is associated with agnosia? 1 Anxiety 2 Hallucinations 3 Dementia 4 Depression

4, 5

Which mental disorders are observed in children? Select all that apply. 1 Delusions 2 Dementia 3 Alzheimer disease 4 Autism spectrum disorder 5 Attention-deficit hyperactivity disorder (ADHD)

Which of the following adults, who were born prematurely, would be at greater risk of developing asthma? A An African American female B A white male C An Asian female D A Hispanic male

Which of the following best illustrates an abnormality of thought process? A. Lability B. Blocking C. Compulsion D. Aphasia

17. During an assessment of an adult, the nurse has noted unequal chest expansion and recognizes that this occurs in which situation? (5 pts) A. when part of the lung is obstructed or collapsed B. when bulging of the intercostal spaces is present C. an obese patient D. when accessory muscles are used to augment respiratory effort

19. During inspection of the precordium of an adult patient, the nurse notices the chest moving in a forceful manner along the sternal border. This finding most likely suggests: (5 pts) A. enlargement of the right ventricle B. a systolic murmur C. a normal heart D. enlargement of the left ventricle

tumor

Lger than a few cm in diameter, deeper into dermis. hemangioma.

Thorax and lungs 21. What type of chest has an elliptical shape with an anteroposterior: transverse diameter of 1:2?

normal chest

50-95

normal pulse range is ____BPM

A patient tells the nurse that "sometimes I wake up at night and I have real trouble breathing. I have to sit up in bed to get a good breath." When documenting this information, the nurse would note:

paroxysmal nocturnal dyspnea.

Thorax and lungs 23. What configuration of the thorax presents with a sunken sternum and adjacent cartilages?

pectus excavatum

SpO2

Pulse Oximeters measure _____: nl. >97%

2, 4, 5

What are the different organic mental disorders? Select all that apply. 1 Anxiety 2 Delirium 3 Schizophrenia 4 Alcohol intoxication 5 Drug intoxication

Heart and neck vessels 20. _____: ensures smooth, friction free movement of the heart

pericardial fluid

9. The sac that surrounds and protects the heart is called the: (5 pts)

pericardium

Heart and neck vessels 17. _______: tough, fibrous, double walled sac that surrounds and protects the heart

pericardium

android obesity

persons with greater proportion of fat in upper body, especially in abdomen

gynoid obesity

persons with most of fat in hips and thighs

psoriasis

pitting can indicate ______

18. A teenage patient comes to the emergency department with complaints of an inability to breathe and a sharp pain in the left side of his chest. The assessment findings include cyanosis, tachypnea, tracheal deviation to the right, decreased tactile fremitus on the left, hyperresonance on the left, and decreased breath sounds on the left. The nurse interprets that these assessment findings are consistent with a: (5 pts)

pneumothorax or a pneumothorax or left pneumothorax

3. Right upper quadrant tenderness may indicate pathology in the: a. liver, pancreas, or ascending colon. b. liver and stomach. c. sigmoid colon, spleen, or rectum. d. appendix or ileocecal valve

6. Auscultation of the abdomen may reveal bruits of the ________________ arteries. a. aortic, renal, iliac, and femoral b. jugular, aortic, carotid, and femoral c. pulmonic, aortic, and portal d. renal, iliac, internal jugular, and basilic

6. Just before going home, a new mother asks the nurse about the infant's unbilical cord. Which of these statements is correct? (5 pts) A. "It should fall off in 10-14 days" B. "It will soften before it falls off" C. "It contains one artery and two veins" D. "Skin will cover the area within 1 week"

subjective

review of systems is limited to ________ data.

A teenage girl has arrived complaining of pain in her left wrist. She has been playing basketball and fell, landing on her left hand. You examine her hand, and expect a fracture if:

she complains of sharp pain that increases with movement.

Thorax and lungs 18. lateral left border c. _____ rib, midclavicular line

sixth

8. During an examination of the anterior thorax, the nurse keeps in mind that the trachea bifurcates anteriorly at the: (5 pts) A. sternal angle B. xiphoid process C. costal angle D. suprasternal notch

17. The component of the conduction system referred to as the pacemaker of the heart is the: (5 pts) A. purkinje fibers B. bundle branches C. sinoatrial node D. atrioventricular node

Which of the following statements is most appropriate when one is obtaining a genitourinary history from an elderly man?

"Do you need to get up at night to urinate?"

During your interview with Mrs. K. you gather data that leads you to believe that she is perimenopausal. Which of the following statements made by Mrs. K. leads to this conclusion?

"I have been noticing that I sweat a lot more than I used to, especially at night."

When one is eliciting an initial sexual history from an adolescent, which of the following statements is most appropriate?

"Often boys your age have questions about sexual activity."

During a well-baby checkup, a mother is concerned because her 2-month-old infant cannot hold her head up when she is pulled to a sitting position. Which response by the nurse is appropriate? a. Head control is usually achieved by 4 months of age. b. You shouldnt be trying to pull your baby up like that until she is older. c. Head control should be achieved by this time. d. This inability indicates possible nerve damage to the neck muscles.

Mr. Peyser is a 38-year-old patient who presents to your office for a yearly physical examination. On exam you note that the foreskin of the penis is very tight, preventing it from retracting over the glans. Which of the following conditions best describes this clinical finding? A. Phimosis B. Paraphimosis C. Spermatocele D. Epispadias

A. Phimosis

8. The nurse is assessing a patient's pulses and notices a difference between the patient's apical pulse and radial pulse. The apical pulse was 118 beats per minute, and the radial pulse was 105 beats per minute. What is the pulse deficit? (5 pts)

The musculoskeletal system provides which of the following functions for the human body? A. Protection and storage B. Movement and elimination C. Storage and control D. Propulsion and preservation

A. Protection and storage

During an assessment, the nurse notices that a patient is handling a small charm that is tied to a leather strip around his neck. Which action by the nurse is appropriate? a. Ask the patient about the item and its significance. b. Ask the patient to lock the item with other valuables in the hospitals safe. c. Tell the patient that a family member should take valuables home. d. No action is necessary.

A 2-week-old infant can fixate on an object but cannot follow a light or bright toy. The nurse would:

ANS: consider this a normal finding. By 2 to 4 weeks an infant can fixate on an object. By the age of 1 month, the infant should fixate and follow a bright light or toy.

During an examination, the nurse finds that a patient has excessive dryness of the skin. The best term to describe this condition is: a. Xerosis. b. Pruritus. c. Alopecia. d. Seborrhea.

During morning rounds, the nurse asks a patient, "How are you today?" The patient responds, "You today, you today, you today!" and mumbles the words. This speech pattern is an example of: a. Echolalia b. Clanging c. Word salad d. Perseveration

Thorax and Lungs 16. apex of lung e. _____ cm above the inner third of the clavicles

3-4

Expert nurses learn to attend to a pattern of assessment data and act without consciously labeling it. These responses are referred to as: a. Intuition. b. The nursing process. c. Clinical knowledge. d. Diagnostic reasoning.

Illness is considered part of lifes rhythmic course and is an outward sign of disharmony within. This statement most accurately reflects the views about illness from which theory? a. Naturalistic b. Biomedical c. Reductionist d. Magicoreligious

The nurse suspects that a patient has hyperthyroidism, and the laboratory data indicate that the patients T4 and T3 hormone levels are elevated. Which of these findings would the nurse most likely find on examination? a. Tachycardia b. Constipation c. Rapid dyspnea d. Atrophied nodular thyroid gland

When examining a patients CN function, the nurse remembers that the muscles in the neck that are innervated by CN XI are the: a. Sternomastoid and trapezius. b. Spinal accessory and omohyoid. c. Trapezius and sternomandibular. d. Sternomandibular and spinal accessory.

When examining children affected with Down syndrome (trisomy 21), the nurse looks for the possible presence of: a. Ear dysplasia. b. Long, thin neck. c. Protruding thin tongue. d. Narrow and raised nasal bridge.

When examining the eye, the nurse notices that the patients eyelid margins approximate completely. The nurse recognizes that this assessment finding: a. Is expected. b. May indicate a problem with extraocular muscles. c. May result in problems with tearing. d. Indicates increased intraocular pressure.

When performing the corneal light reflex assessment, the nurse notes that the light is reflected at 2 oclock in each eye. The nurse should: a. Consider this a normal finding. b. Refer the individual for further evaluation. c. Document this finding as an asymmetric light reflex. d. Perform the confrontation test to validate the findings.

10-20

Norm RR is ____/min

. A 30-year-old woman has recently moved to the United States with her husband. They are living with the womans sister until they can get a home of their own. When company arrives to visit with the womans sister, the woman feels suddenly shy and retreats to the back bedroom to hide until the company leaves. She explains that her reaction to guests is simply because she does not know how to speak perfect English. This woman could be experiencing: a. Culture shock. b. Cultural taboos. c. Cultural unfamiliarity. d. Culture disorientation.

Mr. Frank, a 32-year-old patient, presents to your office with a complaint of urinary frequency. On examination you note a painless lesion with a clear base and indurated borders that is located on the glans penis. Which of the following best describes this clinical finding? A. Syphilitic chancre B. Lymphogranuloma C. Genital warts D. Herpes simplex

A. Syphilitic chancre

During a mental status examination, the nurse wants to assess a patient's affect. The nurse should ask the patient which question? a. "How do you feel today?" b. "Would you please repeat the following words?" c. "Have these medications had any effect on your pain?" d. "Has this pain affected your ability to get dressed by yourself?"

The nurse knows that developing appropriate nursing interventions for a patient relies on the appropriateness of the __________ diagnosis. a. Nursing b. Medical c. Admission d. Collaborative

A husband tells the nurse that his wife worries excessively about dirt, germs, and chemicals in food and clothes. He explains that she also washes her hands every 10 minutes to prevent contracting any infection. What does the nurse infer about the wife? 1 The patient has delusions. 2 The patient has an obsession. 3 The patient has a compulsion. 4 The patient has hypochondriasis.

vitiligo

Acquired condition with complete absence of melanin in patchy areas of white/light skin on face, neck, hands, feet and body folds and around orifices. occurs in all ppl, but dark skin are more severely affected.

Adventitous sounds heard when auscultating the chest are: A additional sounds not normally heard in the lungs. B augmented counds related to an increased rate and depth of respirations. C best heard in the lower lobes of the lungs. D only heard witht he bell of the stethescope.

ecchymosis

An _______ is a hemorrhage that is greater than 3 mm

Obesity defined as BMI of ___

A patient has been admitted to a hospital after the staff in nursing home noticed a pressure ulcer in his sacral area. The nurse examines the pressure ulcer and determines that it is a stage II ulcer. Which of these findings are characteristics of a stage II pressure ulcer? (select all that apply) A. intact skin appears red but is not broken B. partial thickness skin erosion is observed with a loss of epidermis or dermis C. ulcer extends into the subcutaneous tissue D. localized redness in light skin will blanch with fingertip pressure E. open blister areas have a red-pink wound bed F. patches of eschar covers part of the wound

B, E

The abdomen normally moves when a person breathes until the age of ____ years. A. 4 B. 7 C. 14 D. 75

B. 7

Cartilage is which of the following? A. Acellular B. Avascular C. Asynchronous D. Atherosclerotic

B. Avascular

Vaginal lubrication during intercourse is produced by: A. Skene's glands. B. Bartholin's glands. C. sebaceous glands. D. None of the above

B. Bartholin's glands.

The rugae: A. is a corpus spongiosum cone of erectile tissue. B. is folds of thin skin of the scrotal wall. C. controls the size of the scrotum. D. is an acute inflammation of the testes.

B. is folds of thin skin of the scrotal wall.

Bronchial breath sound may be heard over peripheral lung tissue in which of the following situations? A There is an obstruction of the bronchial tree. B The individual has emphysema. C The individual has pneumonia. D The individual is breathing too rapidly and deeply.

The term associated with the number of births is: A. menorrhagia. B. leukorrhea. C. para. D. Hegar's sign.

C. para.

A 13-year-old girl is interested in obtaining information about the cause of her acne. The nurse should share with her that acne: a. Is contagious. b. Has no known cause. c. Is caused by increased sebum production. d. Has been found to be related to poor hygiene.

Common errors in blood pressure measurement include: a taking blood pressure in an arm that is at the level of the heart. b waiting less than 1 to 2 minutes before repeating the blood pressure reading on the same arm. c waiting 30 minutes if the client has just smoked a cigarette. d waiting 30 minutes if the client has just smoked a cigarette.

A female nurse is interviewing a male patient who is near the same age as the nurse. During the interview, the patient makes an overtly sexual comment. The nurses best reaction would be: a. Stop that immediately! b. Oh, you are too funny. Lets keep going with the interview. c. Do you really think I would be interested? d. It makes me uncomfortable when you talk that way. Please stop.

Mr. Jeffries is a 48-year-old patient who comes to the clinic for a follow-up after an emergency room visit. On examination, you note a soft mass of lymphatic tissue immediately under the diaphragm, which is the: A. gallbladder. B. liver. C. cecum. D. spleen.

D. spleen.

reflexive sympathetic dystrophy

Follows trauma to the nerve Most commonly appears in 40- to 60-year-old men and women

Which of the following is a risk factor for peptic ulcer disease?

Frequent use of nonsteroid antiinflammatory drugs

Give a vaccine for pneumonia EVERY ___YEARS! Esp elderly, 55 and above.

Heart and neck vessels 24. What are the 5 major risk factors for heart disease and stroke:

Hypertension, smoking, diabetes, obesity, high cholesterol

A (Ten traps of interviewing: -Providing false assurance or reassurance -Giving unwanted advice -Using authority -Using avoidance language -Engaging in distancing -Using professional jargon -Using leading or biased questions -Talking too much or interrupting -Using "why" questions)

Interviewing traps include using: A avoidance language B egalitarian language C professional language D All of the above

Mr. Cook is a 53 year-old patient who comes to the clinic for routine follow-up for his chronic obstructive pulmonary disease (COPD). Which of the following is indicative of COPD? A acrocyanosis B circumoral cynosis C pitting of nails D clubbing of nails

Mr. Sanchez is a 62-year old patient who presents with long-standing, controlled hypertension. During the examination, you obtain a thigh pressure. Which of the following statements best describes thigh pressure? A Thigh pressure is compared with blood pressure measured at the arm in children or adolescents with low blood pressure. B Thigh pressure is usually higher than blood pressure measured in the arm. C If thigh pressure is found to be higher than arm-blood pressure, it is indicative of ventral-septal defect of the heart. D All of the above.

Bullae

Mr. Verdana is a 41 year old who present with a complaint of skin problems. On examination you note single-chambered, superficial lesions containing free fluid greater than 1 cm in diameter, which are called

You suspect that a patient is suffering from appendicitis. Which of the following procedures would not be helpful in assessing for appendicitis?

Murphy's sign

inspection, palpation, percussion, auscultation

Order of physical assessment:

The nurse should wear gloves for which of these examinations?

Palpation of the mouth and tongue ANS: C Page: 766. Gloves should be worn when the examiner is exposed to the patient's body fluids.

To detect diastasis recti, you should have the patient perform which of the following maneuvers?

Raise the head and shoulders while remaining supine.

Red Zone: __% or < = call 911/go to ER

Cheyne-stokes

Respirations that are cyclical in nature, characterized by an increasing and decreasing rate and depth, and separated by periods of apnea are identified as:

dementia

Tests used to assess for ___________ include the Mini-Mental State Examination, the Set Test, the Short Portable Mental Status Questionnaire, the Mini-Cog, and the Blessed Orientation-Memory-Concentration Test.

The nurse is performing the Mini-Mental State Examination (MMSE) in a patient and confirms that the patient has mild cognitive impairment. What must be the score given to this patient? 1. 7 2. 22 3. 25 4. 27

The patient tells the nurse, "I am the almighty and your creator. You all must do as I say; I am your ruler." Which thought content abnormality does the patient exhibit? 1 Delusions 2 Obsessions 3 Compulsions 4 Hypochondriasis

Annular

The term used to describe the shape of a lesion being circular is

3, 4, 5

What are the characteristic features of a patient with Parkinson's disease? Select all that apply. 1 Loud talking 2 Pressurized talking 3 Masklike expression 4 Monotonous speech 5 Failure in word search

When reviewing the concepts of health, the nurse recalls that the components of holistic health include which of these? a. Disease originates from the external environment. b. The individual human is a closed system. c. Nurses are responsible for a patients health state. d. Holistic health views the mind, body, and spirit as interdependent.

When should an infant be tested for language development skills using a one-word sentence? 1. 1 year 2. 2 years 3. 4 weeks 4. 6 weeks

Which assessment tool does the nurse use to assess the level of consciousness of an older adult with confusion? 1 The Mini-Cog test 2 Denver II screening test 3 The Glasgow Coma Scale 4 Generalized Anxiety Disorder (GAD) scale

Which condition is seen in a patient with aphasia? 1 Inability to smell any fragrances, odors, or aromas 2 Inability to comprehend or express verbal language 3 An inappropriate attention span and impulsiveness 4 Inability to perform a purposeful act on command

Which critical thinking skill helps the nurse see relationships among the data? a. Validation b. Clustering related cues c. Identifying gaps in data d. Distinguishing relevant from irrelevant

Which disability will be seen in a patient with organic dementia? 1 The patient recalls events only from his or her childhood. 2 The patient remembers only most recent events. 3 The patient demonstrates unilateral neglect. 4 The patient has expressive and receptive aphasia.

3, 4, 5

Which factors may cause delirium? Select all that apply. 1 Crises 2 Loneliness 3 Hypoglycemia 4 Hypotension 5 Head injury

The nurse is assisting with a self-breast examination clinic. Which of these women reflect abnormal findings during the inspection phase of breast examination?

Woman whose nipples are in different planes (deviated) ANS:A Pages: 392-393 | Page: 404. The nipples should be symmetrically placed on the same plane on the two breasts. With deviation in pointing, an underlying cancer causes fibrosis in the mammary ducts, which pulls the nipple angle toward it. The other examples are normal findings. See Table 17-3.

9. A 70-year-old patient is being seen in the clinic for severe exacerbation of his heart failure. Which of these findings is the nurse most likely to observe in this situation? Select all that apply (5 pts) Y/N increased respiratory rate Y/N dry cough Y/N orthopnea Y/N fever Y/N ankle edema

Y N Y N Y

11. Signs and symptoms of an aortic aneurysm include: (Select all the apply) (5 pts) Y/N a pulsating mass Y/N bruit Y/N increased pedal pulses Y/N severe low back pain Y/N hypertension

Y Y N Y Y

Stridor

______ is associated with upper airway obstruction from swollen, inflamed tissues or a lodged foreign body.

Peripheral Vascular System and Lymphatics 1. A function of the venous system is: a. to hold more blood when blood volume increases. b. to conserve fluid and plasma proteins that leak out of the capillaries. c. to form a major part of the immune system that defends the body against disease. d. to absorb lipids from the intestinal tract.

Thorax and Lungs 13. The pulse oximeter measures: a. arterial oxygen saturation. b. venous oxygen saturation. c. combined saturation of arterial and venous blood. d. carboxyhemoglobin levels.

11. A dull percussion note forward of the left midaxillary line is: a. normal, an expected finding during splenic percussion. b. expected between the 8th and 12th ribs. c. found if the examination follows a large meal d. indicative of splenic enlargement

A patient is having difficulty in swallowing her medications and her food. In your charting, you would say that she is experiencing:

dysphagia.

Heart and neck vessels 24. What are the other 3 risk factors mentioned?

family history of heart disease, age, physical inactivity

beau line

furrow/groove/depression across nail. occurs bc of trauma that interrupts nail growth such as illness, toxic reaction, or local trauma.

decr

in bronchitis and pneumothorax, there is (inc/decr) tactile fremitus

incr

in pneumonia, there is (incr/decr) tactile fremitus

A patient is complaining of tenderness along the costovertebral angles. This is most often indicative of:

kidney inflammation.

bulla

larger than 1 cm. thin walled, ruptures easily. ex-blister

A mother brings her newborn baby boy in for her check-up; she tells you that he doesn't seem to be moving his right arm as much as his left, and that he seems to have pain when she lifts him up under the arms. You suspect a fractured clavicle and you would:

observe for limited ROM during the Moro reflex.

A patient who is visiting the clinic complains of having "stomach pains for 2 weeks" and describes his stools as being "soft and black" for about the last 10 days. He denies taking any medications. The nurse is aware that these symptoms are most indicative of:

occult blood resulting from gastrointestinal bleeding. ANS:C Page: 712. Black stools may be tarry due to occult blood (melena) from gastrointestinal bleeding or nontarry from ingestion of iron medications (not diet). Excessive fat causes the stool to become frothy; absence of bile pigment causes clay-colored stools.

jaundice

occurs with hepatitis, cirrhosis, sickle-cell disease, transfusion reaction, and hemolytic disease of newborn

errythema

occurs with polycythemia, venous stasis, CO2 poisoning, and extravascular presence of RBCs (petechiae, ecchymosis, hematoma)

During an examination, you note that a male patient has a red, round, superficial ulcer with a yellowish-serous discharge on his penis. Upon palpation, you note a nontender base that feels like a small button between your thumb and fingers. At this point you suspect that this patient has:

syphilitic chancre.

3. A 35-year-old recent immigrant is being seen in the clinic for complaints of a cough that is associated with rust-colored sputum, low-grade afternoon fevers, and night sweats for the past 2 months. The nurse's preliminary analysis, based on this history, is that this patient may be suffering from: (5 pts)

tuberculosis

gyrate

twisted, coils

Mrs. A. has had arthritis for years and is starting to notice that her fingers are drifting to the side. This is commonly referred to as:

ulnar deviation. caused by chronic rheumatoid arthritis

anasarca (bilateral edema, generalized edema)

with _______ , consider a central problem such as kidney or heart failure

less

you will feel (more/less) vibrations in a pt with bronchitis/pneumothorax

A 9-year-old girl is in the clinic for a sports physical. After some initial shyness she finally asks, "Am I normal? I don't seem to need a bra yet, but I have some friends who do. What if I never get breasts?" The nurse's best response would be:

"I understand that it is hard to feel different from your friends. Breasts usually develop between 8 and 10 years of age." ANS: D Page: 386 | Page: 400. Adolescent breast development usually begins between 8 and 10 years of age. The nurse should not belittle the girl's feelings by using statements like "don't worry" or by sharing personal experiences. The beginning of breast development precedes menarche by about 2 years.

Acanthosis Nigricans

-Velvety hyperpigmented skin in darker skin tones -Can be a cutaneous manifestation of insulin resistance, indicating increased risk for type 2 diabetes -Associated with overweight/obesity

A C E F

. The nurse is reviewing data collected after an assessment. Of the data listed below, which would be considered related cues that would be clustered together during data analysis? Select all that apply. a. Inspiratory wheezes noted in left lower lobes b. Hypoactive bowel sounds c. Nonproductive cough d. Edema, +2, noted on left hand e. Patient reports dyspnea upon exertion f. Rate of respirations 16 breaths per minute

a. A patient newly diagnosed with type 2 diabetes mellitus does not know how to check his own blood glucose levels with a glucometer. b. A teenager who was stung by a bee during a soccer match is having trouble breathing. c. An older adult with a urinary tract infection is also showing signs of confusion and agitation. problem

1. a = First-level priority problem 2. b = Second-level priority problem 3. c = Third-level priority

. A woman who has lived in the United States for a year after moving from Europe has learned to speak English and is almost finished with her college studies. She now dresses like her peers and says that her family in Europe would hardly recognize her. This nurse recognizes that this situation illustrates which concept? a. Assimilation b. Heritage consistency c. Biculturalism d. Acculturation

. During a follow-up visit, the nurse discovers that a patient has not been taking his insulin on a regular basis. The nurse asks, Why havent you taken your insulin? Which statement is an appropriate evaluation of this question? a. This question may place the patient on the defensive. b. This question is an innocent search for information. c. Discussing his behavior with his wife would have been better. d. A direct question is the best way to discover the reasons for his behavior.

3. A 35-year-old man is seen in the clinic for an infection in his left foot. Which of these findings should the nurse expect to see during an assessment of this patient? (5 pts) A. enlarged and tender inguinal nodes B. bilateral enlargement of the popliteal nodes C. decreased pulses to the affected extremity D. hard and fixed cervical nodes

A 2-week-old infant can fixate on an object but cannot follow a light or bright toy. The nurse would: a. Consider this a normal finding. b. Assess the pupillary light reflex for possible blindness. c. Continue with the examination, and assess visual fields. d. Expect that a 2-week-old infant should be able to fixate and follow an object.

A 31-year-old patient tells the nurse that he has noticed a progressive loss in his hearing. He says that it does seem to help when people speak louder or if he turns up the volume of a television or radio. The most likely cause of his hearing loss is: a. Otosclerosis. b. Presbycusis. c. Trauma to the bones. d. Frequent ear infections.

A 45-year-old farmer comes in for a skin evaluation and complains of hair loss on his head. His hair seems to be breaking off in patches, and he notices some scaling on his head. The nurse begins the examination suspecting: a. Tinea capitis. b. Folliculitis. c. Toxic alopecia. d. Seborrheic dermatitis.

A 68-year-old woman is in the eye clinic for a checkup. She tells the nurse that she has been having trouble reading the paper, sewing, and even seeing the faces of her grandchildren. On examination, the nurse notes that she has some loss of central vision but her peripheral vision is normal. These findings suggest that she may have: a. Macular degeneration. b. Vision that is normal for someone her age. c. The beginning stages of cataract formation. d. Increased intraocular pressure or glaucoma.

A 75-year-old woman is at the office for a preoperative interview. The nurse is aware that the interview may take longer than interviews with younger persons. What is the reason for this? a. An aged person has a longer story to tell. b. An aged person is usually lonely and likes to have someone with whom to talk. c. Aged persons lose much of their mental abilities and require longer time to complete an interview. d. As a person ages, he or she is unable to hear; thus the interviewer usually needs to repeat much of what is said

A 75-year-old woman who has a history of diabetes and peripheral vascular disease has been trying to remove a corn on the bottom of her foot with a pair of scissors. The nurse will encourage her to stop trying to remove the corn with scissors because: a. The woman could be at increased risk for infection and lesions because of her chronic disease. b. With her diabetes, she has increased circulation to her foot, and it could cause severe bleeding. c. She is 75 years old and is unable to see; consequently, she places herself at greater risk for self-injury with the scissors. d. With her peripheral vascular disease, her range of motion is limited and she may not be able to reach the corn safely.

A female nurse is interviewing a man who has recently immigrated. During the course of the interview, he leans forward and then finally moves his chair close enough that his knees are nearly touching the nurses knees. The nurse begins to feel uncomfortable with his proximity. Which statement most closely reflects what the nurse should do next? a. The nurse should try to relax; these behaviors are culturally appropriate for this person. b. The nurse should discreetly move his or her chair back until the distance is more comfortable, and then continue with the interview. c. These behaviors are indicative of sexual aggression, and the nurse should confront this person about his behaviors. d. The nurse should laugh but tell him that he or she is uncomfortable with his proximity and ask him to move away.

A female patient does not speak English well, and the nurse needs to choose an interpreter. Which of the following would be the most appropriate choice? a. Trained interpreter b. Male family member c. Female family member d. Volunteer college student from the foreign language studies department

A newly admitted patient is in acute pain, has not been sleeping well lately, and is having difficulty breathing. How should the nurse prioritize these problems? a. Breathing, pain, and sleep b. Breathing, sleep, and pain c. Sleep, breathing, and pain d. Sleep, pain, and breathing

A patient describes feeling an unreasonable, irrational fear of snakes. His fear is so persistent that he can no longer comfortably look at even pictures of snakes and has made an effort to identify all the places he might encounter a snake and avoids them. The nurse recognizes that he: a. Has a snake phobia. b. Is a hypochondriac; snakes are usually harmless. c. Has an obsession with snakes. d. Has a delusion that snakes are harmful, which must stem from an early traumatic incident involving snakes.

A patient drifts off to sleep when she is not being stimulated. The nurse can easily arouse her by calling her name, but the patient remains drowsy during the conversation. The best description of this patient's level of consciousness would be: a. Lethargic b. Obtunded c. Stuporous d. Semialert

A patient is admitted to the unit after an automobile accident. The nurse begins the mental status examination and finds that the patient has dysarthric speech and is lethargic. The nurse's best approach regarding this examination is to: a. Plan to defer the rest of the mental status examination. b. Skip the language portion of the examination, and proceed onto assessing mood and affect. c. Conduct an in-depth speech evaluation, and defer the mental status examination to another time. d. Proceed with the examination, and assess the patient for suicidal thoughts because dysarthria is often accompanied by severe depression.

A patient is at the clinic to have her blood pressure checked. She has been coming to the clinic weekly since she changed medications 2 months ago. The nurse should: a. Collect a follow-up data base and then check her blood pressure. b. Ask her to read her health record and indicate any changes since her last visit. c. Check only her blood pressure because her complete health history was documented 2 months ago. d. Obtain a complete health history before checking her blood pressure because much of her history information may have changed.

A patient tells the nurse that he has noticed that one of his moles has started to burn and bleed. When assessing his skin, the nurse pays special attention to the danger signs for pigmented lesions and is concerned with which additional finding? a. Color variation b. Border regularity c. Symmetry of lesions d. Diameter of less than 6 mm

A patient tells the nurse that she has had abdominal pain for the past week. What would be the nurses best response? a. Can you point to where it hurts? b. Well talk more about that later in the interview. c. What have you had to eat in the last 24 hours? d. Have you ever had any surgeries on your abdomen?

A patients laboratory data reveal an elevated thyroxine (T4) level. The nurse would proceed with an examination of the _____ gland. a. Thyroid b. Parotid c. Adrenal d. Parathyroid

A patients vision is recorded as 20/80 in each eye. The nurse interprets this finding to mean that the patient: a. Has poor vision. b. Has acute vision. c. Has normal vision. d. Is presbyopic.

A woman brings her husband to the clinic for an examination. She is particularly worried because after a recent fall, he seems to have lost a great deal of his memory of recent events. Which statement reflects the nurse's best course of action? a. Perform a complete mental status examination. b. Refer him to a psychometrician. c. Plan to integrate the mental status examination into the history and physical examination. d. Reassure his wife that memory loss after a physical shock is normal and will soon subside.

After completing an initial assessment of a patient, the nurse has charted that his respirations are eupneic and his pulse is 58 beats per minute. These types of data would be: a. Objective. b. Reflective. c. Subjective. d. Introspective.

An Asian-American woman is experiencing diarrhea, which is believed to be cold or yin. The nurse expects that the woman is likely to try to treat it with: a. Foods that are hot or yang. b. Readings and Eastern medicine meditations. c. High doses of medicines believed to be cold. d. No treatment is tried because diarrhea is an expected part of life.

As the nurse enters a patients room, the nurse finds her crying. The patient states that she has just found out that the lump in her breast is cancer and says, Im so afraid of, um, you know. The nurses most therapeutic response would be to say in a gentle manner: a. Youre afraid you might lose your breast? b. No, Im not sure what you are talking about. c. Ill wait here until you get yourself under control, and then we can talk. d. I can see that you are very upset. Perhaps we should discuss this later.

During an examination, the nurse knows that the best way to palpate the lymph nodes in the neck is described by which statement? a. Using gentle pressure, palpate with both hands to compare the two sides. b. Using strong pressure, palpate with both hands to compare the two sides. c. Gently pinch each node between ones thumb and forefinger, and then move down the neck muscle. d. Using the index and middle fingers, gently palpate by applying pressure in a rotating pattern.

During reporting, the nurse hears that a patient is experiencing hallucinations. Which is an example of a hallucination? a. Man believes that his dead wife is talking to him. b. Woman hears the doorbell ring and goes to answer it, but no one is there. c. Child sees a man standing in his closet. When the lights are turned on, it is only a dry cleaning bag. d. Man believes that the dog has curled up on the bed, but when he gets closer he sees that it is a blanket.

In an interview, the nurse may find it necessary to take notes to aid his or her memory later. Which statement is true regarding note-taking? a. Note-taking may impede the nurses observation of the patients nonverbal behaviors. b. Note-taking allows the patient to continue at his or her own pace as the nurse records what is said. c. Note-taking allows the nurse to shift attention away from the patient, resulting in an increased comfort level. d. Note-taking allows the nurse to break eye contact with the patient, which may increase his or her level of comfort.

The nurse discovers speech problems in a patient during an assessment. The patient has spontaneous speech, but it is mostly absent or is reduced to a few stereotypical words or sounds. This finding reflects which type of aphasia? a. Global b. Broca's c. Dysphonic d. Wernicke's

The nurse is administering a Mini-Cog test to an older adult woman. When asked to draw a clock showing the time of 10:45, the patient drew a clock with the numbers out of order and with an incorrect time. This result indicates which finding? a. Cognitive impairment b. Amnesia c. Delirium d. Attention-deficit disorder

The nurse is asking a patient for his reason for seeking care and asks about the signs and symptoms he is experiencing. Which of these is an example of a symptom? a. Chest pain b. Clammy skin c. Serum potassium level at 4.2 mEq/L d. Body temperature of 100 F

The nurse is assessing a patient who may have hearing loss. Which of these statements is true concerning air conduction? a. Air conduction is the normal pathway for hearing. b. Vibrations of the bones in the skull cause air conduction. c. Amplitude of sound determines the pitch that is heard. d. Loss of air conduction is called a conductive hearing loss

The nurse is examining a patient who tells the nurse, "I sure sweat a lot, especially on my face and feet but it doesn't have an odor." The nurse knows that this condition could be related to: a. Eccrine glands. b. Apocrine glands. c. Disorder of the stratum corneum. d. Disorder of the stratum germinativum.

The nurse is examining a patients retina with an ophthalmoscope. Which finding is considered normal? a. Optic disc that is a yellow-orange color b. Optic disc margins that are blurred around the edges c. Presence of pigmented crescents in the macular area d. Presence of the macula located on the nasal side of the retina

The nurse is interviewing a male patient who has a hearing impairment. What techniques would be most beneficial in communicating with this patient? a. Determine the communication method he prefers. b. Avoid using facial and hand gestures because most hearing-impaired people find this degrading. c. Request a sign language interpreter before meeting with him to help facilitate the communication. d. Speak loudly and with exaggerated facial movement when talking with him because doing so will help him lip read.

The nurse is obtaining a history from a 30-year-old male patient and is concerned about health promotion activities. Which of these questions would be appropriate to use to assess health promotion activities for this patient? a. Do you perform testicular self-examinations? b. Have you ever noticed any pain in your testicles? c. Have you had any problems with passing urine? d. Do you have any history of sexually transmitted diseases?

The nurse is performing an assessment on a 7-year-old child who has symptoms of chronic watery eyes, sneezing, and clear nasal drainage. The nurse notices the presence of a transverse line across the bridge of the nose, dark blue shadows below the eyes, and a double crease on the lower eyelids. These findings are characteristic of: a. Allergies. b. Sinus infection. c. Nasal congestion. d. Upper respiratory infection.

The nurse is performing an external eye examination. Which statement regarding the outer layer of the eye is true? a. The outer layer of the eye is very sensitive to touch. b. The outer layer of the eye is darkly pigmented to prevent light from reflecting internally. c. The trigeminal nerve (CN V) and the trochlear nerve (CN IV) are stimulated when the outer surface of the eye is stimulated. d. The visual receptive layer of the eye in which light waves are changed into nerve impulses is located in the outer layer of the eye.

The nurse is testing a patients visual accommodation, which refers to which action? a. Pupillary constriction when looking at a near object b. Pupillary dilation when looking at a far object c. Changes in peripheral vision in response to light d. Involuntary blinking in the presence of bright light

The nurse makes which adjustment in the physical environment to promote the success of an interview? a. Reduces noise by turning off televisions and radios b. Reduces the distance between the interviewer and the patient to 2 feet or less c. Provides a dim light that makes the room cozy and helps the patient relax d. Arranges seating across a desk or table to allow the patient some personal space

The nurse recognizes that working with children with a different cultural perspective may be especially difficult because: a. Children have spiritual needs that are influenced by their stages of development. b. Children have spiritual needs that are direct reflections of what is occurring in their homes. c. Religious beliefs rarely affect the parents perceptions of the illness. d. Parents are often the decision makers, and they have no knowledge of their childrens spiritual needs.

The patients record, laboratory studies, objective data, and subjective data combine to form the: a. Data base. b. Admitting data. c. Financial statement. d. Discharge summary.

When reviewing the demographics of ethnic groups in the United States, the nurse recalls that the largest and fastest growing population is: a. Hispanic. b. Black. c. Asian. d. American Indian.

When taking a history from a newly admitted patient, the nurse notices that he often pauses and expectantly looks at the nurse. What would be the nurses best response to this behavior? a. Be silent, and allow him to continue when he is ready. b. Smile at him and say, Dont worry about all of this. Im sure we can find out why youre having these pains. c. Lean back in the chair and ask, You are looking at me kind of funny; there isnt anything wrong, is there? d. Stand up and say, I can see that this interview is uncomfortable for you. We can continue it another time.

While discussing the history of a 6-month-old infant, the mother tells the nurse that she took a significant amount of aspirin while she was pregnant. What question would the nurse want to include in the history? a. Does your baby seem to startle with loud noises? b. Has your baby had any surgeries on her ears? c. Have you noticed any drainage from her ears? d. How many ear infections has your baby had since birth?

While performing an assessment of a 65-year-old man with a history of hypertension and coronary artery disease, the nurse notices the presence of bilateral pitting edema in the lower legs. The skin is puffy and tight but normal in color. No increased redness or tenderness is observed over his lower legs, and the peripheral pulses are equal and strong. In this situation, the nurse suspects that the likely cause of the edema is which condition? a. Heart failure b. Venous thrombosis c. Local inflammation d. Blockage of lymphatic drainage

The nurse is preparing for a certification course in skin care and needs to be familiar with the various lesions that may be identified on assessment of the skin. Which of the following definitions are correct? Select all that apply. a. Petechiae: Tiny punctate hemorrhages, 1 to 3 mm, round and discrete, dark red, purple, or brown in color b. Bulla: Elevated, circumscribed lesion filled with turbid fluid (pus) c. Papule: Hypertrophic scar d. Vesicle: Known as a friction blister e. Nodule: Solid, elevated, and hard or soft growth that is larger than 1 cm

A , D, E

A 42-year-old patient of Asian descent is being seen at the clinic for an initial examination. The nurse knows that including cultural information in his health assessment is important to: a. Identify the cause of his illness. b. Make accurate disease diagnoses. c. Provide cultural health rights for the individual. d. Provide culturally sensitive and appropriate care.

A C E F

A full mental status examination should be completed if the patient: A. has a change in behavior and the family is concerned. B. develops dysphagia. C. has a new diagnosis of type 2 diabetes mellitus. D. complains of insomnia.

A major characteristic of dementia is: A. impaired short-term and long-term memory. B. hallucinations. C. sudden onset of symptoms. D. cognitive deficits that are substance-induced.

A patient is brought by ambulance to the emergency department with multiple traumas received in an automobile accident. He is alert and cooperative, but his injuries are quite severe. How would the nurse proceed with data collection? a. Collect history information first, then perform the physical examination and institute life-saving measures. b. Simultaneously ask history questions while performing the examination and initiating life-saving measures. c. Collect all information on the history form, including social support patterns, strengths, and coping patterns. d. Perform life-saving measures and delay asking any history questions until the patient is transferred to the intensive care unit.

A patient is diagnosed with agoraphobia. Which characteristic behavior would the nurse observe in the patient? 1 The patient feels reluctant to leave home. 2 The patient has difficulty in making decisions. 3 The patient washes his or her hands every 15 minutes. 4 The patient has a debilitating fear of enclosed spaces

A patient reports having difficulty sleeping and concentrating. During the interview, the nurse finds out that the patient's father died suddenly in an accident that the patient witnessed a few days earlier. The nurse observes that the patient gets startled even at the sound of knock on the door. Which condition does the nurse suspect in this patient? 1 Panic attack 2 Specific phobia 3 Generalized anxiety disorder 4 Posttraumatic stress disorder (PTSD)

A patient tells the nurse about being extremely fearful of dogs. The patient has stopped going to the park to take walks because of this. What does the nurse conclude from this finding? 1 The patient has agoraphobia. 2 The patient has a specific phobia. 3 The patient has a generalized anxiety disorder. 4 The patient has obsessive-compulsive disorder.

A patient tells the nurse that he is very nervous, is nauseated, and feels hot. These types of data would be: a. Objective. b. Reflective. c. Subjective. d. Introspective.

A patient tells the nurse, "My favorite activity is to asteldish. And then sometimes I take my oddley and schmake with it." Which abnormality does the patient exhibit? 1 Echolalia 2 Neologism 3 Perseveration 4 Circumstantiality

A visiting nurse is making an initial home visit for a patient who has many chronic medical problems. Which type of data base is most appropriate to collect in this setting? a. A follow-up data base to evaluate changes at appropriate intervals b. An episodic data base because of the continuing, complex medical problems of this patient c. A complete health data base because of the nurses primary responsibility for monitoring the patients health d. An emergency data base because of the need to collect information and make accurate diagnoses rapidly

The nurse is percussing the seventh right intercostal space at the midclavicular line over the liver. Which sound should the nurse expect to hear? A) Dullness B) Tympany C) Resonance D) Hyperresonance

A) Dullness The liver is located in the right upper quadrant and would elicit a dull percussion note. REF: Page: 541

While performing an assessment of a 65-year-old man with a history of hypertension and coronary artery disease, the nurse notices the presence of pitting edema in the lower legs bilaterally. The skin is puffy and tight but of normal color. There is no increased redness or tenderness over his lower legs, and the peripheral pulses are equal and strong. In this situation, the nurse suspects that the likely cause of the edema would be: A) heart failure. B) venous thrombosis. C) a local inflammation. D) blockage of lymphatic drainage.

A) heart failure. Bilateral edema or edema that is generalized over the entire body is caused by a central problem such as heart failure or kidney failure. Unilateral edema usually has a local or peripheral cause. Page 215

15. A woman who is 8 months pregnant comments that she has noticed a change in posture and is having lower back pain. The nurse tells her that during pregnancy women have a posture shift to compensate for the enlarging fetus. This shift in posture is known as: A) lordosis. B) scoliosis. C) ankylosis. D) kyphosis.

A) lordosis. Lordosis compensates for the enlarging fetus, which would shift the center of balance forward. This shift in balance in turn creates strain on the low back muscles, felt as low back pain during late pregnancy by some women. Scoliosis is lateral curvature of portions of the spine; ankylosis is extreme flexion of the wrist, as seen with severe rheumatoid arthritis; and kyphosis is an enhanced thoracic curvature of the spine. Page 573

A woman is in the clinic for an annual gynecologic examination. The nurse should plan to begin the interview with the: A) menstrual history because it is generally nonthreatening. B) obstetric history because it is the most important information. C) urinary system history because there may be problems in this area as well. D) sexual history because it will build rapport to discuss this first.

A) menstrual history because it is generally nonthreatening. Menstrual history is usually nonthreatening; thus it is a good place to start. Obstetric, urinary, and sexual histories are also part of the interview but not necessarily the best topics with which to start.

A 75-year-old woman who has a history of diabetes and peripheral vascular disease has been trying to remove a corn on the bottom of her foot with a pair of scissors. The nurse will encourage her to stop trying to remove the corn with scissors because: A) the woman could be at increased risk for infection and lesions because of her chronic disease. B) with her diabetes, she has increased circulation to her foot and it could cause severe bleeding. C) she is 75 years old and is unable to see, so she puts herself at greater risk for self-injury with the scissors. D) with her peripheral vascular disease, her range of motion is limited and she may not be able to reach the corn safely.

A) the woman could be at increased risk for infection and lesions because of her chronic disease A personal history of diabetes and peripheral vascular disease increases a person's risk for skin lesions in the feet or ankles. The patient needs to see a professional for assistance with corn removal. Pages: 210-211

The nurse is preparing for a certification course in skin care and needs to be familiar with the various lesions that may be identified on the assessment of the skin. Which of the following definitions are correct? (select all that apply) A. Petechiae: tiny punctuate hemorrhages, 1-3 mm, round and discrete, dark red, purple, or brown in color B. Bulla: elevated, circumscribed lesions filled with turbid fluid (pus) C. papule: hypertrophic scar D. vesicle: known as friction blister E. nodule: solid, elevated, and hard or soft growth that is larger than 1cm

A, D, E

Mr. Quigley is a 56-year-old man who presents with a complaint of testicular swelling. On examination you note swelling that occurs in the epididymis as a result of a cyst. Which of the following conditions best describes these clinical findings? A. A spermatocele B. Epispadias C. Balanitis D. A hydrocele

A. A spermatocele

Which of the following occurs with endometriosis? A. Aberrant endometrial tissue growth B. Cervical polyps C. Ovarian cysts D. Red-tinged or bloody urine

A. Aberrant endometrial tissue growth

In which of the following ethnic groups would you expect to see the lowest incidence of osteoporosis? A. Blacks B. Whites C. Asians/Pacific Islanders D. Native Americans

A. Blacks

Mrs. Walker is a 68-year-old patient who is in very good health and comes to the clinic for a routine health assessment. Even though she is in good health, she shows signs of aging. Which is true for older adults? A. Decreased salivation leads to dry mouth. B. Gastric acid secretion increases. C. Liver size increases. D. None of the above.

A. Decreased salivation leads to dry mouth.

Ballottement of the patella is used to assess which of the following? A. Fluid in the knee B. Pain with knee flexion C. Crepitus with palpation of the knee joint D. Presence of an audible pop or click

A. Fluid in the knee

Mr. Holmes is a 54-year-old patient who comes to the clinic for an initial dermatology assessment. On examination, you note a suppurative, inflammatory skin lesion due to an infected hair follicle. Which of the following terms best describes this lesion? A. Furuncle B. Pustule C. Fissure D. Acne

A. Furuncle

Which of the following physiologic processes takes place within the musculoskeletal system? A. Hematopoiesis B. Hemolysis C. Hemoptysis D. Hemianopsia

A. Hematopoiesis

Which of the following statements about hair is correct? A. In humans, hair is vestigial. B. In humans, hair is necessary to protect from cold or trauma. C. Humans have one type of hair. D. None of the above.

A. In humans, hair is vestigial.

The shock absorber of the vertebral disks in the spine is which of the following? A. Nucleus pulposus B. Costal facet C. Vertebral bursae D. Nucleus fasciculi

A. Nucleus pulposus

When you assess an individual for the presence of a herniated nucleus pulposus, which of the following maneuvers should you ask the individual to perform? A. Raise the legs straight while keeping the knee extended. B. Bend over and attempt to touch the ground while keeping the legs straight. C. Do a knee bend. D. Abduct and adduct the legs while keeping the knee extended.

A. Raise the legs straight while keeping the knee extended.

Osteoporosis in older adults is due to which of the following factors? A. Resorption of bone at a greater rate than deposition B. Loss of water content and thinning of the intervertebral disks of the spinal column C. A redistribution of fat and subcutaneous tissue D. Loss of intervertebral cushioning resulting in an increased amount of weight-bearing on the long bones

A. Resorption of bone at a greater rate than deposition

The left upper quadrant of the abdomen contains which of the following organs? A. Stomach B. Gallbladder C. Ureter D. Ovary

A. Stomach

The inguinal canal is: A. a narrow tunnel inferior to the inguinal ligament. B. a muscular duct continuous with the epididymis. C. a narrow tunnel superior to the inguinal ligament. D. the joining of the vas deferens and the seminal vesicle.

A. a narrow tunnel inferior to the inguinal ligament.

The corona is: A. a shoulder where the glans joins the shaft. B. a hood or flap of skin over the glans. C. a corpus spongiosum cone of erectile tissue. D. folds of thin skin on the scrotal wall.

A. a shoulder where the glans joins the shaft

The pancreas is: A. a soft, lobulated gland behind the stomach. B. a soft mass of lymphatic tissue on the postlateral wall. C. a bean-shaped, retroperitoneal gland. D. None of the above

A. a soft, lobulated gland behind the stomach.

The epididymis is: A. a sperm storage site. B. folds of thin skin on the scrotal wall. C. the joining of the vas deferens with the seminal vesicle. D. the muscle that controls the size of the scrotum.

A. a sperm storage site.

The nurse is performing an assessment on a 7 year old child who has symptoms of chronic watery eyes, sneezing, and clear nasal drainage. The nurse notices the presence of a transverse line across the bridge of the nose, dark blue shadows below the eyes, and a double crease on the lower eyelids. These findings are characteristics of: A. allergies B. sinus infection C. nasal congestion D. upper respiratory infection

A. allergies

Mr. Jenkins is a 43-year-old patient who goes to the ambulatory health center with complaints of muscle pain. When testing for muscle strength, the examiner: A. applies an opposing force against the individual's actions during ROM of a joint. B. asks the individual to try to break the examiner's joint movements during ROM. C. measures the degree of muscle tension developed during active extension and flexion of a joint. D. can assume that if an individual has adequate active ROM that muscle strength is fully developed.

A. applies an opposing force against the individual's actions during ROM of a joint.

Mr. Kimbel is a 71-year-old patient who comes to the clinic with his daughter, who is concerned about a mole on her father's abdomen. You know that moles: A. are common on the abdomen. B. are uncommon on the abdomen. C. always require a biopsy. D. are no cause for concern.

A. are common on the abdomen.

A patient tells the nurse that he has noticed that one of his moles has started to burn and bleed. When assessing his skin, the nurse pays special attention to the danger signs for pigmented lesions and is concerned with which additional finding? A. color variation B. border regularity C. symmetry of lesions D. diameter of less than 6mm

A. color variation

During an examination of a 3 year old child, the nurse notices a bruit over the left temporal area. The nurse should: A. continue the examination because a bruit is a normal finding for his age. B. check for the bruit again 1 hour C. notify the parents that a bruit has been detected in their child D. stop the examination, and notify the physician

A. continue the examination because a bruit is a normal finding for his age. Bruits are common in the skull in children under 4 or 5 years of age and in children with anemia. They are systolic or continuous and are heard over the temporal area

Mrs. Davids is a 55-year-old patient who presents with complaints of spots in her nails. As the health care provider, you know that the components of a nail examination include: A. contour, consistency, and color. B. shape, surface, and circulation. C. clubbing, pitting, and grooving. D. texture, toughness, and translucency.

A. contour, consistency, and color.

The lateral view of the spine demonstrates two types of curvature associated with specific divisions of the spinal columns. The two types are: A. convex and concave. B. convex and ellipsoid. C. parabolic and concave. D. parabolic and ellipsoid.

A. convex and concave.

When examining children affected with Down syndrome (trisomy 21), the nurse looks for the possible presence of: A. ear dysplasia B. long, thin neck C. protruding thin tongue D. narrow and raised nasal bridge

A. ear dysplasia With the chromosomal aberration trisomy 21 (Down syndrome), head and face characteristics may include upslanting eyes and inner epicanthal folds, a flat nasal bridge, a small broad flat nose, a protruding thick tongue, ear dysphagia, a short broad neck with webbing, and small hands with a single palmar crease.

For the spleen to be palpable, it must be: A. enlarged three times its normal size. B. enlarged twice its normal size. C. located superficially under the 11th rib. D. rotated to the left side.

A. enlarged three times its normal size.

Bundles of muscle fibers that compose skeletal muscle are identified as: A. fasciculi. B. fasciculations. C. ligaments. D. tendons.

A. fasciculi.

Myoma is a(n): A. hard, painless nodule in the uterine wall. B. extrauterine endometrial nodule. C. cervical nodule. D. enlarged Skene's gland.

A. hard, painless nodule in the uterine wall.

During a well-baby checkup, a other is concerned because her 2 month old infant cannot hold her head up when she is pulled to a sitting position. Which response by the nurse is appropriate? A. head control is usually achieved by 4 months of age B. you shouldn't be trying to pull your baby up like that until she is older C. head control should be achieved at this time D. this inability indicates possible nerve damage to the neck muscles

A. head control is usually achieved by 4 months of age

While performing an assessment of a 65 year old man with a history of hypertension and coronary artery disease, the nurse notices the presence of bilateral pitting edema in the lower legs. The skin is puffy and tight but normal in color. No increased redness or tenderness is observed over his lower legs, and the peripheral pulses are equal and strong. In this situation, the nurse suspects that the likely cause of the edema is which condition? A. heart failure B. venous thrombosis C. local inflammation D. blockage of lymphatic drainage

A. heart failure bilateral edema or edema that s generalized over the entire body is caused by a central problem such a heart failure or kidney failure. unilateral edema usually has a local or peripheral cause

Mrs. Gomeller is a 39-year-old patient who presents to the health clinic. After her examination, you have diagnosed Mrs. Gomeller with menorrhagia. Menorrhagia is a term that describes: A. heavy menses. B. the absence of menstruation. C. scant menstruation. D. None of the above

A. heavy menses.

Cystic fluid in the tunica vaginalis surrounding the testes is called: A. hydrocele. B. varicocele. C. orchitis. D. cryptorchidism.

A. hydrocele.

The penis: A. is composed of two corpora cavernosa and one corpus spongiosum. B. is composed of glans, shaft, and scrotum C. contains the urethra, ejaculatory duct, and testes. D. All of the above

A. is composed of two corpora cavernosa and one corpus spongiosum.

Mrs. Black is a 59-year-old patient who presents to the health center with a complaint of being postmenopausal. When providing patient education to Mrs. Black, you would explain that the postmenopausal woman: A. is more prone to vaginitis. B. is less prone to vaginitis. C. has no change in vaginitis risk. D. None of the above

A. is more prone to vaginitis.

The nurse just noted from the medical record that the patient has a lesion that is confluent in nature. On examination, the nurse expects to find: A. lesions that run together B. annular lesions that have grown together C. lesions arranged in a line along a nerve route D. lesions that are grouped or clustered together

A. lesions that run together confluent lesions (as with urticaria- hives) run together.

Mrs. Peterson is a 43-year-old patient who presents to the women's health clinic from her primary care provider. During the taking of her history, Mrs. Peterson complains of a heavy menstrual flow. An excessively heavy menstrual flow is called: A. menorrhagia. B. multipara. C. salpingitis. D. bloody show.

A. menorrhagia.

Heberden's and Bouchard's nodes are hard and nontender and are associated with: A. osteoarthritis. B. rheumatoid arthritis. C. Dupuytren's contracture. D. metacarpophalangeal bursitis.

A. osteoarthritis.

Dysuria is a term indicating: A. painful urination. B. clear mucous vaginal discharge. C. malodorous vaginal discharge. D. frequent urination.

A. painful urination.

A soft, lobulated gland located behind the stomach is the: A. pancreas. B. liver. C. gallbladder. D. spleen.

A. pancreas.

A flat macular hemorrhage is called a(n): A. purpura. B. ecchymosis. C. petechiae. D. hemangioma.

A. purpura.

Mrs. Wilder, a 42-year-old patient, presents to the dermatology clinic with a confluent and extensive patch of petechiae and ecchymoses; flat macular hemorrhage is called a: A. purpura. B. hemangioma. C. hematoma. D. telengiectasia.

A. purpura.

Mrs. Buckman is a 49-year-old patient who comes to the women's health clinic. On examination, you note a prolapse of the rectum and its vaginal mucosa into the vagina. This is the definition of: A. rectocele. B. menorrhagia. C. hematuria. D. nullipara.

A. rectocele.

Crepitation is an audible sound that is produced by: A. roughened articular surfaces moving over each other. B. tendons or ligaments that slip over bones during motion. C. joints that are stretched when placed in hyperflexion or hyperextension. D. an inflamed bursa.

A. roughened articular surfaces moving over each other.

When examining the patents CN function, the nurse remembers that the muscles in the neck are innervated by CN XI are the: A. sternomastoid and trapezius B. spinal accessory and omohyoid C. trapezius and sternomandibular D. sternomandibular and spinal accessory

A. sternomastoid and trapezius

Chancre is a(n): A. superficial, painless ulcer. B. aberrant growth of endometrial tissue. C. hard, painless nodule in the uterine wall. D. discoloration of the cervix.

A. superficial, painless ulcer.

The nurse suspects that a patient has hyperthyroidism and the lab data indicate that the patients T4 and T3 hormone levels are elevated. Which of these findings would the nurse likely find on examination? A. tachycardia B. constipation C. rapid dyspnea D. atrophied nodular thyroid gland

A. tachycardia T4 and T3 stimulate rate of cellular metabolism, resulting in tachycardia. with enlarged thyroid gland in hyperthyroidism, the nurse might expect to find diffuse enlargement (goiter) or a nodular lump but not an atrophied gland.

The ejaculatory duct is: A. the joining of the vas deferens and the seminal vesicle. B. a muscular duct continuous with the epididymis. C. a narrow tunnel inferior to the inguinal ligament. D. a narrow tunnel superior to the inguinal ligament.

A. the joining of the vas deferens and the seminal vesicle.

A 75-year-old woman who has a history of diabetes and peripheral vascular disease has been trying to remove a corn on the bottom of her foot with a pair of scissors. The nurse will encourage her to stop trying to remove the corn with scissors because: A. the woman could be at increased risk for infection and lesions because of her chronic disease B. with her diabetes, she has increased circulation to her foot, and it could cause severe bleeding C. she is 75 years old and is unable to see; consequently, she places herself at greater risk for self-injury with the scissors D. With her peripheral vascular disease, her range of motion is limited, and she may be able to reach the corn safely.

A. the woman could be at increased risk for infection and lesions because of her chronic disease

A patients lab data reveals an elevated thyroxine (T4) level. The nurse would proceed with an examination of the ____ gland. A. thyroid B. parotid C. adrenal D. parathyroid

A. thyroid thyroid gland secretes T3 and T4.

A 45 year old farmer comes in for a skin evaluation that complains of hair loss on his head. His hair seems to be breaking off in patches, and he notices some scaling on his head. the nurse begins the examination suspecting: A. tina capitis B. folliculitis C. toxic alopecia D. seborrheic dermatitis

A. tinea capitis tinea cpaitis is rounded patchy hair loss on the scalp, leaving broken-off hairs, pustules, and scales n the skin, and is caused by fungal infection. Lesions are fluorescent under a Wood light and are usually observed in children and farmers; tinea capitis is highly contagious

A pinpoint, constricted opening at the meatus or inside along the urethra is: A. urethral stricture. B. urethritis. C. acuminate. D. progenitalis.

A. urethral stricture.

During an examination, the nurse knows that the best way to palpate the lymph nodes in the neck is described by which statement? A. using gentle pressure, palpate with both hands to compare the two sides. B. using strong pressure, palpate with both hands to compare the two sides. C. gently pinch each node between ones thumb and forefinger, and then move down the neck muscle D. using the index and middle fingers, gently palpate by applying pressure in a rotating pattern.

A. using gentle pressure, palpate with both hands to compare the two sides

During an examination, the nurse finds that a patient has excessive dryness of the skin. The best term to describe this condition is: A. xerosis B. pruritus C. alopecia D. seborrhea

A. xerosis

A mother asks when her newborn infant's eyesight will be developed. The nurse should reply:

ANS: "By about 3 months, infants develop more coordinated eye movements and can fixate on an object." Eye movements may be poorly coordinated at birth, but by 3 to 4 months of age, the infant should establish binocularity and should be able to fixate on a single image with both eyes simultaneously

A mother brings her 4-month-old infant to the clinic with concerns regarding a small pad in the middle of the upper lip that has been there since 1 month of age. The infant has no health problems. On physical examination, the nurse notices a 0.5-cm, fleshy, elevated area in the middle of the upper lip. No evidence of inflammation or drainage is observed. What would the nurse tell this mother? a. "This area of irritation is caused from teething and is nothing to worry about." b. "This finding is abnormal and should be evaluated by another health care provider." c. "This area of irritation is the result of chronic drooling and should resolve within the next month or two." d. "This elevated area is a sucking tubercle caused from the friction of breastfeeding or bottle-feeding and is normal."

ANS: D A normal finding in infants is the sucking tubercle, a small pad in the middle of the upper lip from the friction of breastfeeding or bottle-feeding. This condition is not caused by irritation, teething, or excessive drooling, and evaluation by another health care provider is not warranted.

A patient's vision is recorded as 20/80 in each eye. The nurse interprets this finding to mean that the patient:

ANS: Has poor vision. Normal visual acuity is 20/20 in each eye. The larger the denominator, the poorer the vision.

A 52-year-old patient describes the presence of occasional "floaters" or "spots" moving in front of his eyes. The nurse should:

ANS: Know that floaters are usually not significant and are caused by condensed vitreous fibers. Floaters are a common sensation with myopia or after middle age owing to condensed vitreous fibers. Usually they are not significant, but acute onset of floaters may occur with retinal detachment.

The nurse is reviewing for a class in age-related changes in the eye. Which of these physiological changes is responsible for presbyopia?

ANS: Loss of lens elasticity The lens loses elasticity and decreases its ability to change shape to accommodate for near vision. This condition is called presbyopia.

A 60-year-old man is at the clinic for an eye examination. The nurse suspects that he has ptosis of one eye. How should the nurse check for this?

ANS: Observe the distance between the palpebral fissures. Ptosis is drooping of the upper eyelid that would be apparent by observing the distance between the upper and lower eyelids. The confrontation test measures peripheral vision. Measuring near vision or the corneal light test does not check for ptosis.

The nurse is performing the diagnostic positions test. Normal findings would be which of these results?

ANS: Parallel movement of both eyes A normal response for the diagnostic positions test is parallel tracking of the object with both eyes. Eye movement that is not parallel indicates weakness of an extraocular muscle or dysfunction of the cranial nerve innervating it.

The nurse is testing a patient's visual accommodation, which refers to which action?

ANS: Pupillary constriction when looking at a near object The muscle fibers of the iris contract the pupil in bright light and accommodate for near vision, which also results in pupil constriction. The other responses are not correct.

When assessing the pupillary light reflex, the nurse should use which technique?

ANS: Shine a light across the pupil from the side and observe for direct and consensual pupillary constriction. To test the pupillary light reflex, the nurse should advance a light in from the side and note the direct and consensual pupillary constriction.

A patient is unable to read even the largest letters on the Snellen chart. The nurse should take which action next?

ANS: Shorten the distance between the patient and the chart until it is seen and record that distance. If the person is unable to see even the largest letters, then the nurse should shorten the distance to the chart until it is seen and should record that distance (e.g., "10/200"). If visual acuity is even lower, then the nurse should assess whether the person can count fingers when they are spread in front of the eyes or can distinguish light perception from a penlight. If vision is poorer than 20/30, then a referral to an ophthalmologist or optometrist is necessary, but first the nurse must assess the visual acuity.

The nurse is conducting a visual examination. Which of these statements regarding visual pathways and visual fields is true?

ANS: The image formed on the retina is upside down and reversed from its actual appearance in the outside world. The image formed on the retina is upside down and reversed from its actual appearance in the outside world. The light rays are refracted through the transparent media of the eye before striking the retina, and the nerve impulses are conducted through the optic nerve tract to the visual cortex of the occipital lobe of the brain. The left side of the brain interprets vision for the right eye.

The nurse is performing an external eye examination. Which statement regarding the outer layer of the eye is true?

ANS: The outer layer of the eye is very sensitive to touch. The cornea and the sclera make up the outer layer of the eye. The cornea is very sensitive to touch. The middle layer, the choroid, has dark pigmentation to prevent light from reflecting internally. The trigeminal (CN V) and facial (CN VII) are stimulated when the outer surface of the eye is stimulated. The retina, in the inner layer of the eye, is where light waves are changed into nerve impulses.

ANS: The patient experiences tunnel vision in late stages. Vision loss begins with peripheral vision. There are virtually no symptoms. Open-angle glaucoma is the most common type of glaucoma; there are virtually no symptoms. Vision loss begins with the peripheral vision, which often goes unnoticed because individuals learn to compensate intuitively by turning their heads. The other characteristics are those of closed-angle glaucoma.

During an assessment of the sclera of an African-American patient, the nurse would consider which of these an expected finding?

ANS: The presence of small brown macules on the sclera In dark-skinned people, one normally may see small brown macules in the sclera.

The nurse is performing an eye assessment on an 80-year-old patient. Which of these findings is considered abnormal?

ANS: Unequal pupillary constriction in response to light Pupils are small in old age, and the pupillary light reflex may be slowed, but pupillary constriction should be symmetric. The assessment findings in the other responses are considered normal in older persons.

The nurse is preparing to assess the visual acuity of a 16-year-old patient. How should the nurse proceed?

ANS: Use the Snellen chart positioned 20 feet away from the patient. The Snellen alphabet chart is the most commonly used and most accurate measure of visual acuity. The confrontation test is a gross measure of peripheral vision. The Jaeger card or newspaper tests are used to test near vision.

The nurse notices the presence of periorbital edema when performing an eye assessment on a 70-year-old patient. The nurse should:

ANS: ask the patient if he or she has a history of heart failure. Periorbital edema occurs with local infections, crying, and systemic conditions such as heart failure, renal failure, allergy, and hypothyroidism. Periorbital edema is not associated with blepharitis.

When performing the corneal light reflex assessment, the nurse notes that the light is reflected at 2 o'clock in each eye. The nurse should:

ANS: consider this a normal finding. Reflection of the light on the corneas should be in exactly the same spot on each eye, or symmetric. If asymmetry is noted, then the nurse should administer the cover test.

In using the ophthalmoscope to assess a patient's eyes, the nurse notices a red glow in the patient's pupils. On the basis of this finding, the nurse would:

ANS: consider this a normal reflection of the ophthalmoscope light off the inner retina. The red glow filling the person's pupil is the red reflex, and it is a normal finding caused by the reflection of the ophthalmoscope light off the inner retina. The other responses are not correct.

A patient comes into the clinic complaining of pain in her right eye. On examination, the nurse sees a pustule at the lid margin that is painful to touch, red, and swollen. The nurse recognizes that this is

ANS: dacryocystitis. A hordeolum, or stye, is a painful, red, and swollen pustule at the lid margin. A chalazion is a nodule protruding on the lid, toward the inside, and is nontender, firm, with discrete swelling. Dacryocystitis is an inflammation of the lacrimal sac. Blepharitis is inflammation of the eyelids. See Table 14-3.

During a physical education class, a student is hit in the eye with the end of a baseball bat. When examined in the emergency department, the nurse notices the presence of blood in the anterior chamber of the eye. This finding indicates the presence of:

ANS: hyphema. Hyphema is the term for blood in anterior chamber is a serious result of blunt trauma (a fist or a baseball) or spontaneous hemorrhage and may indicate scleral rupture or major intraocular trauma. See Table 14-7 for descriptions of the other terms.

An ophthalmic examination reveals papilledema. The nurse is aware that this finding indicates:

ANS: increased intracranial pressure. Papilledema, or choked disk, is a serious sign of increased intracranial pressure, which is caused by a space-occupying mass such as a brain tumor or hematoma. This pressure causes venous stasis in the globe, showing redness, congestion, and elevation of the optic disc, blurred margins, hemorrhages, and absent venous pulsations. Papilledema is not associated with the conditions in the other responses.

In a patient who has anisocoria, the nurse would expect to observe:

ANS: pupils of unequal size. Unequal pupil size is termed anisocoria. It exists normally in 5% of the population but may also be indicative of central nervous system disease.

A patient comes to the emergency department after a boxing match, and his left eye is swollen almost shut. He has bruises on his face and neck. He says he is worried because he "can't see well" from his left eye. The physician suspects retinal damage. The nurse recognizes that signs of retinal detachment include:

ANS: shadow or diminished vision in one quadrant or one half of the visual field. With retinal detachment, the person has shadows or diminished vision in one quadrant or one half of the visual field. The other responses are not signs of retinal detachment.

A 68-year-old woman is in the eye clinic for a checkup. She tells the nurse that she has been having trouble with reading the paper, sewing, and even seeing the faces of her grandchildren. On examination, the nurse notes that she has some loss of central vision but her peripheral vision is normal. These findings suggest that:

ANS: she may have macular degeneration. Macular degeneration is the most common cause of blindness. It is characterized by loss of central vision. Cataracts would show lens opacity. Chronic open-angle glaucoma, the most common type of glaucoma, involves a gradual loss of peripheral vision.

The nurse is assessing color vision of a male child. Which statement is correct? The nurse should:

ANS: test for color vision once between the ages of 4 and 8. Test only boys for color vision once between the ages of 4 and 8 years. It is not tested in females because it is rare in females. Testing is done with the Ishihara test, which is a series of polychromatic cards.

The nurse is performing an eye-screening clinic at a daycare center. When examining a 2-year-old child, the nurse suspects that the child has "lazy eye" and should:

ANS: test for strabismus by performing the corneal light reflex test. Testing for strabismus is done by performing the corneal light reflex test as well as the cover test. The Snellen eye chart and confrontation test are not used to test for strabismus.

When a light is directed across the iris of a patient's eye from the temporal side, the nurse is assessing for:

ANS: the presence of shadows, which may indicate glaucoma. The presence of shadows in the anterior chamber may be a sign of acute angle-closure glaucoma. The normal iris is flat and creates no shadows. This is not the correct method for assessment for dacryocystitis, conjunctivitis, or cataracts.

Barrel chest

Anterior/posterior part bigger than transverse diameter. Hyperinflation of the lungs

Aphasia is best described as: A. a language disturbance in speaking, writing, or understanding. B. the impaired ability to carry out motor activities despite intact motor function. C. the impaired ability to recognize or identify objects despite intact sensory function. D. a disturbance in executive functioning (planning, organizing, sequencing, abstracting).

A 70-year-old man is visiting the clinic for difficulty in passing urine. In the history he indicates he has to urinate frequently, especially at night. He has burning when he urinates and has noticed pain in his back. Given this history, what might the nurse expect to find during the physical assessment?

Asymmetric, hard, fixed prostate gland ANS: a Subjective symptoms of carcinoma of the prostate include frequency, nocturia, hematuria, weak stream, hesitancy, pain or burning on urination, and continuous pain in lower back, pelvis, and thighs. Objective symptoms of carcinoma of the prostate include a malignant neoplasm often starts as a single hard nodule on the posterior surface, producing asymmetry and a change in consistency. As it invades normal tissue, multiple hard nodules appear, or the entire gland feels stone hard and fixed.

. During a visit to the clinic, a patient states, The doctor just told me he thought I ought to stop smoking. He doesnt understand how hard Ive tried. I just dont know the best way to do it. What should I do? The nurses most appropriate response in this case would be: a. Id quit if I were you. The doctor really knows what he is talking about. b. Would you like some information about the different ways a person can quit smoking? c. Stopping your dependence on cigarettes can be very difficult. I understand how you feel. d. Why are you confused? Didnt the doctor give you the information about the smoking cessation program we offer?

1. An older client has been diagnosed with pernicious anemia. The nurse knows that this condition could be related to: (5 pts) A. increased gastrointestinal emptying time B. decreased gastric acid secretion C. delayed gastrointestinal emptying time D. increased gastric acid secretion

A 16-year-old boy has just been admitted to the unit for overnight observation after being in an automobile accident. What is the nurses best approach to communicating with him? a. Use periods of silence to communicate respect for him. b. Be totally honest with him, even if the information is unpleasant. c. Tell him that everything that is discussed will be kept totally confidential. d. Use slang language when possible to help him open up.

A 22-year-old woman comes to the clinic because of severe sunburn and states, "I was out in the sun for just a couple of minutes." The nurse begins a medication review with her, paying special attention to which medication class? a. Nonsteroidal antiinflammatory drugs for pain b. Tetracyclines for acne c. Proton pump inhibitors for heartburn d. Thyroid replacement hormone for hypothyroidism

A 31-year-old patient tells the nurse that he has noticed pain in his left ear when people speak loudly to him. The nurse knows that this finding: a. Is normal for people of his age. b. Is a characteristic of recruitment. c. May indicate a middle ear infection. d. Indicates that the patient has a cerumen impaction.

A 40-year-old woman reports a change in mole size, accompanied by color changes, itching, burning, and bleeding over the past month. She has a dark complexion and has no family history of skin cancer, but she has had many blistering sunburns in the past. The nurse would: a. Tell the patient to watch the lesion and report back in 2 months. b. Refer the patient because of the suggestion of melanoma on the basis of her symptoms. c. Ask additional questions regarding environmental irritants that may have caused this condition. d. Tell the patient that these signs suggest a compound nevus, which is very common in young to middle-aged adults.

A 52-year-old woman has a papule on her nose that has rounded, pearly borders and a central red ulcer. She said she first noticed it several months ago and that it has slowly grown larger. The nurse suspects which condition? a. Acne b. Basal cell carcinoma c. Melanoma d. Squamous cell carcinoma

A female patient tells the nurse that she has had six pregnancies, with four live births at term and two spontaneous abortions. Her four children are still living. How would the nurse record this information? a. P-6, B-4, (S)Ab-2 b. Grav 6, Term 4, (S)Ab-2, Living 4 c. Patient has had four living babies. d. Patient has been pregnant six times.

A few days after a summer hiking trip, a 25-year-old man comes to the clinic with a rash. On examination, the nurse notes that the rash is red, macular, with a bull's eye pattern across his midriff and behind his knees. The nurse suspects: a. Rubeola. b. Lyme disease. c. Allergy to mosquito bites. d. Rocky Mountain spotted fever.

A male patient with a history of acquired immunodeficiency syndrome (AIDS) has come in for an examination and he states, I think that I have the mumps. The nurse would begin by examining the: a. Thyroid gland. b. Parotid gland. c. Cervical lymph nodes. d. Mouth and skin for lesions.

A mother brings her 28-month-old daughter into the clinic for a well-child visit. At the beginning of the visit, the nurse focuses attention away from the toddler, but as the interview progresses, the toddler begins to warm up and is smiling shyly at the nurse. The nurse will be most successful in interacting with the toddler if which is done next? a. Tickle the toddler, and get her to laugh. b. Stoop down to her level, and ask her about the toy she is holding. c. Continue to ignore her until it is time for the physical examination. d. Ask the mother to leave during the examination of the toddler, because toddlers often fuss less if their parent is not in view.

A patient is unable to differentiate between sharp and dull stimulation to both sides of her face. The nurse suspects: a. Bell palsy. b. Damage to the trigeminal nerve. c. Frostbite with resultant paresthesia to the cheeks. d. Scleroderma.

A patient repeats, "I feel hot. Hot, cot, rot, tot, got. I'm a spot." The nurse documents this as an illustration of: a. Blocking b. Clanging c. Echolalia d. Neologism

A patient reports excruciating headache pain on one side of his head, especially around his eye, forehead, and cheek that has lasted approximately to 2 hours, occurring once or twice each day. The nurse should suspect: a. Hypertension. b. Cluster headaches. c. Tension headaches. d. Migraine headaches.

A patient says that she has recently noticed a lump in the front of her neck below her Adams apple that seems to be getting bigger. During the assessment, the finding that leads the nurse to suspect that this may not be a cancerous thyroid nodule is that the lump (nodule): a. Is tender. b. Is mobile and not hard. c. Disappears when the patient smiles. d. Is hard and fixed to the surrounding structures.

A patients vision is recorded as 20/30 when the Snellen eye chart is used. The nurse interprets these results to indicate that: a. At 30 feet the patient can read the entire chart. b. The patient can read at 20 feet what a person with normal vision can read at 30 feet. c. The patient can read the chart from 20 feet in the left eye and 30 feet in the right eye. d. The patient can read from 30 feet what a person with normal vision can read from 20 feet.

A pregnant woman states, I just know labor will be so painful that I wont be able to stand it. I know it sounds awful, but I really dread going into labor. The nurse responds by stating, Oh, dont worry about labor so much. I have been through it, and although it is painful, many good medications are available to decrease the pain. Which statement is true regarding this response? The nurses reply was a: a. Therapeutic response. By sharing something personal, the nurse gives hope to this woman. b. Nontherapeutic response. By providing false reassurance, the nurse actually cut off further discussion of the womans fears. c. Therapeutic response. By providing information about the medications available, the nurse is giving information to the woman. d. Nontherapeutic response. The nurse is essentially giving the message to the woman that labor cannot be tolerated without medication.

A semiconscious woman is brought to the emergency department after she was found on the floor in her kitchen. Her face, nail beds, lips, and oral mucosa are a bright cherry-red color. The nurse suspects that this coloring is due to: a. Polycythemia. b. Carbon monoxide poisoning. c. Carotenemia. d. Uremia.

A woman is discussing the problems she is having with her 2-year-old son. She says, He wont go to sleep at night, and during the day he has several fits. I get so upset when that happens. The nurses best verbal response would be: a. Go on, Im listening. b. Fits? Tell me what you mean by this. c. Yes, it can be upsetting when a child has a fit. d. Dont be upset when he has a fit; every 2 year old has fits.

An individual who takes the magicoreligious perspective of illness and disease is likely to believe that his or her illness was caused by: a. Germs and viruses. b. Supernatural forces. c. Eating imbalanced foods. d. An imbalance within his or her spiritual nature.

An older adult woman is brought to the emergency department after being found lying on the kitchen floor for 2 days; she is extremely dehydrated. What would the nurse expect to see during the examination? a. Smooth mucous membranes and lips b. Dry mucous membranes and cracked lips c. Pale mucous membranes d. White patches on the mucous membranes

As part of the health history of a 6-year-old boy at a clinic for a sports physical examination, the nurse reviews his immunization record and notes that his last measles-mumps-rubella (MMR) vaccination was at 15 months of age. What recommendation should the nurse make? a. No further MMR immunizations are needed. b. MMR vaccination needs to be repeated at 4 to 6 years of age. c. MMR immunization needs to be repeated every 4 years until age 21 years. d. A recommendation cannot be made until the physician is consulted.

During a mental status assessment, which question by the nurse would best assess a person's judgment? a. "Do you feel that you are being watched, followed, or controlled?" b. "Tell me what you plan to do once you are discharged from the hospital." c. "What does the statement, 'People in glass houses shouldn't throw stones,' mean to you?" d. "What would you do if you found a stamped, addressed envelope lying on the sidewalk?"

During a prenatal check, a patient begins to cry as the nurse asks her about previous pregnancies. She states that she is remembering her last pregnancy, which ended in miscarriage. The nurses best response to her crying would be: a. Im so sorry for making you cry! b. I can see that you are sad remembering this. It is all right to cry. c. Why dont I step out for a few minutes until youre feeling better? d. I can see that you feel sad about this; why dont we talk about something else?

In response to a question regarding the use of alcohol, a patient asks the nurse why the nurse needs to know. What is the reason for needing this information? a. This information is necessary to determine the patients reliability. b. Alcohol can interact with all medications and can make some diseases worse. c. The nurse needs to be able to teach the patient about the dangers of alcohol use. d. This information is not necessary unless a drinking problem is obvious.

In the majority culture of America, coughing, sweating, and diarrhea are symptoms of an illness. For some individuals of Mexican-American origin, however, these symptoms are a normal part of living. The nurse recognizes that this difference is true, probably because Mexican-Americans: a. Have less efficient immune systems and are often ill. b. Consider these symptoms part of normal living, not symptoms of ill health. c. Come from Mexico, and coughing is normal and healthy there. d. Are usually in a lower socioeconomic group and are more likely to be sick

Symptoms, such as pain, are often influenced by a persons cultural heritage. Which of the following is a true statement regarding pain? a. Nurses attitudes toward their patients pain are unrelated to their own experiences with pain. b. Nurses need to recognize that many cultures practice silent suffering as a response to pain. c. A nurses area of clinical practice will most likely determine his or her assessment of a patients pain. d. A nurses years of clinical experience and current position are strong indicators of his or her response to patient pain.

The nurse has just completed a lymph node assessment on a 60-year-old healthy female patient. The nurse knows that most lymph nodes in healthy adults are normally: a. Shotty. b. Nonpalpable. c. Large, firm, and fixed to the tissue. d. Rubbery, discrete, and mobile.

The nurse has used interpretation regarding a patients statement or actions. After using this technique, it would be best for the nurse to: a. Apologize, because using interpretation can be demeaning for the patient. b. Allow time for the patient to confirm or correct the inference. c. Continue with the interview as though nothing has happened. d. Immediately restate the nurses conclusion on the basis of the patients nonverbal response.

The nurse is assessing a new patient who has recently immigrated to the United States. Which question is appropriate to add to the health history? a. Why did you come to the United States? b. When did you come to the United States and from what country? c. What made you leave your native country? d. Are you planning to return to your home?

The nurse is assessing a patient who has liver disease for jaundice. Which of these assessment findings is indicative of true jaundice? a. Yellow patches in the outer sclera b. Yellow color of the sclera that extends up to the iris c. Skin that appears yellow when examined under low light d. Yellow deposits on the palms and soles of the feet where jaundice first appears

The nurse is assessing the skin of a patient who has acquired immunodeficiency syndrome (AIDS) and notices multiple patchlike lesions on the temple and beard area that are faint pink in color. The nurse recognizes these lesions as: a. Measles (rubeola). b. Kaposi's sarcoma. c. Angiomas. d. Herpes zoster.

The nurse is conducting a class for new graduate nurses. During the teaching session, the nurse should keep in mind that novice nurses, without a background of skills and experience from which to draw, are more likely to make their decisions using: a. Intuition. b. A set of rules. c. Articles in journals. d. Advice from supervisors.

The nurse is conducting a heritage assessment. Which question is most appropriate for this assessment? a. What is your religion? b. Do you mostly participate in the religious traditions of your family? c. Do you smoke? d. Do you have a history of heart disease?

The nurse is conducting a visual examination. Which of these statements regarding visual pathways and visual fields is true? a. The right side of the brain interprets the vision for the right eye. b. The image formed on the retina is upside down and reversed from its actual appearance in the outside world. c. Light rays are refracted through the transparent media of the eye before striking the pupil. d. Light impulses are conducted through the optic nerve to the temporal lobes of the brain.

The nurse is conducting an interview with a woman who has recently learned that she is pregnant and who has come to the clinic today to begin prenatal care. The woman states that she and her husband are excited about the pregnancy but have a few questions. She looks nervously at her hands during the interview and sighs loudly. Considering the concept of communication, which statement does the nurse know to be most accurate? The woman is: a. Excited about her pregnancy but nervous about the labor. b. Exhibiting verbal and nonverbal behaviors that do not match. c. Excited about her pregnancy, but her husband is not and this is upsetting to her. d. Not excited about her pregnancy but believes the nurse will negatively respond to her if she states this.

The nurse is incorporating a persons spiritual values into the health history. Which of these questions illustrates the community portion of the FICA (faith and belief, importance and influence, community, and addressing or applying in care) questions? a. Do you believe in God? b. Are you a part of any religious or spiritual congregation? c. Do you consider yourself to be a religious or spiritual person? d. How does your religious faith influence the way you think about your health?

The nurse is performing an eye assessment on an 80-year-old patient. Which of these findings is considered abnormal? a. Decrease in tear production b. Unequal pupillary constriction in response to light c. Presence of arcus senilis observed around the cornea d. Loss of the outer hair on the eyebrows attributable to a decrease in hair follicles

The nurse is reviewing concepts of cultural aspects of pain. Which statement is true regarding pain? a. All patients will behave the same way when in pain. b. Just as patients vary in their perceptions of pain, so will they vary in their expressions of pain. c. Cultural norms have very little to do with pain tolerance, because pain tolerance is always biologically determined. d. A patients expression of pain is largely dependent on the amount of tissue injury associated with the pain.

The nurse is reviewing in age-related changes in the eye for a class. Which of these physiologic changes is responsible for presbyopia? a. Degeneration of the cornea b. Loss of lens elasticity c. Decreased adaptation to darkness d. Decreased distance vision abilities

The nurse is reviewing the development of culture. Which statement is correct regarding the development of ones culture? Culture is: a. Genetically determined on the basis of racial background. b. Learned through language acquisition and socialization. c. A nonspecific phenomenon and is adaptive but unnecessary. d. Biologically determined on the basis of physical characteristics.

The nurse is reviewing theories of illness. The germ theory, which states that microscopic organisms such as bacteria and viruses are responsible for specific disease conditions, is a basic belief of which theory of illness? a. Holistic b. Biomedical c. Naturalistic d. Magicoreligious

The nurse keeps in mind that a thorough skin assessment is extremely important because the skin holds information about a person's: a. Support systems. b. Circulatory status. c. Socioeconomic status. d. Psychological wellness.

The nurse recognizes that an example of a person who is heritage consistent would be a: a. Woman who has adapted her clothing to the clothing style of her new country. b. Woman who follows the traditions that her mother followed regarding meals. c. Man who is not sure of his ancestors country of origin. d. Child who is not able to speak his parents native language.

The physician reports that a patient with a neck tumor has a tracheal shift. The nurse is aware that this means that the patients trachea is: a. Pulled to the affected side. b. Pushed to the unaffected side. c. Pulled downward. d. Pulled downward in a rhythmic pattern.

The review of systems provides the nurse with: a. Physical findings related to each system. b. Information regarding health promotion practices. c. An opportunity to teach the patient medical terms. d. Information necessary for the nurse to diagnose the patients medical problem.

When examining the ear with an otoscope, the nurse notes that the tympanic membrane should appear: a. Light pink with a slight bulge. b. Pearly gray and slightly concave. c. Pulled in at the base of the cone of light. d. Whitish with a small fleck of light in the superior portion.

When the nurse is evaluating the reliability of a patients responses, which of these statements would be correct? The patient: a. Has a history of drug abuse and therefore is not reliable. b. Provided consistent information and therefore is reliable. c. Smiled throughout interview and therefore is assumed reliable. d. Would not answer questions concerning stress and therefore is not reliable.

Which critical thinking skill helps the nurse see relationships among the data? a. Validation b. Clustering related cues c. Identifying gaps in data d. Distinguishing relevant from irrelevant

Which of these assessment findings would the nurse expect to see when examining the eyes of a black patient? a. Increased night vision b. Dark retinal background c. Increased photosensitivity d. Narrowed palpebral fissures

A patient calls the clinic for instructions before having a Papanicolaou (Pap) smear. The most appropriate instructions from the nurse are: A) "If you are menstruating, please use pads to avoid placing anything into the vagina." B) "Avoid intercourse, inserting anything into the vagina, or douching within 24 hours of your appointment." C) "If you suspect that you have a vaginal infection, please gather a sample of the discharge to bring with you." D) "We would like you to use a mild saline douche before your examination. You may pick this up in our office."

B) "Avoid intercourse, inserting anything into the vagina, or douching within 24 hours of your appointment." When instructing a patient before a Papanicolaou (Pap) smear is obtained, the nurse should follow these guidelines: Do not obtain during the woman's menses or if a heavy infectious discharge is present. Instruct the woman not to douche, have intercourse, or put anything into the vagina within 24 hours before collecting the specimens. Any specimens will be obtained during the visit, not beforehand.

The nurse is watching a new graduate nurse perform auscultation of a patient's abdomen. Which statement by the new graduate shows a correct understanding of the reason auscultation precedes percussion and palpation of the abdomen? A) "We need to determine areas of tenderness before using percussion and palpation." B) "It prevents distortion of bowel sounds that might occur after percussion and palpation." C) "It allows the patient more time to relax and therefore be more comfortable with the physical examination." D) "This prevents distortion of vascular sounds such as bruits and hums that might occur after percussion and palpation."

B) "It prevents distortion of bowel sounds that might occur after percussion and palpation." Auscultation is performed first (after inspection) because percussion and palpation can increase peristalsis, which would give a false interpretation of bowel sounds. REF: Pages: 538-539

During an abdominal assessment, the nurse would consider which of these findings as normal? A) The presence of a bruit in the femoral area B) A tympanic percussion note in the umbilical region C) A palpable spleen between the ninth and eleventh ribs in the left midaxillary line D) A dull percussion note in the left upper quadrant at the midclavicular line

B) A tympanic percussion note in the umbilical region Tympany should predominate in all four quadrants of the abdomen because air in the intestines rises to the surface when the person is supine. Vascular bruits are not usually present. Normally the spleen is not palpable. Dullness would not be found in the area of lung resonance (left upper quadrant at the midclavicular line). REF: Pages: 539-540

A 22-year-old woman comes to the clinic because of a severe sunburn and states, "I was just out in the sun for a couple of minutes." The nurse begins a medication review with her, paying special attention to which medication class? A) Nonsteroidal anti-inflammatory drugs for pain B) Tetracyclines for acne C) Proton pump inhibitors for heartburn D) Thyroid replacement hormone for hypothyroidism

B) Tetracyclines for acne Drugs that may increase sunlight sensitivity and give a burn response include sulfonamides, thiazide diuretics, oral hypoglycemic agents, and tetracycline. Pages: 208-209

The nurse is assessing the abdomen of a pregnant woman who is complaining of having "acid indigestion" all the time. The nurse knows that esophageal reflux during pregnancy can cause: A) diarrhea. B) pyrosis. C) dysphagia. D) constipation.

B) pyrosis.

The nurse is assessing a 1-month-old infant at his well-baby checkup. Which assessment findings are appropriate for this age? Select all that apply. a. Head circumference equal to chest circumference b. Head circumference greater than chest circumference c. Head circumference less than chest circumference d. Fontanels firm and slightly concave e. Absent tonic neck reflex f. Nonpalpable cervical lymph nodes

B, D, F

A patient has been admitted to a hospital after the staff in the nursing home noticed a pressure ulcer in his sacral area. The nurse examines the pressure ulcer and determines that it is a stage II ulcer. Which of these findings are characteristic of a stage II pressure ulcer? Select all that apply. a. Intact skin appears red but is not broken. b. Partial thickness skin erosion is observed with a loss of epidermis or dermis. c. Ulcer extends into the subcutaneous tissue. d. Localized redness in light skin will blanch with fingertip pressure. e. Open blister areas have a red-pink wound bed. f. Patches of eschar cover parts of the wound.

B, E

Mrs. Jones is a 32-year-old patient who is pregnant and comes to the clinic for a routine health assessment. As part of your patient education, you tell Mrs. Jones that she may feel some discomfort during the third trimester of her pregnancy. What kind of discomfort do you tell her to expect? A. Stiffer joints B. Back pain C. Osteoporosis D. Kyphosis

B. Back pain

The spinous processes that are prominent at the base of the neck are: A. T7 and T8. B. C7 and T1. C. T12 and L1. D. L3 and L4.

B. C7 and T1.

Mrs. Baker comes to your office with her 2-year-old son. On examination you note that the urinary meatus appears on the upper surface of the penis. Which of the following conditions best describes these clinical findings? A. Varicocele B. Epispadias C. Hydrocele D. Balanitis

B. Epispadias

Assessing an older adult patient's ability to engage in activities of daily living is a part of which assessment? A. Developmental B. Functional C. Cultural D. Screening

B. Functional

Which of the following would you expect to see in an individual who demonstrates genu valgum? A. Bowleg B. Knock-knee C. Pigeon-toed D. Clubfoot

B. Knock-knee

Mr. Bowers is a 39-year-old patient who presents to the clinic, and you examine the abdomen. The right upper quadrant of the abdomen contains which of the following organs? A. Spleen B. Liver C. Cecum D. Left ureter

B. Liver

A pregnant woman is most likely to demonstrate which of the following alterations in her posture, which is directly related to her pregnancy? A. Kyphosis B. Lordosis C. Scoliosis D. List

B. Lordosis

Which of the following complaints are the most common musculoskeletal concerns that prompt an individual to seek health care? A. Joint pain and myalgia B. Loss of function and joint pain C. Neuralgia and loss of function D. Neuralgia and myalgia

B. Loss of function and joint pain

Which of the following conditions would best utilize the assessment technique of transilluminatation? A. Palpating for inguinal hernia B. Observing for hydrocele C. Observing for phimosis D. Palpating for tender testes

B. Observing for hydrocele

Which of the following muscles may be congenitally absent in certain individuals? A. Palmaris shortus B. Palmaris longus C. Peroneus secondus D. Synovin membranous

B. Palmaris longus

Which of the following terms describes "compact, desiccated flakes of skin from shedding of dead skin cells"? A. Crust B. Scale C. Dandruff D. Plaque

B. Scale

Mr. Sanchez is a 48-year-old patient who presents for a routine health assessment, and you examine his abdomen. The left lower quadrant contains which of the following organs? A. Pancreas B. Sigmoid colon C. Kidney D. Gallbladder

B. Sigmoid colon

A 52 year old woman has a papule on her nose that has rounded, pearly borders and a central red ulcer. She said she first noticed it several months ago and that it has slowly grown larger. The nurse suspects which condition? A. acne B. basal cell carcinoma C. melanoma D. squamous cell carcinoma

B. basal cell carcinoma basal cell carcinoma usually starts as a skin-colored papule that develops rounded, pearly borders with a central red ulcer. It is the most common form of skin cancer and grows slowly.

Hematuria is a term used for: A. bloody discharge. B. blood in the urine. C. bleeding after intercourse. D. bloody vaginal discharge.

B. blood in the urine.

Fluid in the knee may be confirmed by performing: A. Tinel's sign. B. bulge sign. C. ROM. D. McMurray's test.

B. bulge sign.

A semiconscious woman is brought to the ED after she was found on the floor in her kitchen. Her face, nail beds, lips, and oral mucosa and a bright cherry-red color. The nurse suspects that this coloring is due to: A. polycythemia B. carbon monoxide poisoning C. carotenemia D. uremeia

B. carbon monoxide poisoning a bright cherry-red coloring in the face, upper torso, nail beds, lips, and oral mucosa appears in cases of carbon monoxide poisoning

The nurse keeps in mind that a thorough skin assessment is extremely important because the skin holds information about a persons: A. support systems B. circulatory status C. socioeconomic status D. psychological wellness

B. circulatory status

A patient reports excruciating headache pain on one side of his head, especially around his eye, forehead, and cheek that has lasted approximately to 2 hours, occurring once or twice each day. The nurse should suspect: A. hypertension B. cluster headaches C. tension headaches D. migraine headaches

B. cluster headaches cluster headaches produce pain around eye, temple, forehead, and cheek and are unilateral and always on the same side of the head. they are excruciating and occur once or twice per day and last to 2 hours each.

A patient is unable to differentiate sharp and dull stimulation on both sides of her face. The nurse suspects: A. Bell palsy B. damage to trigeminal nerve C. frostbite with resultant paresthesia to the cheeks D. scleroderma

B. damage to trigeminal nerve Facial sensations of pain or touch or mediated by CN V, which is the trigeminal nerve.

During an assessment of an infant, the nurse notes that the fontanels are depressed and sunken. The nurse suspects which condition? A. rickets B. dehydration C. mental retardation D. increase intracranial pressure

B. dehydration

An older adult woman is brought to the ED after being found lying on the kitchen floor for 2 days; she is extremely dehydrated. What would the nurse expect to see during the examination? A. smooth mucous membranes and lips B. dry mucous membranes and cracked lips C. pale mucous membranes D. white patches on the mucous membranes

B. dry mucous membranes and cracked lips

Mrs. Hoist is a 26-year-old patient who reports to the health clinic with complaints of painful intercourse. A synonym for painful intercourse is: A. dysmenorrhea. B. dyspareunia. C. dysuria. D. None of the above

B. dyspareunia.

A mother brings her newborn in for assessment and asks, is there something wrong with my baby? his head seems so big. Which statement is true regarding the relative proportions of the head and trunk of newborn? A. at birth, the head is 1/5 the total length B. head circumference should be greater than chest circumference at birth C. the head size reaches 90% of its final size when the child is 3 years old D. when the anterior fontanel closes at 2 months, the head will be more proportioned to the body.

B. head circumference should be greater than chest circumference at birth

An STD characterized by clusters of small, painful vesicles caused by a virus is: A. chancre. B. herpes genitalis. C. orchitis. D. cystitis.

B. herpes genitalis.

A mother has noticed that her son, who has been to a new babysitter, has some blisters and scabs on his face and buttocks. On examination, the nurse notices moist, thin-roofed vesicles with a thin erythematous base and suspects: A. eczema B. impetigo C. herpes zoster D. diaper dermatitis

B. impetigo impetigo is moist, thin-roofed vesicles with a thin erythematous base and is contagious bacterial infection of the skin and most common in infants and children

A patient says that she has recently noticed a lump in the front of her neck below her adams apple that seems to be getting bigger. During the assessment, the finding that leads the nurse to suspect that this may not be a cancerous thyroid nodule is that the lump (nodule): A. is tender B. is mobile and not hard C. disappears when the patient smiles D. is hard and fixed to the surrounding structures

B. is mobile and not hard painles, rapidly growing nodules may be cancerous, especially the appearance of single nodule in a young person. However, cancerous nodules tend to be hard and fixed to surrounding structures, not mobile

During a skin assessment, the nurse notices that a Mexican-American patient has skin that is yellowish-brown; however, the skin on the hard and soft palate is pink and the patients scleras are not yellow. From this finding, the nurse could probably rule out: A. pallor B. jaundice C. cyanosis D. iron deficiency

B. jaundice jaundice is exhibited by a yellow color, which indicates rising levels of bilirubin in the blood. Jaundice is first noticed in the junction of the hard and soft palate in the mouth and in the scleras.

The nurse is assessing the skin of a patient who has acquired AIDS and notices multiple patch-like lesions on the temple and beard area that are faint pink in color. The nurse recognizes these lesions are: A. measles (rubeola) B. kaposis sarcoma C. angiomas D. herpes zoster

B. kaposis sarcoma kaposis sarcoma is a vascular tumor that, in early stages, appears as multiple, patch-like, faint pink lesions over the patients temple and beard areas

Mrs. Jones is a 65-year-old patient who presents with complaints of skin spots during a dermatology follow-up. As the health care provider, you note some hyperpigmentation in this aging adult. On examination, you would expect to see: A. café au lait spots and hemangioma. B. keratosis and lentigines. C. linea nigra and chloasma. D. None of the above.

B. keratosis and lentigines.

A few days after a summer hiking trip, a 25 year old man comes to the clinic with a rash. On examination, the nurse notes that the rash is red, macular, with a bulls-eye pattern across his midriff and behind his knees. the nurse suspects the: A. rubeola B. lyme disease C. allergy to mosquito bites D. rocky mountain spotted fever

B. lyme disease lyme disease occurs in people who spend time outdoors in May- September. The first disease states exhibits the distinctive bulls eye and red macular or papular rash that radiates from the site of the tick bite with some central clearing. The rash spreads 5cm or larger, and is usually in the axilla, midriff, inguinal, or behind the knee, with regional lymphadenoatphy.

Cessation of menses is known as: A. menarche. B. menopause. C. salpingitis. D. adnexa.

B. menopause.

Finding mild tenderness is normal when: A. palpating the kidneys. B. palpating the sigmoid colon. C. palpating the uterus. D. None of the above.

B. palpating the sigmoid colon.

A medical emergency due to a retracted and fixed foreskin behind the glans is called: A. Peyronie disease. B. paraphimosis. C. phimosis. D. cryptorchidism.

B. paraphimosis.

A patient has come in for an examination and state, I have this spot in front of my ear lobe on my cheek that seems to be getting bigger and is tender. What do you think it is? The nurse notes swelling below the angle of the jaw and suspects that it could be an inflammation of his: A. thyroid gland B. parotid gland C. occipital lymph node D. submental lymph node

B. parotid gland Swelling of the parotid gland is evident below the angle of the jaw and is most visible when the head is extended. painful inflammation occurs with mumps, and swelling also occurs with abscesses or tumors. Swelling occurs anterior to the lower ear lobe.

A male patient with a history of AIDS has come in for an examination and he states, I think I have the mumps. The nurse would begin by examining the: A. thyroid gland B. parotid gland C. cervical lymph nodes D. mouth and skin for lesions

B. parotid gland the parotid gland may become swollen with the onset of mumps, and parotid enlargement has been found with HIV

Ms. McMahon is a 33-year-old patient who presents for a routine yearly health assessment. On examination you note a bright red pedunculated growth emerging from the os. This is a: A. caruncle. B. polyp. C. rectouterine pouch. D. salpingitis.

B. polyp.

The name for the hood or flap of skin over the glans is: A. varicocele. B. prepuce. C. genitalis. D. progenitalis.

B. prepuce.

Mrs. Harris is a 45-year-old patient who comes to the ambulatory health center for a yearly examination. On examination you note a cystocele. This is a: A. prolapse of the rectum into the urinary bladder. B. prolapse of the bladder into the vagina. C. membranous fold of tissue protruding from the cervical os. D. prolapse of the vagina into the bladder

B. prolapse of the bladder into the vagina.

The physician reports that a patient with a neck tumor has a tracheal shift. The nurse is aware that his means that the patients trachea is: A. pulled to the affected side B. pushed to the unaffected side C. pulled downward D. pulled downward in a rhythmic pattern.

B. pushed to the unaffected side the trachea is pushed to the unaffected side with an aortic aneurysm, a tumor, unilateral thyroid lobe enlargement, or a pneumothorax. The trachea is pulled to the affected side with large atelectasis, pleural adhesions, or fibrosis. Tracheal tug is a rhythmic downward pull that is synchronous with systole and occurs with aortic arch aneurysm.

A 40 year old woman reports a change in mole size, accompanied by color changes, itching, burning, and bleeding over the past month. She has a dark complexion that has no family of skin cancer, but she has many blistering sunburns in the past. The nurse would: A. tell the patient to watch the lesion and report back in 2 months B. refer the patient because of the suggestion of melanoma on the basis of her symptoms C. ask additional questions regarding environmental irritants that may have caused this condition. D. tell the patient that these signs suggest a compound nevus, which is very common in young to middle-aged adults

B. refer the patient because of the suggestion of melanoma on the basis of her symptoms the ABCD danger signs of melanoma are asymmetry, border irregularity, color variation, and diameter.

Inflammation of the fallopian tubes is known as: A. vaginitis. B. salpingitis. C. cystocele. D. dyspareunia.

B. salpingitis.

A caruncle is a(n): A. vestibular gland located on either side of the vaginal orifice. B. small, red mass protruding from the urethral meatus. C. aberrant growth of endometrial tissue. D. hard, painless nodule in the uterine wall.

B. small, red mass protruding from the urethral meatus.

A retention cyst in the epididymis filled with milky fluid containing sperm is called a: A. varicocele. B. spermatocele. C. Peyronie's disease. D. prepuce.

B. spermatocele.

Mrs. Painter is a 62-year-old patient who comes to the clinic for a follow-up health assessment for complaints of joint tenderness. On examination you note a joint that has a boggy, soft feel to palpation. This is generally indicative of: A. rheumatoid arthritis. B. synovial thickening. C. synovial subluxation. D. crepitation.

B. synovial thickening.

A 22-year-old woman comes tot he clinic because of severe sunburn and states, I was out in the sun for just a couple of minutes. The nurse begins a medication review with her, paying special attention to which medication class? A. Nonsteroidal antiinflammatory drugs for pain B. tetracyclines for acne C. proton pump inhibitors for heartburn D. thryoid replacement hormone for hypothyroidism.

B. tetracyclines for acne

Synovial joints are freely movable because: A. the ligaments holding the joint together are more elastic. B. the bones that form the joint are separated from each other and enclosed in a fluid-filled cavity. C. the muscles attached to the joint are shorter, thus giving them the ability to move in more directions. D. they are composed of cartilage, which is very soft and cushiony.

B. the bones that form the joint are separated from each other and enclosed in a fluid-filled cavity.

The cremaster is: A. a sperm storage site. B. the muscle that controls the size of the scrotum. C. a muscular duct continuous with the epididymis. D. a shoulder where the glans joins the shaft.

B. the muscle that controls the size of the scrotum.

Barriers to incorporating EBP include: a. Nurses lack of research skills in evaluating the quality of research studies. b. Lack of significant research studies. c. Insufficient clinical skills of nurses. d. Inadequate physical assessment skills.

. During a class on cultural practices, the nurse hears the term cultural taboo. Which statement illustrates the concept of a cultural taboo? a. Believing that illness is a punishment of sin b. Trying prayer before seeking medical help c. Refusing to accept blood products as part of treatment d. Stating that a childs birth defect is the result of the parents sins

. The nurse makes this comment to a patient, I know it may be hard, but you should do what the doctor ordered because she is the expert in this field. Which statement is correct about the nurses comment? a. This comment is inappropriate because it shows the nurses bias. b. This comment is appropriate because members of the health care team are experts in their area of patient care. c. This type of comment promotes dependency and inferiority on the part of the patient and is best avoided in an interview situation. d. Using authority statements when dealing with patients, especially when they are undecided about an issue, is necessary at times.

A 17-year-old single mother is describing how difficult it is to raise a 3-year-old child by herself. During the course of the interview she states, I cant believe my boyfriend left me to do this by myself! What a terrible thing to do to me! Which of these responses by the nurse uses empathy? a. You feel alone. b. You cant believe he left you alone? c. It must be so hard to face this all alone. d. I would be angry, too; raising a child alone is no picnic.

A 30-year-old female patient is describing feelings of hopelessness and depression. She has attempted self-mutilation and has a history of suicide attempts. She describes difficulty sleeping at night and has lost 10 pounds in the past month. Which of these statements or questions is the nurse's best response in this situation? a. "Do you have a weapon?" b. "How do other people treat you?" c. "Are you feeling so hopeless that you feel like hurting yourself now?" d. "People often feel hopeless, but the feelings resolve within a few weeks."

A 42-year-old woman complains that she has noticed several small, slightly raised, bright red dots on her chest. On examination, the nurse expects that the spots are probably: a. Anasarca. b. Scleroderma. c. Senile angiomas. d. Latent myeloma.

A 45-year-old woman is at the clinic for a mental status assessment. In giving her the Four Unrelated Words Test, the nurse would be concerned if she could not ____ four unrelated words ____. a. Invent; within 5 minutes b. Invent; within 30 seconds c. Recall; after a 30-minute delay d. Recall; after a 60-minute delay

A 60-year-old man is at the clinic for an eye examination. The nurse suspects that he has ptosis of one eye. How should the nurse check for this? a. Perform the confrontation test. b. Assess the individuals near vision. c. Observe the distance between the palpebral fissures. d. Perform the corneal light test, and look for symmetry of the light reflex.

A 70-year-old woman who loves to garden has small, flat, brown macules over her arms and hands. She asks, "What causes these liver spots?" The nurse tells her, "They are: a. "Signs of decreased hematocrit related to anemia." b. "Due to the destruction of melanin in your skin from exposure to the sun." c. "Clusters of melanocytes that appear after extensive sun exposure." d. "Areas of hyperpigmentation related to decreased perfusion and vasoconstriction."

A mother brings in her newborn infant for an assessment and tells the nurse that she has noticed that whenever her newborns head is turned to the right side, she straightens out the arm and leg on the same side and flexes the opposite arm and leg. After observing this on examination, the nurse tells her that this reflex is: a. Abnormal and is called the atonic neck reflex. b. Normal and should disappear by the first year of life. c. Normal and is called the tonic neck reflex, which should disappear between 3 and 4 months of age. d. Abnormal. The baby should be flexing the arm and leg on the right side of his body when the head is turned to the right.

A nurse is taking complete health histories on all of the patients attending a wellness workshop. On the history form, one of the written questions asks, You dont smoke, drink, or take drugs, do you? This question is an example of: a. Talking too much. b. Using confrontation. c. Using biased or leading questions. d. Using blunt language to deal with distasteful topics.

A patient comes in for a physical examination and complains of "freezing to death" while waiting for her examination. The nurse notes that her skin is pale and cool and attributes this finding to: a. Venous pooling. b. Peripheral vasodilation. c. Peripheral vasoconstriction. d. Decreased arterial perfusion.

A patient comes to the clinic and tells the nurse that he has been confined to his recliner chair for approximately 3 days with his feet down and he asks the nurse to evaluate his feet. During the assessment, the nurse might expect to find: a. Pallor b. Coolness c. Distended veins d. Prolonged capillary filling time

A patient has been admitted for severe psoriasis. The nurse expects to see what finding in the patient's fingernails? a. Splinter hemorrhages b. Paronychia c. Pitting d. Beau lines

A patient has been in the intensive care unit for 10 days. He has just been moved to the medical-surgical unit, and the admitting nurse is planning to perform a mental status examination. During the tests of cognitive function, the nurse would expect that he: a. May display some disruption in thought content. b. Will state, "I am so relieved to be out of intensive care." c. Will be oriented to place and person, but the patient may not be certain of the date. d. May show evidence of some clouding of his level of consciousness.

A patient has been shown to have a sensorineural hearing loss. During the assessment, it would be important for the nurse to: a. Speak loudly so the patient can hear the questions. b. Assess for middle ear infection as a possible cause. c. Ask the patient what medications he is currently taking. d. Look for the source of the obstruction in the external ear.

A patient is especially worried about an area of skin on her feet that has turned white. The health care provider has told her that her condition is vitiligo. The nurse explains to her that vitiligo is: a. Caused by an excess of melanin pigment b. Caused by an excess of apocrine glands in her feet c. Caused by the complete absence of melanin pigment d. Related to impetigo and can be treated with an ointment

A patient repeatedly seems to have difficulty coming up with a word. He says, "I was on my way to work, and when I got there, the thing that you step into that goes up in the air was so full that I decided to take the stairs." The nurse will note on his chart that he is using or experiencing: a. Blocking b. Neologism c. Circumlocution d. Circumstantiality

A patient states, "I feel so sad all of the time. I can't feel happy even doing things I used to like to do." He also states that he is tired, sleeps poorly, and has no energy. To differentiate between a dysthymic disorder and a major depressive disorder, the nurse should ask which question? a. "Have you had any weight changes?" b. "Are you having any thoughts of suicide?" c. "How long have you been feeling this way?" d. "Are you having feelings of worthlessness?"

A patient tells the nurse that he is very nervous, is nauseated, and feels hot. These types of data would be: a. Objective. b. Reflective. c. Subjective. d. Introspective.

A patient with a middle ear infection asks the nurse, What does the middle ear do? The nurse responds by telling the patient that the middle ear functions to: a. Maintain balance. b. Interpret sounds as they enter the ear. c. Conduct vibrations of sounds to the inner ear. d. Increase amplitude of sound for the inner ear to function.

A patient, an 85-year-old woman, is complaining about the fact that the bones in her face have become more noticeable. What explanation should the nurse give her? a. Diets low in protein and high in carbohydrates may cause enhanced facial bones. b. Bones can become more noticeable if the person does not use a dermatologically approved moisturizer. c. More noticeable facial bones are probably due to a combination of factors related to aging, such as decreased elasticity, subcutaneous fat, and moisture in her skin. d. Facial skin becomes more elastic with age. This increased elasticity causes the skin to be more taught, drawing attention to the facial bones.

A patients thyroid gland is enlarged, and the nurse is preparing to auscultate the thyroid gland for the presence of a bruit. A bruit is a __________ sound that is heard best with the __________ of the stethoscope. a. Low gurgling; diaphragm b. Loud, whooshing, blowing; bell c. Soft, whooshing, pulsatile; bell d. High-pitched tinkling; diaphragm

A physician has diagnosed a patient with purpura. After leaving the room, a nursing student asks the nurse what the physician saw that led to that diagnosis. The nurse should say, "The physician is referring to the: a. "Blue dilation of blood vessels in a star-shaped linear pattern on the legs." b. "Fiery red, star-shaped marking on the cheek that has a solid circular center." c. "Confluent and extensive patch of petechiae and ecchymoses on the feet." d. "Tiny areas of hemorrhage that are less than 2 mm, round, discrete, and dark red in color."

A physician tells the nurse that a patients vertebra prominens is tender and asks the nurse to reevaluate the area in 1 hour. The area of the body the nurse will assess is: a. Just above the diaphragm. b. Just lateral to the knee cap. c. At the level of the C7 vertebra. d. At the level of the T11 vertebra.

A visitor from Poland who does not speak English seems to be somewhat apprehensive about the nurse examining his neck. He would probably be more comfortable with the nurse examining his thyroid gland from: a. Behind with the nurses hands placed firmly around his neck. b. The side with the nurses eyes averted toward the ceiling and thumbs on his neck. c. The front with the nurses thumbs placed on either side of his trachea and his head tilted forward. d. The front with the nurses thumbs placed on either side of his trachea and his head tilted backward.

A woman comes to the clinic and states, Ive been sick for so long! My eyes have gotten so puffy, and my eyebrows and hair have become coarse and dry. The nurse will assess for other signs and symptoms of: a. Cachexia. b. Parkinson syndrome. c. Myxedema. d. Scleroderma.

After a class on culture and ethnicity, the new graduate nurse reflects a correct understanding of the concept of ethnicity with which statement? a. Ethnicity is dynamic and ever changing. b. Ethnicity is the belief in a higher power. c. Ethnicity pertains to a social group within the social system that claims shared values and traditions. d. Ethnicity is learned from birth through the processes of language acquisition and socialization.

An older Mexican-American woman with traditional beliefs has been admitted to an inpatient care unit. A culturally sensitive nurse would: a. Contact the hospital administrator about the best course of action. b. Automatically get a curandero for her, because requesting one herself is not culturally appropriate. c. Further assess the patients cultural beliefs and offer the patient assistance in contacting a curandero or priest if she desires. d. Ask the family what they would like to do because Mexican-Americans traditionally give control of decision making to their families.

During a seminar on cultural aspects of nursing, the nurse recognizes that the definition stating the specific and distinct knowledge, beliefs, skills, and customs acquired by members of a society reflects which term? a. Mores b. Norms c. Culture d. Social learning

During a well-baby checkup, the nurse notices that a 1-week-old infants face looks small compared with his cranium, which seems enlarged. On further examination, the nurse also notices dilated scalp veins and downcast or setting sun eyes. The nurse suspects which condition? a. Craniotabes b. Microcephaly c. Hydrocephalus d. Caput succedaneum

During an admission assessment, the nurse notices that a male patient has an enlarged and rather thick skull. The nurse suspects acromegaly and would further assess for: a. Exophthalmos. b. Bowed long bones. c. Coarse facial features. d. Acorn-shaped cranium.

During an assessment, the nurse notices that an older adult patient has tears rolling down his face from his left eye. Closer examination shows that the lower lid is loose and rolling outward. The patient complains of his eye feeling dry and itchy. Which action by the nurse is correct? a. Assessing the eye for a possible foreign body b. Documenting the finding as ptosis c. Assessing for other signs of ectropion d. Contacting the prescriber; these are signs of basal cell carcinoma

During an examination of a female patient, the nurse notes lymphadenopathy and suspects an acute infection. Acutely infected lymph nodes would be: a. Clumped. b. Unilateral. c. Firm but freely movable. d. Firm and nontender.

During an examination of a patient in her third trimester of pregnancy, the nurse notices that the patients thyroid gland is slightly enlarged. No enlargement had been previously noticed. The nurse suspects that the patient: a. Has an iodine deficiency. b. Is exhibiting early signs of goiter. c. Is exhibiting a normal enlargement of the thyroid gland during pregnancy. d. Needs further testing for possible thyroid cancer.

During an examination, the nurse can assess mental status by which activity? a. Examining the patient's electroencephalogram b. Observing the patient as he or she performs an intelligence quotient (IQ) test c. Observing the patient and inferring health or dysfunction d. Examining the patient's response to a specific set of questions

During an examination, the nurse finds that a patients left temporal artery is tortuous and feels hardened and tender, compared with the right temporal artery. The nurse suspects which condition? a. Crepitation b. Mastoiditis c. Temporal arteritis d. Bell palsy

During an examination, the nurse notes that a patient is exhibiting flight of ideas. Which statement by the patient is an example of flight of ideas? a. "My stomach hurts. Hurts, spurts, burts." b. "Kiss, wood, reading, ducks, onto, maybe." c. "Take this pill? The pill is red. I see red. Red velvet is soft, soft as a baby's bottom." d. "I wash my hands, wash them, wash them. I usually go to the sink and wash my hands."

During an interview, a woman says, I have decided that I can no longer allow my children to live with their fathers violence, but I just cant seem to leave him. Using interpretation, the nurses best response would be: a. You are going to leave him? b. If you are afraid for your children, then why cant you leave? c. It sounds as if you might be afraid of how your husband will respond. d. It sounds as though you have made your decision. I think it is a good one.

During an interview, the nurse would expect that most of the interview will take place at what distance? a. Intimate zone b. Personal distance c. Social distance d. Public distance

If an American Indian woman has come to the clinic to seek help with regulating her diabetes, then the nurse can expect that she: a. Will comply with the treatment prescribed. b. Has obviously given up her belief in naturalistic causes of disease. c. May also be seeking the assistance of a shaman or medicine man. d. Will need extra help in dealing with her illness and may be experiencing a crisis of faith.

In a patient who has anisocoria, the nurse would expect to observe: a. Dilated pupils. b. Excessive tearing. c. Pupils of unequal size. d. Uneven curvature of the lens.

In response to a question about stress, a 39-year-old woman tells the nurse that her husband and mother both died in the past year. Which response by the nurse is most appropriate? a. This has been a difficult year for you. b. I dont know how anyone could handle that much stress in 1 year! c. What did you do to cope with the loss of both your husband and mother? d. That is a lot of stress; now lets go on to the next section of your history.

In using the ophthalmoscope to assess a patients eyes, the nurse notices a red glow in the patients pupils. On the basis of this finding, the nurse would: a. Suspect that an opacity is present in the lens or cornea. b. Check the light source of the ophthalmoscope to verify that it is functioning. c. Consider the red glow a normal reflection of the ophthalmoscope light off the inner retina. d. Continue with the ophthalmoscopic examination, and refer the patient for further evaluation.

Many Asians believe in the yin/yang theory, which is rooted in the ancient Chinese philosophy of Tao. Which statement most accurately reflects health in an Asian with this belief? a. A person is able to work and produce. b. A person is happy, stable, and feels good. c. All aspects of the person are in perfect balance. d. A person is able to care for others and function socially.

Receiving is a part of the communication process. Which receiver is most likely to misinterpret a message sent by a health care professional? a. Well-adjusted adolescent who came in for a sports physical b. Recovering alcoholic who came in for a basic physical examination c. Man whose wife has just been diagnosed with lung cancer d. Man with a hearing impairment who uses sign language to communicate and who has an interpreter with him

The nurse has discovered decreased skin turgor in a patient and knows that this finding is expected in which condition? a. Severe obesity b. Childhood growth spurts c. Severe dehydration d. Connective tissue disorders such as scleroderma

The nurse has implemented several planned interventions to address the nursing diagnosis of acute pain. Which would be the next appropriate action? a. Establish priorities. b. Identify expected outcomes. c. Evaluate the individuals condition, and compare actual outcomes with expected outcomes. d. Interpret data, and then identify clusters of cues and make inferences.

The nurse is assessing a 75-year-old man. As the nurse begins the mental status portion of the assessment, the nurse expects that this patient: a. Will have no decrease in any of his abilities, including response time. b. Will have difficulty on tests of remote memory because this ability typically decreases with age. c. May take a little longer to respond, but his general knowledge and abilities should not have declined. d. Will exhibit had a decrease in his response time because of the loss of language and a decrease in general knowledge.

The nurse is assessing color vision of a male child. Which statement is correct? The nurse should: a. Check color vision annually until the age of 18 years. b. Ask the child to identify the color of his or her clothing. c. Test for color vision once between the ages of 4 and 8 years. d. Begin color vision screening at the childs 2-year checkup.

The nurse is assessing for inflammation in a dark-skinned person. Which technique is the best? a. Assessing the skin for cyanosis and swelling b. Assessing the oral mucosa for generalized erythema c. Palpating the skin for edema and increased warmth d. Palpating for tenderness and local areas of ecchymosis

The nurse is comparing the concepts of religion and spirituality. Which of the following is an appropriate component of ones spirituality? a. Belief in and the worship of God or gods b. Attendance at a specific church or place of worship c. Personal effort made to find purpose and meaning in life d. Being closely tied to ones ethnic background

The nurse is conducting a patient interview. Which statement made by the patient should the nurse more fully explore during the interview? a. "I sleep like a baby." b. "I have no health problems." c. "I never did too good in school." d. "I am not currently taking any medications."

The nurse is examining a patients ears and notices cerumen in the external canal. Which of these statements about cerumen is correct? a. Sticky honey-colored cerumen is a sign of infection. b. The presence of cerumen is indicative of poor hygiene. c. The purpose of cerumen is to protect and lubricate the ear. d. Cerumen is necessary for transmitting sound through the auditory canal.

The nurse is performing a mental status examination. Which statement is true regarding the assessment of mental status? a. Mental status assessment diagnoses specific psychiatric disorders. b. Mental disorders occur in response to everyday life stressors. c. Mental status functioning is inferred through the assessment of an individual's behaviors. d. Mental status can be directly assessed, similar to other systems of the body (e.g., heart sounds, breath sounds).

The nurse is performing a review of systems on a 76-year-old patient. Which of these statements is correct for this situation? a. The questions asked are identical for all ages. b. The interviewer will start incorporating different questions for patients 70 years of age and older. c. Questions that are reflective of the normal effects of aging are added. d. At this age, a review of systems is not necessarythe focus should be on current problems.

The nurse is planning health teaching for a 65-year-old woman who has had a cerebrovascular accident (stroke) and has aphasia. Which of these questions is most important to use when assessing mental status in this patient? a. "Please count backward from 100 by seven." b. "I will name three items and ask you to repeat them in a few minutes." c. "Please point to articles in the room and parts of the body as I name them." d. "What would you do if you found a stamped, addressed envelope on the sidewalk?"

The nurse is planning to assess new memory with a patient. The best way for the nurse to do this would be to: a. Administer the FACT test. b. Ask him to describe his first job. c. Give him the Four Unrelated Words Test. d. Ask him to describe what television show he was watching before coming to the clinic.

The nurse is preparing to assess the visual acuity of a 16-year-old patient. How should the nurse proceed? a. Perform the confrontation test. b. Ask the patient to read the print on a handheld Jaeger card. c. Use the Snellen chart positioned 20 feet away from the patient. d. Determine the patients ability to read newsprint at a distance of 12 to 14 inches.

The nurse is providing instructions to newly hired graduates for the mini-mental state examination (MMSE). Which statement best describes this examination? a. Scores below 30 indicate cognitive impairment. b. The MMSE is a good tool to evaluate mood and thought processes. c. This examination is a good tool to detect delirium and dementia and to differentiate these from psychiatric mental illness. d. The MMSE is useful tool for an initial evaluation of mental status. Additional tools are needed to evaluate cognition changes over time.

The nurse is reviewing information about evidence-based practice (EBP). Which statement best reflects EBP? a. EBP relies on tradition for support of best practices. b. EBP is simply the use of best practice techniques for the treatment of patients. c. EBP emphasizes the use of best evidence with the clinicians experience. d. The patients own preferences are not important with EBP.

The nurse is reviewing the function of the cranial nerves (CNs). Which CN is responsible for conducting nerve impulses to the brain from the organ of Corti? a. I b. III c. VIII d. XI

The nurse is taking a family history. Important diseases or problems about which the patient should be specifically asked include: a. Emphysema. b. Head trauma. c. Mental illness. d. Fractured bones.

The nurse needs to palpate the temporomandibular joint for crepitation. This joint is located just below the temporal artery and anterior to the: a. Hyoid bone. b. Vagus nerve. c. Tragus. d. Mandible.

The nurse notices that a patients palpebral fissures are not symmetric. On examination, the nurse may find that damage has occurred to which cranial nerve (CN)? a. III b. V c. VII d. VIII

The nurse notices that an infant has a large, soft lump on the side of his head and that his mother is very concerned. She tells the nurse that she noticed the lump approximately 8 hours after her babys birth and that it seems to be getting bigger. One possible explanation for this is: a. Hydrocephalus. b. Craniosynostosis. c. Cephalhematoma. d. Caput succedaneum

The nurse notices the presence of periorbital edema when performing an eye assessment on a 70-year-old patient. The nurse should: a. Check for the presence of exophthalmos. b. Suspect that the patient has hyperthyroidism. c. Ask the patient if he or she has a history of heart failure. d. Assess for blepharitis, which is often associated with periorbital edema.

The nurse recognizes that the concept of prevention in describing health is essential because: a. Disease can be prevented by treating the external environment. b. The majority of deaths among Americans under age 65 years are not preventable. c. Prevention places the emphasis on the link between health and personal behavior. d. The means to prevention is through treatment provided by primary health care practitioners.

When a light is directed across the iris of a patients eye from the temporal side, the nurse is assessing for: a. Drainage from dacryocystitis. b. Presence of conjunctivitis over the iris. c. Presence of shadows, which may indicate glaucoma. d. Scattered light reflex, which may be indicative of cataracts.

When assessing the pupillary light reflex, the nurse should use which technique? a. Shine a penlight from directly in front of the patient, and inspect for pupillary constriction. b. Ask the patient to follow the penlight in eight directions, and observe for bilateral pupil constriction. c. Shine a light across the pupil from the side, and observe for direct and consensual pupillary constriction. d. Ask the patient to focus on a distant object. Then ask the patient to follow the penlight to approximately 7 cm from the nose.

When examining a patients eyes, the nurse recalls that stimulation of the sympathetic branch of the autonomic nervous system: a. Causes pupillary constriction. b. Adjusts the eye for near vision. c. Elevates the eyelid and dilates the pupil. d. Causes contraction of the ciliary body.

When examining the face of a patient, the nurse is aware that the two pairs of salivary glands that are accessible to examination are the ___________ and ___________ glands. a. Occipital; submental b. Parotid; jugulodigastric c. Parotid; submandibular d. Submandibular; occipital

When listening to a patients breath sounds, the nurse is unsure of a sound that is heard. The nurses next action should be to: a. Immediately notify the patients physician. b. Document the sound exactly as it was heard. c. Validate the data by asking a coworker to listen to the breath sounds. d. Assess again in 20 minutes to note whether the sound is still present.

When the nurse asks for a description of who lives with a child, the method of discipline, and the support system of the child, what part of the assessment is being performed? a. Family history b. Review of systems c. Functional assessment d. Reason for seeking care

Which of these statements represents subjective data the nurse obtained from the patient regarding the patients skin? a. Skin appears dry. b. No lesions are obvious. c. Patient denies any color change. d. Lesion is noted on the lateral aspect of the right arm.

Which of these would be formulated by a nurse using diagnostic reasoning? a. Nursing diagnosis b. Medical diagnosis c. Diagnostic hypothesis d. Diagnostic assessment

While performing a well-child assessment on a 5 year old, the nurse notes the presence of palpable, bilateral, cervical, and inguinal lymph nodes. They are approximately 0.5 cm in size, round, mobile, and nontender. The nurse suspects that this child: a. Has chronic allergies. b. May have an infection. c. Is exhibiting a normal finding for a well child of this age. d. Should be referred for additional evaluation.

During the interview a patient reveals that she has some vaginal discharge. She is worried that it may be a sexually transmitted infection. The nurse's most appropriate response to this would be: A) "Oh, don't worry. Some cyclic vaginal discharge is normal." B) "Have you been engaging in unprotected sexual intercourse?" C) "I'd like some information about the discharge. What color is it?" D) "Have you had any urinary incontinence associated with the discharge?"

C) "I'd like some information about the discharge. What color is it?" Ask questions that help the patient reveal more information about her symptoms in a nonthreatening manner. Assess vaginal discharge further by asking about the amount, color, and odor. Normal vaginal discharge is small, clear or cloudy, and always nonirritating.

Which statement would be most appropriate when the nurse is introducing the topic of sexual relationships during an interview? A) "Now it is time to talk about your sexual history. When did you first have intercourse?" B) "Women often feel dissatisfied with their sexual relationships. Would it be okay to discuss this now?" C) "Often women have questions about their sexual relationship and how it affects their health. Do you have any questions?" D) "Most women your age have had more than one sexual partner. How many would you say you have had?"

C) "Often women have questions about their sexual relationship and how it affects their health. Do you have any questions?" The nurse should begin with an open-ended question to assess individual needs. The nurse should include appropriate questions as a routine part of the history, because doing so communicates that the nurse accepts the individual's sexual activity and believes it is important. The nurse's comfort with discussion prompts the patient's interest and possibly relief that the topic has been introduced. This establishes a database for comparison with any future sexual activities and provides an opportunity to screen sexual problems.

The nurse has discovered decreased skin turgor in a patient and knows that this is an expected finding in which of these conditions? A) Severe obesity B) Childhood growth spurts C) Severe dehydration D) Connective tissue disorders such as scleroderma

C) Severe dehydration Decreased skin turgor is associated with severe dehydration or extreme weight loss. Page 215

11. A patient is being assessed for range of joint movement. The nurse asks him to move his arm in toward the center of his body. This movement is called: A) flexion. B) abduction. C) adduction. D) extension.

C) adduction. Moving a limb toward the midline of the body is called adduction; abduction is moving a limb away from the midline of the body. Flexion is bending a limb at a joint; extension is straightening a limb at a joint. Pages: 566-567

An increase in fluid within a bursa is manifested by which of the following characteristics? A. A decrease in the expected ROM of the joint B. Crepitus heard when putting the joint through ROM C. A bulge that appears on the opposite side of the joint after pushing on the other side D. Subluxation of the joint after flexing and extending the joint

C. A bulge that appears on the opposite side of the joint after pushing on the other side

John, a baby boy, is admitted to the transition nursery for a comprehensive physical, medications, and a bath prior to being transferred to the postpartum floor. Before you conduct the physical assessment, you review common skin variations of the newborn. Which of the following conditions requires further evaluation by the in-house neonatal nurse practitioner? A. Cutis marmorata, which is a mottling of the trunk and extremities B. Harlequin pattern, a condition that causes one side of the body to appear deep red and the other side pale, with a distinct demarcation down the midline C. A grouping of café au lait spots D. Erythema toxicum, a condition that causes punctuate macular-papular rash on cheeks, truck, back, and buttocks

C. A grouping of café au lait spots

An individual with functional scoliosis will demonstrate which of the following? A. A lateral spinal curvature that remains visible in the standing and bending position B. A lateral spinal curvature that remains at less than 20 degrees C. A lateral spinal curvature that is visible in the standing position but disappears when the individual bends over D. A lateral spinal curvature that affects either the thoracic area or the lumbar area but not both

C. A lateral spinal curvature that is visible in the standing position but disappears when the individual bends over

Priapism is: A. a meatus opening on the dorsal side of the glans or shaft. B. an advanced and fixed foreskin too tight to retract over the glans. C. a prolonged, painful erection of the penis without sexual desire. D. a circumscribed collection of serous fluid in the tunica vaginalis surrounding the testes.

C. a prolonged, painful erection of the penis without sexual desire.

Increased deposits of subcutaneous fat on the abdomen occur in: A. toddlers. B. teenagers. C. aging adults. D. pregnant women.

C. aging adults.

A black patient is in the intensive care unit because of impending shock after an accident. The nurse expects to find what characteristics in this patients skin? A. ruddy blue B. generalized pallor C. ashen, gray, or dull D. patchy areas of pallor

C. ashen, gray, or dull pallor attributed to shock, with decreased perfusion and vasoconstriction, in black-skinned people will cause the skin to appear ashen, gray, or dull

A physician tells the nurse that a patients vertebra prominens is tender and asks the nurse to reevaluate the area in 1 hour. The area of the body the nurse will assess is: A. just above the diaphgram B. just lateral to the knee cap C. at the level of C7 vertebra D. at the level of the T11 vertebra

C. at the level of C7 vertebra The C7 vertebra has a long spinous process, called the vertebra prominens, which is palpable when the head is flexed

A term for dislodging the thick cervical mucous plug at the end of pregnancy is: A. placenta. B. menstruation. C. bloody show. D. All of the above

C. bloody show.

Having the individual place the backs of the hands together while flexing the wrist 90 degrees assesses for the presence of: A. Dupuytren's contracture. B. wrist ganglion. C. carpal tunnel syndrome. D. Tinel's sign.

C. carpal tunnel syndrome.

A patient is especially worried about an area of skin on her feet that has turned white. The health care provider has told her that her condition is vitiligo. The nurse explains that vitiligo is: A. caused by an excess of melanin pigment B. caused by an excess of apocrine glands in her feet C. caused by the complete absence of melanin pigment D. related to impetigo and can be treated with an ointment.

C. caused by the complete absence of melanin pigment

The nurse notices that an infant as a large, soft lump on the side of his head and his mother is very concerned. She tells the nurse that she notices the lump approximately 8 hours after the baby's birth and that it seem to be getting larger. One possible explanation for this is: A. hydrocephalus B. craniosynostosis C. cephalhematoma D. caput succedaneum

C. cephalhematoma A cephalhematoma is subperiosteal hemorrhage that is a result of birth trauma. It is soft, fluctuant, and well-defined over one cranial bone. It appears several hours after birth and gradually increases in size.

The most commonly reported sexually transmitted infection in the United States is: A. gonorrhea. B. syphilis. C. chlamydia. D. HIV.

C. chlamydia.

A 35 year old pregnant woman comes to the clinic for a monthly appointment. During the assessment, the nurse notices that she has a brown patch of hyperpigmentation on her face. The nurse continues the skin assessment aware that another finding may be: A. keratoses B. xerosis C. chloasma D. arochordons

C. chloasma in pregnancy, skin changes can include striae, linea nigra (a brownish-black line down the midline), chloasma (brown patches of hyperpigmentation), and vascular spiders.

A 70 year old woman who loves to garden has a small, flat, brown macules over her arms and hands. She asks, what causes liver spots? The nurse tells her, they are: A. signs of decreased hematocrit related to anemia B. due to the destruction of melanin in your skin from exposure to the sun. C. clusters of melanocytes that appear after extensive sun exposure D. areas of hyperpigmentation related to decreased perfusion and vasoconstriction

C. clusters of melanocyte that appear after extensive sun exposure liver spots (senile lentigines) are clusters of melanocytes that appear on the forearms and dorsa of the hands after extensive sun exposure

During an admission assessment, the nurse notices that a male patient has an enlarged and rather thick skull. The nurse suspects acromegaly and would further assess for: A. exophthalmos B. bowed long bones C. coarse facial features D. acorn-shaped cranium

C. coarse facial features acromegaly is excessive secretion of growth hormone that creates an enlarged skull and thickened cranial bones. Patients will have elongated heads, massive faces, prominent noses, and lower jaws, heavy eyebrow ridges, and coarse facial features.

A physician has diagnosed a patient with purpura. After leaving the room, a nursing student asks the nurse what the physician saw that led to the diagnosis. The nurse should say, the physician is referring to the: A. blue dilation of blood vessels in a star-shaped linear pattern on the legs B. fiery red, star-shaped marking on the cheek that has a solid circular center C. confluent and extensive patch of petechiae and ecchymoses on the feet D. tiny areas of hemorrhage that are less than 2 mm, round, discrete, and dark red in color

C. confluent and extensive patch of petechiae and ecchymoses on the feet. purpura is a confluent and extensive patch of petechiae and ecchymoses and flat macular hemorrhage observed in generalized disorders such as thrombocytopenia and scruvy

Pyloric stenosis is defined as a(n): A. abnormal enlargement of the pyloric sphincter. B. inflammation of the pyloric sphincter. C. congenital narrowing of the pyloric sphincter. D. None of the above.

C. congenital narrowing of the pyloric sphincter.

Bloody show is the term used for: A. red-tinged or bloody urine. B. aberrant growths of endometrial tissue. C. dislodging the cervical mucous plug in labor. D. whitish or yellowish discharge from the vaginal orifice.

C. dislodging the cervical mucous plug in labor.

A patient comes in to the clinic and tells the nurse that he has been confined to his recliner chair for approximately 3 days with his feet down and he asks the nurse to evaluate his feet. During the assessment, the nurse might expect to find: A. pallor B. coolness C. distended veins D. prolonged capillary filling time

C. distended veins keeping the feet in a dependent position causes venous pooling, resulting in redness, warmth, and distended veins.

During an examination of a female patient, the nurse notes lymphadenopathy and suspects an acute infection. Acutely infected lymph nodes would be: A. clumped B. unilateral C. firm but freely moving D. firm and nontender

C. firm but freely moving. acutely infected lymph nodes are bilateral, enlarged, warm, tender, and firm but freely movable. unilaterally enlarged nodes that are firm and nontender may indicate cancer

Mr. Hutchins is a 32-year-old patient who presents for follow-up examination. On examination you note painful clusters of small vesicles with surrounding erythema that erupt on the glans or foreskin. These are signs of: A. cystitis B. urethritis. C. herpes progenitalis. D. Peyronie disease.

C. herpes progenitalis.

Mrs. Bicker brings her infant son to the health clinic for a routine examination. When performing Ortolani's maneuver on the newborn infant, you feel a clunk as you abduct the infant's legs and flexed knees. The presence of a "clunk" is indicative of: A. tibial torsion. B. genu valgum. C. hip dislocation. D. talipes equinovarus.

C. hip dislocation.

Mrs. Harris brings her newborn infant to the office for a routine health assessment. On examination, you measure the equality of the infant's leg lengths, called the allis test. This assesses the presence of: A. talipes equinovarus. B. tibial torsion. C. hip dislocation. D. Colles fracture.

C. hip dislocation.

A 13-year-old girl is interested in obtaining information about the cause of her acne. The nurse should share with her that acne: A. is contagious B. has no known cause C. is caused by increased sebum production D. has been found to be related to poor hygiene

C. is caused by increased sebum production

During an examination for a patient in her third trimester of pregnancy, the nurse notices that the patients thyroid gland is slightly enlarged. No enlargement had been previously noticed. The nurse suspects that the patient: A. has an iodine deficiency B. is exhibiting early signs of goiter C. is exhibiting a normal enlargement of the thyroid gland during pregnancy D. needs further testing for possible thyroid cancer

C. is exhibiting a normal enlargement of the thyroid gland during pregnancy

While performing a well-child assessment on a 5 year old, the nurse notes the presence of palpable, bilateral, cervical, and inguinal lymph nodes. They are approximately 0.5 cm in size, round, mobile, and nontender. The nurse suspects that this child: A. has chronic allergies B. may have an infection C. is exhibiting a normal finding for a well child of his age D. should be referred for additional evaluation.

C. is exhibiting a normal finding for a well child his age

The functional unit of the skeletal system is the: A. bursa. B. articulation. C. joint. D. epiphysis.

C. joint.

Casey Galen, a student nurse, conducts a dermatology in-service for nurses and students assigned to a medical surgical floor at the local hospital. Ms. Galen stresses the impact of accumulated risk factors in skin disease and breakdown. Such factors include: A. loss of protective cushioning of the epidermal and dermal skin layers. B. decreased vascular fragility. C. lifetime of environmental trauma. D. All of the above.

C. lifetime of environmental trauma.

Mrs. Black, a 29-year-old patient who is pregnant, comes to the office with concerns about skin changes. As the health care provider, you know that some skin changes occur during pregnancy as a result of increased pigmentation, including: A. café au lait spots. B. keratosis. C. linea nigra. D. lentigines.

C. linea nigra.

Hymen is the term used for the: A. vestibular glands on either side of the vaginal orifice. B. uterine accessory organs. C. membranous fold of tissue partially closing the vaginal orifice. D. hard, painless nodules in the uterine wall.

C. membranous fold of tissue partially closing the vaginal orifice.

Linea alba is/are the: A. midline abdominal muscles extending from the rib cage to the pubic bone. B. ligament extending from the pubic bone to the anterosuperior iliac spine. C. midline tendinous seam joining the abdominal muscles. D. angle formed by the twelfth rib and the vertebral column.

C. midline tendinous seam joining the abdominal muscles.

A patient, 85 years old woman, is complaining about the fact that the bones in her face have become more noticeable. What explanation should the nurse give her? A. diets low in protein and high in carbohydrates may cause enhanced facial bones B. bones can become more noticeable if the person doesn't use dermatologically approved moisturizer. C. more noticeable facial bones are probably due to a combination of factors related to aging, such a decrease elasticity, subcutaneous fat, and moisture in her skin D. facial skin becomes more elastic with age. this increased elasticity causes the skin to be more taught, drawing attention to the facial bones

C. more noticeable facial bones are probably due to a combination of factors related to aging, such a decrease elasticity, subcutaneous fat, and moisture in her skin

A woman comes to the clinic and states, I've been sick for so long! My eyes have gotten so puffy, and my eyebrows and hair have become coarse and dry. The nurse will assess for other signs and symptoms of: A. cachexia B. parkinson syndrome C. myxedema D. scleroderma

C. myxedema Myxedema (hypothyroidism) is a deficiency of thyroid hormone that, when severe, causes a nonpitting edema or myxedema. The patient will have a puffy edamatous face, especially around the eyes (periorbital edema); coarse facial features; dry skin; and dry, coarse hair and eyebrows.

Elevated skin lesions that are greater than 1 cm in diameter are called: A. bullae. B. papules. C. nodules. D. furuncles.

C. nodules.

A mother brings in her newborn infant for an assessment and tells the nurse that she has noticed that whenever her newborns head is turned to the right side, she straightens out the arm and leg on the same side and flexes the opposite arm and leg. After observing this on examination, the nurse tells her that this reflex is: A. abnormal and is called the atonic neck reflex B. normal and should disappear by the first year of life. C. normal and is called the tonic neck reflex, which should disappear between 3-4 months of age. D. abnormal. The baby should be flexing the arm and leg on the right side of his body when the head is turned to the right.

C. normal and is called the tonic neck reflex, which should disappear between 3-4 months of age. By 2 weeks, the infant shoes the tonic reflex when supine and the head is turned to one side (extension of same arm and leg, flexion of opposite arm and leg.) the tonic neck reflex disappears between 3-4 months of age

Acute inflammation of the testes is: A. herpes progenitalis. B. priapism. C. orchitis. D. paraphimosis.

C. orchitis.

The nurse is assessing for inflammation in a dark-skinned person. Which technique is best? A. assessing the skin for cyanosis and swelling B. assessing the oral mucosa for generalized erythema C. palpating the skin for edema and increased warmth D. palpating for tenderness and local areas of ecchymosis

C. palpating the skin for edema and increased warmth

A solid, circumscribed palpable skin lesion, which is less than 1 cm in diameter, is a: A. nodule. B. bulla. C. papule. D. vesicle.

C. papule.

When examining the face of a patient, the nurse is aware that the two pairs of salivary glands are accessible to examination are the ____ & ____ glands. A. occipital; submental B. parotid; jugulodigastric C. parotid; submandibular D. submandibular; occipital

C. parotid; submandibular

A patient comes in for a physical examination and complains of freezing to death while waiting for her examination. The nurse notes that her skin is pale and cool and attributes this finding to: A. venous pooling B. peripheral vasodilation C. peripheral vasoconstriction D. decreased arterial perfusion

C. peripheral vasoconstriction

A patient has been admitted for severe psoriasis. The nurse expects to see what finding in the patients fingernails? A. splinter hemorrhages B. paronychia C. pitting D. beau lines

C. pitting sharply defined pitting and crumbling of the nails, each with distal detachment characterized pitting nails and are associated with psoriasis

A 42 year old woman complains that she has noticed several small, slightly raised, bright red dos on her chest. On examination, the nurse expects that the spots are probably: A. anasarca B. scleroderma C. senile angiomas D. latent myeloma

C. senile (cherry) angiomas senile angiomas are small, smooth, slightly raised bright red dots that are commonly appear on the trunks of adults over 30 years old

A nurse has discovered decreased skin turgor in a patient and knows that his finding is expected in which condition? A. severe obesity B. childhood growth spurts C. severe dehydration D. connective tissue disorders such as scleroderma

C. severe dehydration

During an examination, the nurse finds that a patients left temporal artery is tortuous and feels hardened and tender, compared with the right temporal artery. The nurse suspects which condition? A. crepitation B. mastoiditis C. temporal arteritis D. bell palsy

C. temporal arteritis

Mr. Lee comes to the office for a routine health assessment. As part of it, you perform a screening MS exam. This consists of all the following except: A. inspection and palpation of joints integrated with each body region. B. observation of ROM as the individual proceeds through motions required for preparation for the exam and during the exam. C. testing muscle strength of the major muscle groups. D. age-specific measures.

C. testing muscle strength of the major muscle groups.

The sudden twisting of the spermatic cord causes a surgical emergency called: A. prepuce. B. spermatocele. C. torsion. D. progenitalis.

C. torsion.

(excessive or uncontrolled) drinking

CAGE is a screening questionnaire to identify _______ (C = Cut down; A = Annoyed; G = Guilty; E = Eye opener).

secondary skin lesions

CRUST: thickened, dried out exudate left when vesicles or pustules burst or dry up SCALE: compact desiccated flakes of skin. dry or greasy, silvery or white, dead skin FISSURE: linear crack with abrupt edges, extends into dermis, dry or moist EROSION: scooped out, but shallow depression, superficial ULCER: deeper depression extending into dermis, irregular shape, may bleed

. When providing culturally competent care, nurses must incorporate cultural assessments into their health assessments. Which statement is most appropriate to use when initiating an assessment of cultural beliefs with an older American-Indian patient? a. Are you of the Christian faith? b. Do you want to see a medicine man? c. How often do you seek help from medical providers? d. What cultural or spiritual beliefs are important to you?

A 19-year-old college student is brought to the emergency department with a severe headache he describes as, Like nothing Ive ever had before. His temperature is 40 C, and he has a stiff neck. The nurse looks for other signs and symptoms of which problem? a. Head injury b. Cluster headache c. Migraine headache d. Meningeal inflammation

A 29-year-old woman tells the nurse that she has excruciating pain in her back. Which would be the nurses appropriate response to the womans statement? a. How does your family react to your pain? b. The pain must be terrible. You probably pinched a nerve. c. Ive had back pain myself, and it can be excruciating. d. How would you say the pain affects your ability to do your daily activities?

A 5-year-old boy is being admitted to the hospital to have his tonsils removed. Which information should the nurse collect before this procedure? a. Childs birth weight b. Age at which he crawled c. Whether the child has had the measles d. Childs reactions to previous hospitalizations

A 59-year-old patient tells the nurse that he has ulcerative colitis. He has been having black stools for the last 24 hours. How would the nurse best document his reason for seeking care? a. J.M. is a 59-year-old man seeking treatment for ulcerative colitis. b. J.M. came into the clinic complaining of having black stools for the past 24 hours. c. J.M. is a 59-year-old man who states that he has ulcerative colitis and wants it checked. d. J.M. is a 59-year-old man who states that he has been having black stools for the past 24 hours.

A 63-year-old Chinese-American man enters the hospital with complaints of chest pain, shortness of breath, and palpitations. Which statement most accurately reflects the nurses best course of action? a. The nurse should focus on performing a full cardiac assessment. b. The nurse should focus on psychosomatic complaints because the patient has just learned that his wife has cancer. c. This patient is not in any danger at present; therefore, the nurse should send him home with instructions to contact his physician. d. It is unclear what is happening with this patient; consequently, the nurse should perform an assessment in both the physical and the psychosocial realms.

A 65-year-old man with emphysema and bronchitis has come to the clinic for a follow-up appointment. On assessment, the nurse might expect to see which finding? a. Anasarca b. Scleroderma c. Pedal erythema d. Clubbing of the nails

A 90-year-old patient tells the nurse that he cannot remember the names of the medications he is taking or for what reason he is taking them. An appropriate response from the nurse would be: a. Can you tell me what they look like? b. Dont worry about it. You are only taking two medications. c. How long have you been taking each of the pills? d. Would you have a family member bring in your medications?

A female American Indian has come to the clinic for follow-up diabetic teaching. During the interview, the nurse notices that she never makes eye contact and speaks mostly to the floor. Which statement is true regarding this situation? a. The woman is nervous and embarrassed. b. She has something to hide and is ashamed. c. The woman is showing inconsistent verbal and nonverbal behaviors. d. She is showing that she is carefully listening to what the nurse is saying.

A man arrives at the clinic for his annual wellness physical. He is experiencing no acute health problems. Which question or statement by the nurse is most appropriate when beginning the interview? a. How is your family? b. How is your job? c. Tell me about your hypertension. d. How has your health been since your last visit?

A man has been admitted to the observation unit for observation after being treated for a large cut on his forehead. As the nurse works through the interview, one of the standard questions has to do with alcohol, tobacco, and drug use. When the nurse asks him about tobacco use, he states, I quit smoking after my wife died 7 years ago. However, the nurse notices an open pack of cigarettes in his shirt pocket. Using confrontation, the nurse could say: a. Mr. K., I know that you are lying. b. Mr. K., come on, tell me how much you smoke. c. Mr. K., I didnt realize your wife had died. It must be difficult for you at this time. Please tell me more about that. d. Mr. K., you have said that you dont smoke, but I see that you have an open pack of cigarettes in your pocket.

A man has come in to the clinic for a skin assessment because he is worried he might have skin cancer. During the skin assessment the nurse notices several areas of pigmentation that look greasy, dark, and "stuck on" his skin. Which is the best prediction? a. Senile lentigines, which do not become cancerous b. Actinic keratoses, which are precursors to basal cell carcinoma c. Acrochordons, which are precursors to squamous cell carcinoma d. Seborrheic keratoses, which do not become cancerous

A mother brings her 2-month-old daughter in for an examination and says, My daughter rolled over against the wall, and now I have noticed that she has this spot that is soft on the top of her head. Is something terribly wrong? The nurses best response would be: a. Perhaps that could be a result of your dietary intake during pregnancy. b. Your baby may have craniosynostosis, a disease of the sutures of the brain. c. That soft spot may be an indication of cretinism or congenital hypothyroidism. d. That soft spot is normal, and actually allows for growth of the brain during the first year of your babys life

A patient comes into the emergency department after an accident at work. A machine blew dust into his eyes, and he was not wearing safety glasses. The nurse examines his corneas by shining a light from the side across the cornea. What findings would suggest that he has suffered a corneal abrasion? a. Smooth and clear corneas b. Opacity of the lens behind the cornea c. Bleeding from the areas across the cornea d. Shattered look to the light rays reflecting off the cornea

A patient comes to the clinic and states that he has noticed that his skin is redder than normal. The nurse understands that this condition is due to hyperemia and knows that it can be caused by: a. Decreased amounts of bilirubin in the blood b. Excess blood in the underlying blood vessels c. Decreased perfusion to the surrounding tissues d. Excess blood in the dilated superficial capillaries

A patient complains that while studying for an examination he began to notice a severe headache in the frontotemporal area of his head that is throbbing and is somewhat relieved when he lies down. He tells the nurse that his mother also had these headaches. The nurse suspects that he may be suffering from: a. Hypertension. b. Cluster headaches. c. Tension headaches. d. Migraine headaches.

A patient has a normal pupillary light reflex. The nurse recognizes that this reflex indicates that: a. The eyes converge to focus on the light. b. Light is reflected at the same spot in both eyes. c. The eye focuses the image in the center of the pupil. d. Constriction of both pupils occurs in response to bright light.

A patient has finished giving the nurse information about the reason he is seeking care. When reviewing the data, the nurse finds that some information about past hospitalizations is missing. At this point, which statement by the nurse would be most appropriate to gather these data? a. Mr. Y., at your age, surely you have been hospitalized before! b. Mr. Y., I just need permission to get your medical records from County Medical. c. Mr. Y., you mentioned that you have been hospitalized on several occasions. Would you tell me more about that? d. Mr. Y., I just need to get some additional information about your past hospitalizations. When was the last time you were admitted for chest pain?

A patient has had a "terrible itch" for several months that he has been continuously scratching. On examination, the nurse might expect to find: a. A keloid. b. A fissure. c. Keratosis. d. Lichenification.

A patient has had a cerebrovascular accident (stroke). He is trying very hard to communicate. He seems driven to speak and says, "I buy obie get spirding and take my train." What is the best description of this patient's problem? a. Global aphasia b. Broca's aphasia c. Echolalia d. Wernicke's aphasia

A patient is describing his symptoms to the nurse. Which of these statements reflects a description of the setting of his symptoms? a. It is a sharp, burning pain in my stomach. b. I also have the sweats and nausea when I feel this pain. c. I think this pain is telling me that something bad is wrong with me. d. This pain happens every time I sit down to use the computer.

A patient is unable to read even the largest letters on the Snellen chart. The nurse should take which action next? a. Refer the patient to an ophthalmologist or optometrist for further evaluation. b. Assess whether the patient can count the nurses fingers when they are placed in front of his or her eyes. c. Ask the patient to put on his or her reading glasses and attempt to read the Snellen chart again. d. Shorten the distance between the patient and the chart until the letters are seen, and record that distance.

A patient tells the nurse that he is allergic to penicillin. What would be the nurses best response to this information? a. Are you allergic to any other drugs? b. How often have you received penicillin? c. Ill write your allergy on your chart so you wont receive any penicillin. d. Describe what happens to you when you take penicillin.

A patient visits the clinic because he has recently noticed that the left side of his mouth is paralyzed. He states that he cannot raise his eyebrow or whistle. The nurse suspects that he has: a. Cushing syndrome. b. Parkinson disease. c. Bell palsy. d. Experienced a cerebrovascular accident (CVA) or stroke.

A woman has just entered the emergency department after being battered by her husband. The nurse needs to get some information from her to begin treatment. What is the best choice for an opening phase of the interview with this patient? a. Hello, Nancy, my name is Mrs. C. b. Hello, Mrs. H., my name is Mrs. C. It sure is cold today! c. Mrs. H., my name is Mrs. C. How are you? d. Mrs. H., my name is Mrs. C. Ill need to ask you a few questions about what happened.

A woman is leaving on a trip to Hawaii and has come in for a checkup. During the examination the nurse learns that she has diabetes and takes oral hypoglycemic agents. The patient needs to be concerned about which possible effect of her medications? a. Increased possibility of bruising b. Skin sensitivity as a result of exposure to salt water c. Lack of availability of glucose-monitoring supplies d. Importance of sunscreen and avoiding direct sunlight

After a symptom is recognized, the first effort at treatment is often self-care. Which of the following statements about self-care is true? Self-care is: a. Not recognized as valuable by most health care providers. b. Usually ineffective and may delay more effective treatment. c. Always less expensive than biomedical alternatives. d. Influenced by the accessibility of over-the-counter medicines.

An ophthalmic examination reveals papilledema. The nurse is aware that this finding indicates: a. Retinal detachment. b. Diabetic retinopathy. c. Acute-angle glaucoma. d. Increased intracranial pressure.

During a class on religion and spirituality, the nurse is asked to define spirituality. Which answer is correct? Spirituality: a. Is a personal search to discover a supreme being. b. Is an organized system of beliefs concerning the cause, nature, and purpose of the universe. c. Is a belief that each person exists forever in some form, such as a belief in reincarnation or the afterlife. d. Arises out of each persons unique life experience and his or her personal effort to find purpose in life.

During a class on the aspects of culture, the nurse shares that culture has four basic characteristics. Which statement correctly reflects one of these characteristics? a. Cultures are static and unchanging, despite changes around them. b. Cultures are never specific, which makes them hard to identify. c. Culture is most clearly reflected in a persons language and behavior. d. Culture adapts to specific environmental factors and available natural resources.

During a staff meeting, nurses discuss the problems with accessing research studies to incorporate evidence-based clinical decision making into their practice. Which suggestion by the nurse manager would best help these problems? a. Form a committee to conduct research studies. b. Post published research studies on the units bulletin boards. c. Encourage the nurses to visit the library to review studies. d. Teach the nurses how to conduct electronic searches for research studies.

During an assessment of the sclera of a black patient, the nurse would consider which of these an expected finding? a. Yellow fatty deposits over the cornea b. Pallor near the outer canthus of the lower lid c. Yellow color of the sclera that extends up to the iris d. Presence of small brown macules on the sclera

During an assessment, the nurse uses the CAGE test. The patient answers yes to two of the questions. What could this be indicating? a. The patient is an alcoholic. b. The patient is annoyed at the questions. c. The patient should be thoroughly examined for possible alcohol withdrawal symptoms. d. The nurse should suspect alcohol abuse and continue with a more thorough substance abuse assessment.

During an examination of a 3-year-old child, the nurse will need to take her blood pressure. What might the nurse do to try to gain the childs full cooperation? a. Tell the child that the blood pressure cuff is going to give her arm a big hug. b. Tell the child that the blood pressure cuff is asleep and cannot wake up. c. Give the blood pressure cuff a name and refer to it by this name during the assessment. d. Tell the child that by using the blood pressure cuff, we can see how strong her muscles are.

During an examination of the eye, the nurse would expect what normal finding when assessing the lacrimal apparatus? a. Presence of tears along the inner canthus b. Blocked nasolacrimal duct in a newborn infant c. Slight swelling over the upper lid and along the bony orbit if the individual has a cold d. Absence of drainage from the puncta when pressing against the inner orbital rim

During an interview, a parent of a hospitalized child is sitting in an open position. As the interviewer begins to discuss his sons treatment, however, he suddenly crosses his arms against his chest and crosses his legs. This changed posture would suggest that the parent is: a. Simply changing positions. b. More comfortable in this position. c. Tired and needs a break from the interview. d. Uncomfortable talking about his sons treatment.

During an interview, the nurse states, You mentioned having shortness of breath. Tell me more about that. Which verbal skill is used with this statement? a. Reflection b. Facilitation c. Direct question d. Open-ended question

During an interview, the patient states he has the sensation that everything around him is spinning. The nurse recognizes that the portion of the ear responsible for this sensation is the: a. Cochlea. b. CN VIII. c. Organ of Corti. d. Labyrinth.

During ocular examinations, the nurse keeps in mind that movement of the extraocular muscles is: a. Decreased in the older adult. b. Impaired in a patient with cataracts. c. Stimulated by cranial nerves (CNs) I and II. d. Stimulated by CNs III, IV, and VI.

During the aging process, the hair can look gray or white and begin to feel thin and fine. The nurse knows that this occurs because of a decrease in the number of functioning: a. Metrocytes. b. Fungacytes. c. Phagocytes. d. Melanocytes.

During the interview portion of data collection, the nurse collects __________ data. a. Physical b. Historical c. Objective d. Subjective

In obtaining a review of systems on a healthy 7-year-old girl, the health care provider knows that it would be important to include the: a. Last glaucoma examination. b. Frequency of breast self-examinations. c. Date of her last electrocardiogram. d. Limitations related to her involvement in sports activities.

In recording the childhood illnesses of a patient who denies having had any, which note by the nurse would be most accurate? a. Patient denies usual childhood illnesses. b. Patient states he was a very healthy child. c. Patient states his sister had measles, but he didnt. d. Patient denies measles, mumps, rubella, chickenpox, pertussis, and strep throat.

In the health promotion model, the focus of the health professional includes: a. Changing the patients perceptions of disease. b. Identifying biomedical model interventions. c. Identifying negative health acts of the consumer. d. Helping the consumer choose a healthier lifestyle.

In the hot/cold theory, illnesses are believed to be caused by hot or cold entering the body. Which of these patient conditions is most consistent with a cold condition? a. Patient with diabetes and renal failure b. Teenager with an abscessed tooth c. Child with symptoms of itching and a rash d. Older man with gastrointestinal discomfort

In using verbal responses to assist the patients narrative, some responses focus on the patients frame of reference and some focus on the health care providers perspective. An example of a verbal response that focuses on the health care providers perspective would be: a. Empathy. b. Reflection. c. Facilitation. d. Confrontation.

The mother of a 16-month-old toddler tells the nurse that her daughter has an earache. What would be an appropriate response? a. Maybe she is just teething. b. I will check her ear for an ear infection. c. Are you sure she is really having pain? d. Describe what she is doing to indicate she is having pain.

The mother of a 2-year-old is concerned because her son has had three ear infections in the past year. What would be an appropriate response by the nurse? a. It is unusual for a small child to have frequent ear infections unless something else is wrong. b. We need to check the immune system of your son to determine why he is having so many ear infections. c. Ear infections are not uncommon in infants and toddlers because they tend to have more cerumen in the external ear. d. Your sons eustachian tube is shorter and wider than yours because of his age, which allows for infections to develop more easily.

The nurse asks, I would like to ask you some questions about your health and your usual daily activities so that we can better plan your stay here. This question is found at the __________ phase of the interview process. a. Summary b. Closing c. Body d. Opening or introduction

The nurse educator is preparing an education module for the nursing staff on the dermis layer of skin. Which of these statements would be included in the module? The dermis: a. Contains mostly fat cells. b. Consists mostly of keratin. c. Is replaced every 4 weeks. d. Contains sensory receptors.

The nurse educator is preparing an education module for the nursing staff on the epidermal layer of skin. Which of these statements would be included in the module? The epidermis is: a. Highly vascular. b. Thick and tough. c. Thin and nonstratified. d. Replaced every 4 weeks.

The nurse is assessing a patients eyes for the accommodation response and would expect to see which normal finding? a. Dilation of the pupils b. Consensual light reflex c. Conjugate movement of the eyes d. Convergence of the axes of the eyes

The nurse is assessing for clubbing of the fingernails and expects to find: a. Nail bases that are firm and slightly tender. b. Curved nails with a convex profile and ridges across the nails. c. Nail bases that feel spongy with an angle of the nail base of 150 degrees. d. Nail bases with an angle of 180 degrees or greater and nail bases that feel spongy.

The nurse is assessing orientation in a 79-year-old patient. Which of these responses would lead the nurse to conclude that this patient is oriented? a. "I know my name is John. I couldn't tell you where I am. I think it is 2010, though." b. "I know my name is John, but to tell you the truth, I get kind of confused about the date." c. "I know my name is John; I guess I'm at the hospital in Spokane. No, I don't know the date." d. "I know my name is John. I am at the hospital in Spokane. I couldn't tell you what date it is, but I know that it is February of a new year—2010."

The nurse is aware that the four areas in the body where lymph nodes are accessible are the: a. Head, breasts, groin, and abdomen. b. Arms, breasts, inguinal area, and legs. c. Head and neck, arms, breasts, and axillae. d. Head and neck, arms, inguinal area, and axillae.

The nurse is bathing an 80-year-old man and notices that his skin is wrinkled, thin, lax, and dry. This finding would be related to which factor in the older adult? a. Increased vascularity of the skin b. Increased numbers of sweat and sebaceous glands c. An increase in elastin and a decrease in subcutaneous fat d. An increased loss of elastin and a decrease in subcutaneous fat

The nurse is conducting a class on priority setting for a group of new graduate nurses. Which is an example of a first-level priority problem? a. Patient with postoperative pain b. Newly diagnosed patient with diabetes who needs diabetic teaching c. Individual with a small laceration on the sole of the foot d. Individual with shortness of breath and respiratory distress

The nurse is obtaining a health history on an 87-year-old woman. Which of the following areas of questioning would be most useful at this time? a. Obstetric history b. Childhood illnesses c. General health for the past 20 years d. Current health promotion activities

The nurse is performing an eye-screening clinic at a daycare center. When examining a 2-year-old child, the nurse suspects that the child has a lazy eye and should: a. Examine the external structures of the eye. b. Assess visual acuity with the Snellen eye chart. c. Assess the childs visual fields with the confrontation test. d. Test for strabismus by performing the corneal light reflex test.

The nurse is preparing to complete a health assessment on a 16-year-old girl whose parents have brought her to the clinic. Which instruction would be appropriate for the parents before the interview begins? a. Please stay during the interview; you can answer for her if she does not know the answer. b. It would help to interview the three of you together. c. While I interview your daughter, will you please stay in the room and complete these family health history questionnaires? d. While I interview your daughter, will you step out to the waiting room and complete these family health history questionnaires?

The nurse is preparing to conduct a health history. Which of these statements best describes the purpose of a health history? a. To provide an opportunity for interaction between the patient and the nurse b. To provide a form for obtaining the patients biographic information c. To document the normal and abnormal findings of a physical assessment d. To provide a database of subjective information about the patients past and current health

The nurse is preparing to do a functional assessment. Which statement best describes the purpose of a functional assessment? a. The functional assessment assesses how the individual is coping with life at home. b. It determines how children are meeting developmental milestones. c. The functional assessment can identify any problems with memory the individual may be experiencing. d. It helps determine how a person is managing day-to-day activities.

The nurse is reviewing causes of increased intraocular pressure. Which of these factors determines intraocular pressure? a. Thickness or bulging of the lens b. Posterior chamber as it accommodates increased fluid c. Contraction of the ciliary body in response to the aqueous within the eye d. Amount of aqueous produced and resistance to its outflow at the angle of the anterior chamber

The nurse is reviewing the hot/cold theory of health and illness. Which statement best describes the basic tenets of this theory? a. The causation of illness is based on supernatural forces that influence the humors of the body. b. Herbs and medicines are classified on their physical characteristics of hot and cold and the humors of the body. c. The four humors of the body consist of blood, yellow bile, spiritual connectedness, and social aspects of the individual. d. The treatment of disease consists of adding or subtracting cold, heat, dryness, or wetness to restore the balance of the humors of the body.

The nurse is reviewing the structures of the ear. Which of these statements concerning the eustachian tube is true? a. The eustachian tube is responsible for the production of cerumen. b. It remains open except when swallowing or yawning. c. The eustachian tube allows passage of air between the middle and outer ear. d. It helps equalize air pressure on both sides of the tympanic membrane.

The nurse manager is explaining culturally competent care during a staff meeting. Which statement accurately describes the concept of culturally competent care? The caregiver: a. Is able to speak the patients native language. b. Possesses some basic knowledge of the patients cultural background. c. Applies the proper background knowledge of a patients cultural background to provide the best possible health care. d. Understands and attends to the total context of the patients situation.

The nurse notices that a patient has a solid, elevated, circumscribed lesion that is less than 1 cm in diameter. When documenting this finding, the nurse reports this as a: a. Bulla. b. Wheal. c. Nodule. d. Papule.

The nursing process is a sequential method of problem solving that nurses use and includes which steps? a. Assessment, treatment, planning, evaluation, discharge, and follow-up b. Admission, assessment, diagnosis, treatment, and discharge planning c. Admission, diagnosis, treatment, evaluation, and discharge planning d. Assessment, diagnosis, outcome identification, planning, implementation, and evaluation

What step of the nursing process includes data collection by health history, physical examination, and interview? a. Planning b. Diagnosis c. Evaluation d. Assessment

When assessing aging adults, the nurse knows that one of the first things that should be assessed before making judgments about their mental status is: a. Presence of phobias b. General intelligence c. Presence of irrational thinking patterns d. Sensory-perceptive abilities

When discussing the use of the term subculture, the nurse recognizes that it is best described as: a. Fitting as many people into the majority culture as possible. b. Defining small groups of people who do not want to be identified with the larger culture. c. Singling out groups of people who suffer differential and unequal treatment as a result of cultural variations. d. Identifying fairly large groups of people with shared characteristics that are not common to all members of a culture.

When observing a patients verbal and nonverbal communication, the nurse notices a discrepancy. Which statement is true regarding this situation? The nurse should: a. Ask someone who knows the patient well to help interpret this discrepancy. b. Focus on the patients verbal message, and try to ignore the nonverbal behaviors. c. Try to integrate the verbal and nonverbal messages and then interpret them as an average. d. Focus on the patients nonverbal behaviors, because these are often more reflective of a patients true feelings.

Which of these individuals would the nurse consider at highest risk for a suicide attempt? a. Man who jokes about death b. Woman who, during a past episode of major depression, attempted suicide c. Adolescent who just broke up with her boyfriend and states that she would like to kill herself d. Older adult man who tells the nurse that he is going to "join his wife in heaven" tomorrow and plans to use a gun

Which of these responses might the nurse expect during a functional assessment of a patient whose leg is in a cast? a. I broke my right leg in a car accident 2 weeks ago. b. The pain is decreasing, but I still need to take acetaminophen. c. I check the color of my toes every evening just like I was taught. d. Im able to transfer myself from the wheelchair to the bed without help.

Which situation is most appropriate during which the nurse performs a focused or problem-centered history? a. Patient is admitted to a long-term care facility. b. Patient has a sudden and severe shortness of breath. c. Patient is admitted to the hospital for surgery the following day. d. Patient in an outpatient clinic has cold and influenza-like symptoms.

Which statement best describes a proficient nurse? A proficient nurse is one who: a. Has little experience with a specified population and uses rules to guide performance. b. Has an intuitive grasp of a clinical situation and quickly identifies the accurate solution. c. Sees actions in the context of daily plans for patients. d. Understands a patient situation as a whole rather than a list of tasks and recognizes the long-term goals for the patient.

20. When assessing muscle strength, the nurse observes that a patient has complete range of motion against gravity with full resistance. What Grade should the nurse record using a 0 to 5 point scale? A) 2 B) 3 C) 4 D) 5

D) 5 Complete range of motion against gravity is normal muscle strength and is recorded as Grade 5 muscle strength. Pages: 578-579

A 22-year-old man comes to the clinic for an examination after falling off his motorcycle and landing on his left side on the handlebars. The nurse suspects that he may have injured his spleen. Which of these statements is true regarding assessment of the spleen in this situation? A) The spleen can be enlarged as a result of trauma. B) The spleen is normally felt upon routine palpation. C) If an enlarged spleen is noticed, then the nurse should palpate thoroughly to determine size. D) An enlarged spleen should not be palpated because it can rupture easily.

D) An enlarged spleen should not be palpated because it can rupture easily. If an enlarged spleen is felt, then the nurse should refer the person but should not continue to palpate it. An enlarged spleen is friable and can rupture easily with overpalpation. REF: Page: 549

The nurse is bathing an 80-year-old man and notices that his skin is wrinkled, thin, lax, and dry. This finding would be related to which factor? A) Increased vascularity of the skin in the elderly B) Increased numbers of sweat and sebaceous glands in the elderly C) An increase in elastin and a decrease in subcutaneous fat in the elderly D) An increased loss of elastin and a decrease in subcutaneous fat in the elderly

D) An increased loss of elastin and a decrease in subcutaneous fat in the elderly An accumulation of factors place the aging person at risk for skin disease and breakdown: the thinning of the skin, the decrease in vascularity and nutrients, the loss of protective cushioning of the subcutaneous layer, a lifetime of environmental trauma to skin, the social changes of aging, the increasingly sedentary lifestyle, and the chance of immobility. Page: 206

A 65-year-old man with emphysema and bronchitis has come to the clinic for a follow-up appointment. On assessment, the nurse might expect to see which assessment finding? A) Anasarca B) Scleroderma C) Pedal erythema D) Clubbing of the nails

D) Clubbing of the nails Clubbing of the nails occurs with congenital cyanotic heart disease, neoplastic, and pulmonary diseases. The other responses are assessment findings not associated with pulmonary diseases. Pages 217-218

The nurse suspects that a patient has a distended bladder. How should the nurse assess for this condition? A) Percuss and palpate in the lumbar region. B) Inspect and palpate in the epigastric region. C) Auscultate and percuss in the inguinal region. D) Percuss and palpate the midline area above the suprapubic bone.

D) Percuss and palpate the midline area above the suprapubic bone. Dull percussion sounds would be elicited over a distended bladder, and the hypogastric area would seem firm to palpation. REF: Pages: 539-540

Which structure is located in the left lower quadrant of the abdomen? A) Liver B) Duodenum C) Gallbladder D) Sigmoid colon

D) Sigmoid colon The sigmoid colon is located in the left lower quadrant of the abdomen. REF: Page: 530

The nurse is assessing for clubbing of the fingernails and would expect to find: A) a nail base that is firm and slightly tender. B) curved nails with a convex profile and ridges across the nail. C) a nail base that feels spongy with an angle of the nail base of 150 degrees. D) an angle of the nail base of 180 degrees or greater with a nail base that feels spongy.

D) an angle of the nail base of 180 degrees or greater with a nail base that feels spongy. The normal nail is firm at its base and has an angle of 160 degrees. In clubbing, the angle straightens to 180 degrees or greater and the nail base feels spongy. Pages: 217-218

The nurse is aware that one change that may occur in the gastrointestinal system of an aging adult is: A) increased salivation. B) increased liver size. C) increased esophageal emptying. D) decreased gastric acid secretion.

D) decreased gastric acid secretion. Gastric acid secretion decreases with aging. As one ages, salivation decreases, esophageal emptying is delayed, and liver size decreases. REF: Page: 531

A 62-year-old man states that his doctor told him that he has an "inguinal hernia." He asks the nurse to explain what a hernia is. The nurse should: A) tell him not to worry and that most men his age develop hernias. B) explain that a hernia is often the result of prenatal growth abnormalities. C) refer him to his physician for additional consultation because the physician made the initial diagnosis. D) explain that a hernia is a loop of bowel protruding through a weak spot in the abdominal muscles.

D) explain that a hernia is a loop of bowel protruding through a weak spot in the abdominal muscles. A hernia is a loop of bowel protruding through a weak spot in the musculature. The other options are not correct responses to the patient's question.

The physician comments that a patient has abdominal borborygmi. The nurse knows that this term refers to: A) a loud continuous hum. B) a peritoneal friction rub. C) hypoactive bowel sounds. D) hyperactive bowel sounds.

D) hyperactive bowel sounds. Borborygmi is the term used for hyperperistalsis when the person actually feels his or her stomach growling. REF: Pages: 539-540

A patient's abdomen is bulging and stretched in appearance. The nurse should describe this finding as: A) obese. B) herniated. C) scaphoid. D) protuberant.

D) protuberant. A protuberant abdomen is rounded, bulging, and stretched. See Figure 21-7. A scaphoid abdomen caves inward. REF: Page: 536

Umbilical hernias in infants: A. appear at 2 to 3 weeks of age. B. are more prominent when the baby cries. C. disappear by the time the baby is 1 year old. D. All of the above

D. All of the above

A father brings in his 2 month old infant to the clinic because the infant has had diarrhea for the last 24 hours. He says his baby has not been able to keep any formula down and that the diarrhea has been at least every 2 hours. The nurse suspects dehydration. The nurse should test skin mobility and turgor over the infants: A. sternum B. forehead C. forearms D. abdomen

D. abdomen mobility and turgor are tested over the abdomen of an infant. Poor turgor (tenting) indicates dehydration or malnutrition.

Dysmenorrhea is a synonym for: A. painful intercourse. B. bowel spasms with defecation. C. cramping with urination. D. abdominal cramping and pain associated with menstruation.

D. abdominal cramping and pain associated with menstruation.

Mr. Kinder is a 59-year-old patient who comes to the clinic for follow-up after an emergency room visit. On examination of the abdomen, you note ascites. Ascites is: A. a bowel obstruction. B. a proximal part of the large intestine. C. an abnormal enlargement of the spleen. D. an abnormal accumulation of serous fluid within the peritoneal cavity.

D. an abnormal accumulation of serous fluid within the peritoneal cavity.

Orchitis is: A. a meatus opening on the dorsal side of the glans or shaft. B. hard, subcutaneous plaques associated with painful bending of the erect penis. C. a circumscribed collection of serous fluid in the tunica vaginalis surrounding the testes. D. an acute inflammation of the testes.

D. an acute inflammation of the testes.

The nurse is bathing an 80-year-old man and notices that his skin is wrinkled, lax, and dry. This finding would be related to which factor in the older adult? A. increased vascularity of the skin B. increased numbers of sweat and sebaceous glands C. an increase in elastin and decrease in subcutaneous fat D. an increased loss of elastin and decrease in subcutaneous fat

D. an increased loss of elastin and decrease in subcutaneous fat

The nurse notices that a patients submental lymph nodes are enlarged. In an effort to identify the cause of the node enlargement, the nurse would assess the patients: A. infraclavicular area B. supraclavicular area C. area distal to the enlarged node D. area proximal to the enlarged node

D. area proximal to the enlarged node when nodes are abnormal, the nurse should check the area into which they drain for the source of the problem. The area proximal (upstream) to the location of the abnormal node should be explored.

A thin, grey-white, fishy smelling vaginal drainage is: A. gonorrhea. B. chlamydia. C. candida. D. bacterial vaginosis.

D. bacterial vaginosis.

A thickened synovial membrane is described as feeling: A. rigid. B. pliable. C. constricted. D. boggy.

D. boggy.

Mr. Verdana is a 41-year-old gentleman who presents with a complaint of skin problems. On examination you note single-chambered, superficial lesions containing free fluid > 1 cm in diameter, which are called: A. furuncles. B. vesicles. C. wheals. D. bullae.

D. bullae.

The left kidney usually: A. can be felt easily. B. can only be felt when the person breathes deeply. C. is 1 cm lower than the right kidney. D. cannot be felt.

D. cannot be felt.

Mr. Yoder is a 49-year-old patient who comes to the clinic for a physical examination for his job. On examination, you perform a Phalen's test. This is used to assess for the presence of: A. elbow joint subluxation. B. wrist ROM. C. osteoporosis. D. carpal tunnel syndrome.

D. carpal tunnel syndrome.

Leukorrhea is the term for: A. white to light yellow vaginal discharge. B. bloody vaginal discharge. C. purulent vaginal discharge. D. clear, mucoid vaginal discharge.

D. clear, mucoid vaginal discharge.

A 65 year old man with emphysema and bronchitis has come to the clinic for a follow-up appointment. On assessment, the nurse might expect to see which finding? A. anasarca B. scleroderma C. pedal erythema D. clubbing of the nails

D. clubbing of the nails clubbing of the nails occurs with congenital cyanotic heart disease and pulmonary diseases.

The nurse educator is preparing an education module for the nursing staff on the dermis layer of skin. Which of these statements would be included in the module? The dermis: A. contains mostly fat cells B. consists mostly of keratin C. is replaced every 4 weeks D. contains sensory receptors

D. contains sensory receptors

A newborn infant has Down syndrome. During the skin assessment, the nurse notices a transient mottling int he trunk and extremities in response to the cool temperature in the examination room. The infants mother also notices that nothing and asks what it is. The nurse knows that this nothing is called: A. caf au lait B. carotenemia C. arocyanosis D. cutis marmorata

D. cutis marmorata persistent or pronounced cutis marmorata occurs with infants born with Down syndrome or those born prematurely and is a transient mottling in the trunk and extremities in response to cool room temperatures

Inflammation of the urinary bladder is called: A. hypospadias. B. orchitis. C. urethritis. D. cystitis.

D. cystitis.

A scooped-out, shallow depression in the skin is called a/an: A. ulcer. B. excoriation. C. fissure. D. erosion.

D. erosion.

A patient comes to the clinic and states that he has noticed that his skin is redder than normal. The nurse understands that this condition is due to hyperemia and knows that it can be caused by: A. decreased amounts of bilirubin in the blood B. excess blood in the underlying blood vessels C. decreased perfusion in the surrounding tissues D. excess blood in the dilated superficial capillaries.

D. excess blood int he dilated superficial capillaries

A patient visits the clinic because he has recently noticed that the left side of his mouth is paralyzed. He states that he can't raise his eyebrow or whistle. The nurse suspects that he has: A. Cushing syndrome B. Parkinson disease C. Bell palsy D. experienced a CVA or stroke

D. experienced a CVA or stroke.

The nurse is aware that the 4 areas in the body where lymph nodes area accessible are the: A. head, breasts, groin, and abdomen B. arms, breasts, inguinal area, and legs C. head and neck, arms, breasts, and axillae D. head and neck, arms, inguinal area, and axillae

D. head and heck, arms, inguinal area, and axillae

During a well-baby checkup, the nurse notices that a 1 week old infants face looks small compared with his cranium, which seems enlarged. On further examination, the nurse also notices dilated scalp veins and downcast or setting sun eyes. The nurse suspects which condition? A. craniotabes B. microcephaly C. hydrocephalus D. caput succedaneum

D. hydrocephalus hydrocephalus occurs w/ the obstruction of drainage of the CSF that results in excessive accumulation, increasing intracranial pressure, and enlargement of the head.

A congenital defect in which the urethra opens on the ventral side of the penis is known as: A. phimosis. B. urethritis. C. priapism. D. hypospadias.

D. hypospadias.

A woman is leaving on a trip to Hawaii and has come in for a checkup. During the examination the nurse learns that she has diabetes and takes oral hypoglycemic agents. The patient needs to be concerned about which possible effect of her medications? A. increased possibility of bruising B. skin sensitivity as a result of exposure to salt water C. lack of availability for glucose-monitoring supplies D. importance of sunscreen an avoiding direct sunlight.

D. importance of sunscreen and avoiding direct sunlight Drugs that may increase sunlight sensitivity and give a burn response include sulfonamides, thiazides, diuretics, oral hypoglycemic agents, and tetracycline.

A patient has had a terrible itch for several months that he has been continuously scratching. On examination, the nurse might expect to find: A. a keloid B. a fissure C. keratosis D. lichenification

D. lichenification lichenification results from prolonged, intense scratching that eventually thickens the skin and produces tightly packed sets of papules.

During the aging process, the hair can look gray or white and begin to feel thin and fine. The nurse knows that this occurs because of a decrease in the number of functioning: A. metrocytes B. fungacytes C. phatgocytes D. melanocytes

D. melanocytes

A 19 year old college student is brought to the ED with a severe headache he describes as, like nothing i've ever had before. his temperature is 40C, and he has a stiff neck. The nurse looks for other signs and symptoms of which problem? A. head injury B. cluster headache C. migraine headache D. meningeal inflammtion

D. meningeal inflammation

A patient complains that while studying for an exam he began to notice a severe headache in the frontotemporal area of his head that is throbbing and somewhat relieved when he lies down. He tells the nurse that his mother also had these headaches. The nurse suspects that he may be suffering from: A. hypertension B. cluster headaches C. tension headaches D. migraine headaches

D. migraine headaches migraine headaches tend to be supraorbital, retroorbital, or frontotemporal with a throbbing quality. they are severe in quality and relieved by lying down. migraines are associated with a family history of migraine headaches

The nurse is assessing for clubbing of fingernails and expects to find: A. nail bases that are firm and slightly tender B. curved nails with a convex profile and ridges across the nails C. nail bases that feel spongy with an angle of the nail base of 150 degrees D. nail bases with an angle of 180 degrees or greater and nail bases that feel spongy

D. nail bases with an angle of 180 degrees or greater and nail bases that are spongy

The nurse notices that a patient has a solid, elevated, circumscribed lesion that is less than 1 cm in diameter. When documenting this finding, the nurse reports this as a: A. bulla B. wheal C. nodule D. papule

D. papule a papule is something one can feel, is solid, elevated, circumscribed, less than 1 cm in diameter, and is due to superficial thickening in the epidermis

An elevated cavity containing thick, turbid fluid is a: A. cyst. B. vesicle. C. bulla. D. pustule.

D. pustule.

The nurse notices that school-aged child has bluish-white, red-based spots in her mouth that are elevated approximately 1-3 mm. What other signs would the nurse expect to find in this patient? A. pink, papular rash on the face and neck B. pruritic vesicles over her tunk and neck C. hyperpigmentation on the chest, abdomen, and back of the arms. D. red-purple, maculopapular, blotchy rash behind the ears and on the face.

D. red-purple, maculopapular, blotchy rash behind the ears and on the face. With measles (rubeola), the examiner assesses a red-purple, blotchy rash on the third or fourth day of the illness that appears first behind the hears, spreads over the face, and then over the neck, trunk, arms, and legs. The rash appears coppery and does not blanch. The bluish-white, red-based spots in the mouth are known as Koplik spots

The nurse educator is preparing an education module for the nursing staff on the epidermal layer of skin. Which of these statements would be included in the module? The epidermis is: A. highly vascular B. thick and tough C. thin and nonstratified D. replaced every 4 weeks

D. replaced every 4 weeks

A man has come into the clinic for a skin assessment because he is worked he might have skin cancer. During the skin assessment the nurse notices several areas of pigmentation that look greasy, dark, and stuck on his skin. Which is the best prediction? A. senile lentigines (liver spots), which do not become cancerous B. actinic keratoses, which are precursors to basal cell carcinoma C. acrochordons, which are precursors to squamous cell carcinoma D. seborrheic keratoses, which do not become cancerous

D. seborrheic keratosis, which do not become cancerous seborrheic keratosis appear like dark, greasy, stuck-on lesions that primarily develop on the trunk. These lesions do not become cancerous.

You are preparing the equipment that will be used to examine patients in the dermatology clinic. The equipment needed to assess the skin, its appendages and, if necessary, lesions include: A. strong direct lighting (artificial light preferred), ruler, pen light, goniometer, gloves, filtered ultraviolet light, glass slide, and KOH. B. strong direct lighting (natural daylight preferred), ruler, pen light, monometer, gloves, filtered ultraviolet light, glass slide, and KOH. C. strong direct lighting (artificial light preferred), ruler, pen light, microscope, gloves, filtered ultraviolet light, glass slide, and KOH. D. strong direct lighting (natural daylight preferred), ruler, pen light, magnifier, gloves, filtered ultraviolet light, glass slide, and KOH.

D. strong direct lighting (natural daylight preferred), ruler, pen light, magnifier, gloves, filtered ultraviolet light, glass slide, and KOH.

The shape of the spinal column and the resilient intervertebral disks facilitate: A. greater mobility of the spinal column. B. the ability to coordinate movement between the upper extremities and lower extremities. C. ease and coordination of head and neck movement. D. the ability to absorb a great deal of shock.

D. the ability to absorb a great deal of shock.

Amenorrhea is the term used for: A. painful intercourse. B. the dislodging of the cervical mucous plug. C. the bluish discoloration of the cervix. D. the absence of menstruation.

D. the absence of menstruation.

The knee joint is the articulation of three bones, which are: A. the femur, fibula, and patella. B. the femur, radius, and olecranon process. C. the fibula, tibia, and patella. D. the femur, tibia, and patella.

D. the femur, tibia, and patella.

A mother brings her child into the clinic for an examination for the scalp and hair. She states that the child has developed irregularly shaped patches with broken-off, sublike hair in some places; she is worried that this condition could be some form of premature baldness. The nurse tells her that this is: A. folliculitis that can be treated with an antibiotic B. traumatic alopecia that can be treated with antifungal medications C. tinea capitis that is highly contagious and needs immediate attention D. trichotillomania; her child probably has a habit of absentmindedly twirling her hair.

D. trichotillomania; her child probably has a habit of absentmindedly twirling her hair trichotillomania, self-induced hair loss, is usually due to habit. It forms irregularly shaped patches with broken-off stublike hairs of varying lenghts. A person is never completely bald. It occurs as a child absentmindedly rubs or twirls the area while falling asleep, reading, or watching tv.

Mrs. Griffin is a 31-year-old patient who is pregnant. She comes to the clinic complaining of "morning sickness." The cause of this ailment is: A. hormone changes. B. esophageal reflux. C. an increase in water being reabsorbed from the colon. D. unknown.

D. unknown.

Mr. Thompson is a 44-year-old patient who presents to the office with complaints of urinary burning. On examination you note an infection of the urethra. This is also known as: A. progenitalis. B. orchitis. C. prepuce. D. urethritis.

D. urethritis.

During a conversation, the nurse finds that a 9-year-old child has incomprehensible and jumbled language. The nurse also observes that the child uses new words that have no real meaning. Which thought process abnormality does the child exhibit? 1 Word salad 2 Confabulation 3 Circumstantiality 4 Loosening associations

A 55-year-old man is experiencing severe pain of sudden onset in the scrotal area. It is somewhat relieved by elevation. On examination you note an enlarged, red scrotum that is very tender to palpation. It is difficult to distinguish the epididymis from the testis and the scrotal skin is thick and edematous. This description is consistent with which of the following?

Epididymitis

Which of the following may be the cause of black, tarry stools?

Gastrointestinal bleeding

Mental status assessment documents: A. emotional and cognitive functioning. B. intelligence and educational level. C. artistic or writing ability in the mentally ill person. D. schizophrenia and other mental health disorders.

Mr. Littlefield, a 42 year old gentleman who has been a patient at the clinic for several years, comes in for a routine follow-up examination. The nurse utilizes both open ended and close-ended/direct questions while taking the patient history. Which of the following is an example of a closed/direct question/statement? a "Tell me about your pain" b "On a scale of 1 to 10, how ould you rate your pain?" c "I can see that you are quite uncomfortable" d "How have you been getting along?"

Mrs. Freeman is a 53-year-old patient who comes to the clinic for a follow-up blood pressure check. How would the blood pressure reading be affected if the cuff were too large? A Systolic and diastolic blood pressure readings would be higher. B Results would demonstrate a falsely high systolic reading and low diastolic reading. C Systolic and diastolic blood pressure readings would be lower. D Nothing would be different.

Pneumonia

Mrs. Hess is a 48 year old patient who comes to the ambulatory health center. On examination you note increased tactile fremitus. Which of the following conditions reflects this finding? Emphysema Pneumonia Crepitus Pneumothorax

Mrs. Jones is a 65 year-old patient who presents with complaints of skin spots during a dermatology follow-up. As the healthcare provider, you note some hyperpigmentation in this aging adult. On examination, you would expect to see: A cafe' au lait spots and hemangioma. B keratosis and lentigines. C linea nigra and chloasma. D None of the above.

Mrs. Roman is a 47 year old patient who returns to the emergency room because of several respiratory problems. If you are concerned that a patient was experiencing hemoptysis, which of the following questions should you ask her? A "Have you or are you experiencing shortness of breath?" B "Have you or are you experiencing a chronic productive cough?" C "Have you or are you experiencing difficulty breathing in a lying position?" D "Have you or are you coughing up blood?"

Mrs. Wilder, a 42 year-old patient, presents to the dermatology clinic with a confluent and extensive patch of petechiae and ecchymoses, flat macular hemorrhage is a called a: a purpura b hemangioma c hematoma d telangiectasia

On inspection of a middle-aged client, you observe that the ratio of the anteroposterior/transverse diameter is approximately 1:1. A descriptor of this type of chest would be which of the following? A Pectus excavatum B Pectus carinatum C Barrel Chest D Bronchial Chest

primary skin lesions

PUSTULE: Circular, elevated cavity filled with fluid or pus. MACULE: color change, flat. "Freckle" PAPULE: solid, elevated. Circumscribed PLAQUE: elevated. Wider than 1cm. NODULE: solid, elevated. hard or soft. larger than 1cm. TUMOR: firm or soft. larger than a few cm. Benign or malignant. WHEAL: superficial, raised, slightly irregular due to edema. VESICLE: elevated, contains free fluid. "blister"

Which of these is included in assessment of general appearance?

Skin color ANS:C Page: 764. General appearance includes items such as level of consciousness, skin color, nutritional status, posture, mobility, facial expression, mood and affect, speech, hearing, and personal hygiene. Height, weight, and vital signs are considered measurements.

The order of examination of the internal genitalia is important. Which statement best describes the proper order of examination?

Speculum examination, bimanual examination, rectovaginal examination

apocrine

The _______ glands produce a thick, milky secretion and open into the hair follicles; they are located mainly in the axillae, anogenital area, nipples, and navel.

source of history

The _______ is a record of who furnishes the information, how reliable the informant seems, and how willing he or she is to communicate. In addition, there should be a note of any special circumstances, such as the use of an interpreter.

Which of the following statements regarding the aging adult and abdominal assessment is true?

The abdominal musculature is thinner.

self esteem

The areas assessed under the_________ section of the functional assessment include education, financial status, and value-belief system.

The nurse is conducting a class about breast self-examination (BSE). Which of these statements indicates proper BSE technique?

The best time to perform BSE is 4 to 7 days after the first day of the menstrual period. ANS: C Page: 398 The nurse should help each woman establish a regular schedule of self-care. The best time to conduct breast self-examination is right after the menstrual period, or the fourth through seventh day of the menstrual cycle, when the breasts are the smallest and least congested. Advise the pregnant or menopausal woman who is not having menstrual periods to select a familiar date to examine her breasts each month, for example, her birth date or the day the rent is due.

In performing the bimanual examination, you note that the cervix feels smooth and firm, is round, and is fixed in place (doesn't move). Your cervical palpation produces some pain. Which of the following statements is true regarding these results?

The cervix should move when palpated; an immobile cervix may indicate malignancy.

In performing a breast examination, the nurse knows that it is especially important to examine the upper outer quadrant of the breast. The reason for this is that the upper outer quadrant is:

The location of most breast tumors. ANS:B Pages: 384-385. The upper outer quadrant is the site of most breast tumors. In the upper outer quadrant, the nurse should notice the auxiliary tail of Spence, the cone-shaped breast tissue that projects up into the axilla, close to the pectoral group of auxiliary lymph nodes.

The nurse is assessing a patient who sustained a leg injury due to a motor vehicle accident. When asked about the mechanism of injury, the patient said, "I was crossing the street, then met my friend. Then my leg started bleeding profusely." The patient's caregiver explains that the patient was hit by a car while crossing the road, and never met the friend. Which though process abnormality does the patient exhibit? 1 Flight of ideas 2 Confabulation 3 Circumstantiality 4 Loosening associations

The nurse is assessing a patient with anxiety and depression using the Generalized Anxiety Disorder (GAD) scale. After assessment, the nurse concludes that the patient has moderate levels of anxiety. What was the patient's score on the GAD scale? 1. 0 2. 5 3. 10 4. 15

The nurse is assessing a patient with schizophrenia. The nurse finds that the patient starts communicating and abruptly stops speaking in the middle of a conversation. Which thought process abnormality does the patient exhibit? 1 Blocking 2 Echolalia 3 Flight of ideas 4 Circumlocution

The nurse is assessing an elderly patient for a possible fractured tibia after a fall. The nurse asks when the fall occurred, and the patient responds with a discussion about how much it snowed last night, where the patient went, what the patient was wearing, and how much the meal cost. What does this response indicate? 1 Blocking 2 Delusions 3 Neologisms 4 Confabulation

The nurse is assessing the cognitive functioning of a patient using the Mini-Mental State Examination (MMSE). The patient scores 27 on the examination. What does the nurse infer from the score? 1 The patient has a normal mental status. 2 The patient has mild cognitive impairment. 3 The patient has severe cognitive impairment. 4 The patient has moderate cognitive impairment.

The nurse is caring for a child with posttraumatic stress disorder (PTSD). Which other condition is the patient susceptible to develop as a result of the PTSD? 1 Anxiety 2 Delirium 3 Dementia 4 Alzheimer disease

The nurse is caring for a patient who has difficulty understanding language. Which condition does the nurse expect in the patient? 1 Dysphonia 2 Dysarthria 3 Receptive aphasia 4 Expressive aphasia

The nurse is caring for a patient who has stage IV cancer and is undergoing chemotherapy. The prognosis is terminal, and the patient is being transferred to hospice care. This patient has no history of mood disorders. While communicating with the nurse, the patient says, "I am on top of the world and feel so free and happy." Which mood and affect abnormality does the nurse suspect in this patient? 1 Anxiety 2 Lability 3 Euphoria 4 Depersonalization

1, 2, 5

The nurse is caring for a patient who is at a moderate stage of Alzheimer disease. The nurse determines that the patient has impaired memory and abstract thinking ability. Which other assessment findings will the nurse expect in this patient? Select all that apply. 1 Agnosia 2 Agitation 3 Aggression 4 Paranoid ideation 5 Unaltered level of consciousness

The nurse is caring for a patient with a brain tumor and observes that the patient is reviewing the scan report every 10 minutes. What might be the reason for this behavior? 1 Phobia 2 Obsession 3 Compulsion 4 Hypochondriasis

1, 2 , 5

The nurse is caring for a patient with generalized anxiety disorder. Which associated physiologic complications does the nurse expect in the patient? Select all that apply. 1 Diarrhea 2 Tachypnea 3 Nausea 4 Sweating 5 Sleep disturbance

The nurse is palpating the chest wall of an individual who has just had a traumatic injury to the chest. Upon her/his finding, the nurse feels air pockets underneath the skin. Which of the following assessment findings would be consistent with this type of injury? A Increased fremitus B Rhonical fremitus C Crepitus D Hyperresonance

The nurse is performing a mental status assessment using the Mini-Cog tests in an older adult patient. The nurse observes that the patient is able to recall all three words that were stated to the patient as a part of the test. The patient, however, draws an abnormal clock with misplaced numbers, and presents the hour hand and minute hand in the wrong position. What does the nurse conclude from these findings? 1 The patient has dementia. 2 The patient has depression. 3 The patient has confusion. 4 The patient has cognitive impairment.

The nurse is planning to assess a preschool child's mental status. Which assessment tool should the nurse use to determine if the child has a developmental delay? 1 The Mini-Cog test 2 Denver II screening test 3 Patient Health Questionnaire-9 (PHQ-9) 4 Mini-Mental State Examination (MMSE)

The nurse is using the Patient Health Questionnaire-9 (PHQ-9) to screen a patient who has depression. The patient scores 13 on the test. What does the nurse infer from the test result? 1 The patient has minor depression. 2 The patient has chronic depression. 3 The patient has severe major depression. 4 The patient has moderately severe major depression.

The nurse knows that developing appropriate nursing interventions for a patient relies on the appropriateness of the __________ diagnosis. a. Nursing b. Medical c. Admission d. Collaborative

The nurse observes that a patient's caregiver wears bizarre makeup and eccentric clothing during every visit to the hospital. The patient also talks loudly and continuously, and the speech is too fast to be comprehended. Which mental disorder might the nurse expect in the caregiver? 1 Depression 2 Manic syndrome 3 Alzheimer disease 4 Organic brain syndrome

The nurse performing a cognitive assessment asks the patient about the date and time. What does the nurse intend to assess in the patient? 1 Orientation 2 Thought process 3 Thought content 4 Remote memory

The nurse tells the patient, "You should turn off the lights and sleep now." The patient mockingly mumbles, "Turn off the lights and sleep now. Turn off the lights and sleep now." What does the nurse infer from this behavior? 1 The patient exhibits echolalia. 2 The patient exhibits neologism. 3 The patient exhibits perseveration. 4 The patient exhibits circumstantiality.

The nurse uses the Mini-Cog instrument to test the cognitive ability of a patient and declares that the patient has dementia. How many words did the patient recall? 1 One word 2 Two words 3 Zero words 4 Three words

The patient tells the nurse, "I often hear my dead grandfather's voice." What does the nurse infer from the patient's statement? 1 The patient has illusions. 2 The patient has delusions. 3 The patient has flight of ideas. 4 The patient has hallucinations.

The patient visits the hospital for a routine health checkup, claims to be extremely sick, and expresses the desire to be admitted to the hospital. The test results of the patient are all normal. Which mental disorder does the nurse expect to find in the patient? 1 Hallucination 2 Perseveration 3 Circumlocution 4 Hypochondriasis

The patients record, laboratory studies, objective data, and subjective data combine to form the: a. Data base. b. Admitting data. c. Financial statement. d. Discharge summary.

The practitioner, entering the examining room to meet a patient for the first time, states: "Hello, I'm Jane your, nurse, and I'm here to gather some information from you and to perform your examination. This will take about 30 minutes. This is John, a student nurse, working with me today. If it's all right with you, he will remain during the examination." Which of the following must be added in order to cover all aspects of the interview contract? A A statement regarding confidentiality, patient costs, and the expectation of each person. B The purpose of the interview and the role of the examiner. C Time and place of the interview and a confidentiality statement. D An explicit purpose of the interview and a description of the physical examination, including diagnostic studies.

subjective

The purpose of the complete health history is to collect ____________ data.

You are inspecting the scrotum and testes of a 43-year-old man. Which finding would require additional follow-up and evaluation?

The skin on the scrotum is shiny and smooth.

ulceration

The sloughing of necrotic inflammatory tissue that causes a deep depression in the skin that extends into the dermis is called:

A 22-year-old male comes to the clinic for an examination after falling off his motorcycle and landing on his left side on the handlebars. You suspect that he may have injured his spleen. Which of the following is true regarding assessment of his spleen in this situation?

The spleen can be enlarged due to trauma.

You are examining a 6-month-old baby. You place the baby's feet flat on the table and flex his knees up. You note that the right knee is significantly lower than the left. Which of the following is true of this finding?

This is a positive Allis sign and suggests hip dislocation.

2, 4, 5

What are the common consequences of age-related hearing loss in an older adult patient? Select all that apply. 1 The patient may develop anxiety. 2 The patient may be frustrated. 3 The patient may become aggressive. 4 The patient may become socially isolated. 5 The patient may develop suspicious behavior.

What characteristic abnormality can be observed in a child with oppositional defiant disorder (ODD)? 1 Elation 2 Lability 3 Euphoria 4 Irritability

What does the nurse infer if a patient scores a 12 on the Patient Health Questionnaire-9 (PHQ-9)? 1 Minor depression 2 Chronic depression 3 Major depression, severe 4 Major depression, moderately severe

What is the maximum score given to a patient in the Mini-Mental State Examination (MMSE)? 1. 5 2. 20 3. 25 4. 30

Which disorder is characterized by intrusive thoughts and ritualistic behaviors? 1 Social anxiety disorder 2 Generalized anxiety disorder 3 Posttraumatic stress disorder 4 Obsessive-compulsive disorder

1, 5

Which emotional characteristics are common in a patient with clinical depression? Select all that apply. 1 Irritability 2 Aggression 3 Rapid mood swings 4 Hallucinations 5 Extreme sadness

3, 4, 5

Which findings of a mental status examination of an adolescent patient are considered normal? Select all that apply. 1 The patient has darting, watchful eyes. 2 The patient has a flat, masklike facial expression. 3 The patient has a moderate pace of conversation. 4 The patient has tattoos and piercings on the body. 5 The patient has worn jeans that are torn at the knees.

C (and x2)

Which of the following describes the best technique for measuring the respiratory rate? A Inform the person of the procedure and count for 1 minute. B Count respirations for 15 seconds while keeping your fingers on the pulse, and then multiply the result by 4. C Count for 30 seconds after completing a pulse assessment. D Use a stethoscope to count the apicla pulse for 60 seconds, followed by counting the respirations for a full minute.

Which of the following is a true statement regarding the findings related to percussion? A Percussion is a useful technique for identifying small lesions in lung tissue. B Percussion is helpful only in identifying surface alterations of lung tissue. C Percussion notes are not identified by the overlying chest muscle and fat tissue. D A sull note elicited with percussion is the espected finding.

Which of the following is an appropriate recording of a patient's reason for seeking health care? A Angina pectoris, duration 2 hr B Substernal pain radiating to left axilla, 1 hr duration C "grabbing" chest pain for 2 hr D Pleurisy, 2 days' duration

Which of the following statements about mental status testing of children is correct? A. The results of the Denver II screening test are valid for white, middle-class children only. B. The behavioral checklist is useful to assess children who are 3 to 5 years old. C. Abnormal findings are usually related to not achieving an expected developmental milestone. D. Input from parents and caretakers is discouraged when assessing psychosocial development.

Which of the following statements best describes the general survey? A The general survey is a study of the whole person using objective parameters. B The general survey covers general health status, and any obvious physical characteristics. C Data from the general survey provide clues that guide physical examination. D All of the above.

Which of these would be formulated by a nurse using diagnostic reasoning? a. Nursing diagnosis b. Medical diagnosis c. Diagnostic hypothesis d. Diagnostic assessment

B (Originates from larger interior organs Ureteral colic, acute appendicitis transmitted by ascending nerve fibers along with nerve fibers of the autonomic nervous system vomiting, nausea, pallor, and diaphoresis)

Which type of pain would cholecystitis (gallbladder disease) cause? A Somatic B Visceral C Cutaneous D Chronic

While assessing a child, the nurse finds that the child is unable to follow directions and has trouble staying alert. The child's parents report that the child also talks excessively. Which disorder does the nurse suspect? 1 Eating disorder 2 Autism spectrum disorder 3 Oppositional defiant disorder 4 Attention deficit hyperactivity disorder

While assessing a patient in the intensive care unit, the nurse observes that the patient is responding to touch only on persistent and vigorous shaking. The nurse also notices that the patient withdraws both hands when pressure is applied to the nail beds. What does the nurse conclude from these findings? 1 The patient is in a coma. 2 The patient is lethargic. 3 The patient is in a semi-coma. 4 The patient is in an acute confusional state.

2, 3

While assessing a preschool child, the nurse finds that the child shows strict adherence to routines. Which other findings would confirm that the child has autism spectrum disorder? Select all that apply. 1 Irritable mood 2 Poor eye contact 3 Repetitive speech 4 Aggressive behaviors 5 Short attention span

While collecting the medical history of a patient with cancer, the nurse finds that the patient is laughing for no evident reason. What mood and affect disorder does this behavior indicate? 1 Elation 2 Euphoria 3 Depersonalization 4 Inappropriate affect

5. Signs of chronic arterial symptoms include: (Select all that apply) (5 pts) Y/N patient reporting deep calf pain when walking Y/N pale, cool skin Y/N small weeping ulcers Y/N decreased pedal pulses Y/N leg pain that is relieved with elevation

Y Y N Y N

50-80

Yellow Zone: ____% of PB --> add rescue meds

Petechiae

_______ are tiny punctate hemorrhages that are 1 to 3 mm; round and discrete; and dark red, purple, or brown caused by bleeding from superficial capillaries.

Purpura

_______ is a flat, macular, red-to-purple hemorrhage that is a confluent and extensive patch of petechiae and ecchymoses greater than 3 mm.

Crepitus

____________ is a coarse crackling sensation palpable over the skin surface. It occurs in subcutaneous emphysema when air escapes from the lung and enters the subcutaneous tissue.

Hemangiomas

_________are vascular lesions caused by a benign proliferation of blood vessels in the dermis.

1. During auscultation of the lungs, the nurse expects decreased breath sounds to be heard in which situation? (5 pts) A. When the bronchial tree is obstructed B. In conditions of consolidation, such as pneumonia C. When adventitious sounds are present D. In conjunction with whispered pectoriloquy

10. Auscultation of the abdomen is begun in the right lower quadrant (RLQ) because: a. bowel sounds are always normally present here. b. peristalsis through the descending colon is usually active. c. this is the location of the pyloric sphincter. d. vascular sounds are best heard in this area.

11. The congenital displacement of the urethral meatus to the inferior surface of the penis is: a. hypospadias. b. epispadias. c. hypoesthesia. d. hypophysis

12. Shifting dullness is a test for: a. ascites. b. splenic enlargement. c. inflammation of the kidney. d. hepatomegaly

12. Which of the following is (are) normal, common finding(s) on inspection and palpation of the vulva and perineum? a. labia majora that are wide apart and gaping b. palpable Bartholin's glands c. clear, thin discharge from paraurethral glands d. bulging at introitus during Valsalva maneuver

13. During the assessment of a newborn infant, the nurse recalls that pyloric stenosis would be manifested by: (5 pts) A. projectile vomiting B. palpable olive-shaped mass in the right lower quadrant C. hypoactive bowel sounds D. pronounced peristaltic waves crossing from right to left

13. Which of the following is the most common bacterial sexually transmitted infection in the United States? a. chlamydia b. gonorrhea c. trichomoniasis d. syphilis e. bacterial vaginosis

16. The nurse is percussing over the lungs of a client with pneumonia. The nurse knows that percussion over an area of atelectasis in the lungs would reveal: (5 pts) A. dullness B. tympany C. resonance D. hyperresonance

2. A young woman has come for her first gynecologic examination. Because she has not had any children, the examiner would expect the cervical os to appear: a. smooth and circular. b. irregular and slitlike. c. irregular and circular. d. smooth and enlarged

7. When assessing for for jugular vein distension, what position should the nurse place the client in to assure an accurate assessment? (5 pts) A. 40-45 degree angle B. supine C. 10-15 degree angle D. 90 degree angle

8. During the examination of a full-term newborn male, a finding requiring investigation would be: a. absent testes. b. meatus centered at the tip of the penis. c. wrinkled scrotum. d. penis 2 to 3 cm in length

Breasts and Regional Lymphatics 3. During visit for school physical, 13 year old girl being examined questions asymmetry of breasts. Best response? a. "One breast may grow faster than the other during development" b. "I will give you referral for mammogram c. "You will probably have fibrocystic disease when you are older" d. "This may be an indication of hormonal imbalance. We will check again in 6 mod"

Breasts and Regional Lymphatics 5. This is the first visit for a woman aged 38. Practitioner instructs her that a baseline mammogram is recommended for women between 35 and 39 and the clinical exam would be based on age. Recommendation for women ages 40-49 years is: a. every year b. every 2 years c. twice a year d. only baseline exam needed unless woman has symptoms

Breasts and Regional Lymphatics 14. Gynecomastia is: a. enlargement of the male breast. b. presence of "mast" cells in the male breast. c. cancer of the male breast. d. presence of supernumerary breast on the male chest.

Heart and neck vessels 10. The examiner wishes to listen for a pericardial friction rub. Select the best method of listening. a. with the diaphragm, patient sitting up and leaning forward, breath held in expiration b. using the bell with the patient leaning forward c. at the base during normal respiration d. with the diaphragm, patient turned to the left side

Heart and neck vessels 11. When auscultating the heart, your first step is to: a. identify S1 and S2. b. listen for S3 and S4. c. listen for murmurs. d. identify all four sounds on the first round.

Heart and neck vessels 9. Select the statement that best differentiates a split S2 from S3. a. S3 is lower pitched and is heard at the apex. b. S2 is heard at the left lower sternal border. c. The timing of S2 varies with respirations. d. S3 is heard at the base; timing varies with respirations.

Peripheral Vascular System and Lymphatics 13. A known risk factor for venous ulcer development is: a. obesity. b. male gender. c. history of hypertension. d. daily aspirin therapy

Peripheral Vascular System and Lymphatics 7. During the examination of the lower extremities, you are unable to palpate the popliteal pulse. You should: a. proceed with the examination. It is often impossible to palpate this pulse. b. refer the patient to a vascular surgeon for further evaluation. c. schedule the patient for a venogram. d. schedule the patient for an arteriogram.

Peripheral Vascular System and Lymphatics 11. Atrophic skin changes that occur with peripheral arterial insufficiency include: a. thin, shiny skin with loss of hair. b. brown discoloration. c. thick, leathery skin. d. slow-healing blisters on the skin.

Thorax and Lungs 1. The manubriosternal angle is: a. the articulation of the manubrium and the body of the sternum. b. a hollow, U-shaped depression just above the sternum. c. also known as the breastbone. d. a term synonymous with costochondral junction.

Thorax and Lungs 15. A barrel-shaped chest is characterized by: a. equal anteroposterior-to-transverse diameter and ribs being horizontal. b. anteroposterior-to-transverse diameter of 1 : 2 and an elliptical shape. c. anteroposterior-to-transverse diameter of 2 : 1 and ribs being elevated. d. anteroposterior-to-transverse diameter of 3 : 7 and ribs sloping back.

Thorax and Lungs 4. Symmetric chest expansion is best confirmed by: a. placing hands on the posterolateral chest wall with thumbs at the level of T9 or T10 and then sliding the hands up to pinch up a small fold of skin between the thumbs. b. inspection of the shape and configuration of the chest wall. c. placing the palmar surface of the fingers of one hand against the chest and having the person repeat the words "ninety-nine." d. percussion of the posterior chest.

When testing stool for occult blood, the nurse is aware that a false-positive result may occur with:

a large amount of red meat within the last 3 days. ANS:D Pages: 716-717. When testing for occult blood, a false-positive finding may occur if the person has ingested significant amounts of red meat within 3 days of the test. Absent bile pigment causes the stools to be gray or tan in color. Increased fat content causes the stool to be pale, yellow, and greasy. Increased ingestion of iron medication causes the stool to be black in color.

1. a = First-level priority problem 2. b = Second-level priority problem 3. c = Third-level priority

13. A 65-year-old patient with a history of heart failure comes to the clinic with complaints of "being awakened from sleep with shortness of breath." Which action by the nurse is most appropriate? (5 pts) A. assure the client that this is normal and will probably resolve within the next week B. assess for other signs and symptoms of paroxysmal nocturnal dyspnea C. tell the client to sleep on his or her right side to facilitate ease of respirations D. obtain a detailed history of the patient's allergies

14. Murphy sign is best described as: a. the pain felt when the hand of the examiner is rapidly removed from an inflamed appendix. b. pain felt when taking a deep breath when the examiner's fingers are on the approximate location of the inflamed gallbladder. c. a sharp pain felt by the patient when one hand of the examiner is used to thump the other at the costovertebral angle. d. not a valid examination technique

14. The nurse is reviewing anatomy and physiology of the heart. Which statement best describes what is meant by atrial kick? (5 pts) A. the contraction of the atria at the beginning of diastole can be felt as a palpation B. the atria contract toward the end of diastole and push the remaining blood into the ventricles C. the atria contract during systole and attempt to push against closed valves D. This is the pressure exerted against the atria as the ventricles contract during systole

15. A patient has been admitted to the emergency department for a suspected drug overdose. His respirations are shallow, with an irregular pattern, with a rate of 12 per minute. The nurse interprets this respiration pattern as which of the following? (5 pts) A. chronic obstructive breathing B. hypoventilation C. bradypnea D. Cheyne-Stokes respirations

15. Arteriosclerosis is the: a. deposition of fatty plaques on the intima of the arteries. b. loss of elasticity of the walls of blood vessels. c. loss of lymphatic tissue that occurs in the aging process. d. progressive enlargement of the intramuscular calf veins.

15. What does the notation in a health record indicating the patient is a "G2 P3 Ab0" mean? a. The woman has delivered 3 children, 2 of whom are living; her blood type is Ab 0. b. The woman has been pregnant twice with 3 children (twins and another child), and all her children are living. c. The woman has been pregnant 3 times, has delivered 2 children, and had no abortions. d. The woman has been pregnant 3 times, has 2 living children, and had no spontaneous abortions

16. A patient has soft, moist, fleshy, painless papules around the anus. The examiner suspects this condition is: a. HSV-2. b. HPV. c. gonorrhea. d. Peyronie disease

16. During an assessment of a healthy adult, where would the nurse expect to palpate the apical impulse? (5 pts) A. Fourth left intercostal space at the sternal border B. Fifth left intercostal space at the midclavicular line C. Fourth left intercostal space at the anterior axillary line D. Third left intercostal space at the midclavicular line

16. Raynaud's phenomenon occurs: a. when the patient's extremities are exposed to heat and compression. b. in hands and feet as a result of exposure to cold, vibration, and stress. c. after removal of lymph nodes or damage to lymph nodes and channels. d. as a result of leg cramps due to excessive walking or climbing stairs.

16. What problems are associated with smoking and the use of oral contraceptives? a. increased risk of alcoholism and cirrhosis of the liver b. thrombophlebitis and pulmonary emboli c. infertility and weight gain d. urinary tract infections and skin cancer

19. During palpation of the anterior chest wall, the nurse notices a coarse, crackling sensation over the skin surface. On the basis of these findings, the nurse suspects: (5 pts) A. tactile fremitus B. crepitus C. air embolus D. adventitious sounds

4. When performing a respiratory assessment on a client, the nurse notices a costal angle of approximately 90 degrees. This characteristic is: (5 pts) A. seen in clients with kyphosis B. a normal finding in a healthy adult C. indicative of pectus excavatum D. an expected finding in a client with a barrel chest

7. A 20-year-old man has indicated that he does not perform testicular self-examination. One of the facts that should be shared with him is that testicular cancer, though rare, does occur in men ages: a. younger than 15 years. b. 15 to 34 years. c. 35 to 55 years. d. 55 years and older

8. To insert the speculum as comfortably as possible, the examiner: a. opens the speculum slightly and inserts in an upward direction. b. presses the introitus down with one hand and inserts the blades obliquely with the other. c. spreads the labia with one hand, inserts the closed speculum horizontally with the other. d. pushes down on the introitus and inserts the speculum in an upward direction

9. The nurse suspects that the client has a distended bladder. How should the nurse assess for this condition? (5 pts) A. auscultate and percuss in the inguinal area B. percuss and palpate the midline area above the suprapubic bone C. percuss and palpate in the lumbar region D. inspect and palpate in the epigastric area

Breasts and Regional Lymphatics 2. The most common site of breast tumors: a. upper inner quadrant b. upper outer quadrant c. lower inner quadrant d. lower outer quadrant

Breasts and Regional Lymphatics 9. During a breast examination, you detect a mass. Identify the description that is most consistent with cancer rather than benign breast disease. a. round, firm, well demarcated b. irregular, poorly defined, fixed c. rubbery, mobile, tender d. lobular, clear margins, negative skin retraction

Breasts and Regional Lymphatics 12. Breast asymmetry: a. increases with age and parity. b. may be normal. c. indicates a neoplasm. d. is accompanied by enlarged axillary lymph nodes.

Breasts and Regional Lymphatics 15. Which is the first physical change associated with puberty in girls? a. areolar elevation b. breast bud development c. height spurt d. pubic hair development e. menarche

Breasts and Regional Lymphatics 16. During the examination of a 30-year-old woman, she questions you about "the 2 large moles" that are below her left breast. After examining the area, how do you respond? a. "I think you should be examined by a dermatologist." b. "This appears to be a normal finding of supernumerary nipples, due to the small areolae and nipples that are present." c. "These are Montgomery's glands, which are common." d. "Is there a possibility you are pregnant?"

Heart and neck vessels 12. You will hear a split S2 most clearly in what area? a. apical b. pulmonic c. tricuspid d. aortic

Heart and neck vessels 15. When assessing the carotid artery, the examiner should palpate: a. bilaterally at the same time, while standing behind the patient. b. medial to the sternomastoid muscle, one side at a time. c. for a bruit while asking the patient to hold his or her breath briefly. d. for unilateral distention while turning the patient's head to one side.

Heart and neck vessels 2. Select the best description of the tricuspid valve. a. left semilunar valve b. right atrioventricular valve c. left atrioventricular valve d. right semilunar valve

Heart and neck vessels 4. Atrial systole occurs: a. during ventricular systole. b. during ventricular diastole. c. concurrently with ventricular systole. d. independently of ventricular function.

Heart and neck vessels 7. The examiner is palpating the apical impulse. The normal size of this impulse: a. is less than 1 cm. b. is about 2 cm. c. is 3 cm. d. varies depending on the size of the person.

Heart and neck vessels 8. The examiner wishes to listen in the pulmonic valve area. To do this, the stethoscope would be placed at the: a. second right interspace. b. second left interspace. c. left lower sternal border. d. fifth interspace, left midclavicular line.

Peripheral Vascular System and Lymphatics 9. The examiner wishes to assess for arterial deficit in the lower extremities. After raising the legs 12 inches off the table and then having the person sit up and dangle the leg, the color should return in: a. 5 seconds or less. b. 10 seconds or less. c. 15 seconds. d. 30 seconds.

Peripheral Vascular System and Lymphatics 4. A pulse with an amplitude of 3+ would be considered: a. irregular, with 3 premature beats. b. increased, full. c. normal. d. weak.

Thorax and Lungs 11. In order to use the technique of egophony, ask the patient to: a. take several deep breaths and then hold for 5 seconds. b. say "eeeeee" each time the stethoscope is moved. c. repeat the phrase "ninety-nine" each time the stethoscope is moved. d. whisper a phrase as auscultation is performed.

Thorax and Lungs 7. Select best description of bronchovesicular breath sounds: a. high pitched, of longer duration on inspiration than expiration. b. moderate pitched, inspiration equal to expiration. c. low pitched, inspiration greater than expiration. d. rustling sound, like the wind in the tree

Thorax and Lungs 2. Select the correct description of the left lung. a. narrower than the right lung with three lobes b. narrower than the right lung with two lobes c. wider than the right lung with two lobes d. shorter than the right lung with three lobes

Thorax and Lungs 3. Some conditions have a cough with characteristic timing. The cough associated with chronic bronchitis is best described as: a. continuous throughout the day. b. productive cough for at least 3 months of the year for 2 years in a row. c. occurring in the afternoon/evening because of exposure to irritants at work. d. occurring in the early morning.

Thorax and Lungs 6. Auscultation of breath sounds is an important component of respiratory assessment. Select the most accurate description of this part of the examination. a. Hold the bell of the stethoscope against the chest wall; listen to the entire right field and then the entire left field. b. Hold the diaphragm of the stethoscope against the chest wall; listen to one full respiration in each location, being sure to do side-to-side comparisons. c. Listen from the apices to the bases of each lung field using the bell of the stethoscope. d. Select the bell or diaphragm depending upon the quality of sounds heard; listen for one respiration in each location, moving from side to side

Thorax and lungs 22. What kind of chest presents with anteroposterior=transverse diameter?

barrel chest

2. During examination of the scrotum, a normal finding would be: a. The left testicle is firmer to palpation than the right. b. The left testicle is larger than the right. c. The left testicle hangs lower than the right. d. The left testicle is more tender to palpation than the right

3. A 25-year-old woman in her fifth month of pregnancy has a blood pressure of 100/70 mm Hg. In reviewing her previous exam, the nurse notes that her blood pressure in her second month was 124/80 mm Hg. In evaluating this change, what does the nurse know to be true? (5 pts) A. Because of increased cardiac output, the blood pressure should be higher this time. B. This would mean a decrease in circulating blood volume, which is dangerous for the fetus. C. This is the result of peripheral vasodilatation and is an expected change. D. This is not an expected finding because it would mean a decreased cardiac output.

4. During the examination of the genitalia of a 70-year-old woman, a normal finding would be: a. hypertrophy of the mons pubis. b. increase in vaginal secretions. c. thin and sparse pubic hair. d. bladder prolapse

4. Prostatic hypertrophy occurs frequently in older men. The symptoms that may indicate this problem are: a. polyuria and urgency. b. dysuria and oliguria. c. straining, loss of force, and sense of residual urine. d. foul-smelling urine and dysuria

5. A 64-year-old man has come for a health examination. A normal age-related change in the scrotum would be: a. testicular atrophy. b. testicular hypertrophy. c. pendulous scrotum. d. increase in scrotal rugae

5. For a woman, history of her mother's health during pregnancy is important. A medication that requires frequent follow-up is: a. corticosteroid. b. theophylline. c. diethylstilbestrol. d. aminoglycoside

5. The absence of bowel sounds is established after listening for: a. 1 full minute. b. 3 full minutes. c. 5 full minutes. d. none of the above. (note difference between this and in class Dr. McGowan saying 5 minutes per quadrant, 20 mins total)

8. The nurse notices that the client has ascites, which indicates the presence of: (5 pts) A. feces B. fibroid tumors C. fluid D. flatus

9. Before withdrawing the speculum, the examiner swabs the cervix with a swab soaked in acetic acid. This examination is done to assess for: a. herpes simplex virus. b. contact dermatitis. c. human papillomavirus. d. carcinoma

Breasts and Regional Lymphatics 4. When teaching the breast self exam, you would inform woman that the best time to conduct self breast exam is: a. at onset of menstrual period b. on 14th day of menstrual cycle c. 4th to 7th day of cycle d. just before menstrual period

Breasts and Regional Lymphatics 6. The examiner is going to inspect the breasts for retraction. The best position for this part of the exam is: a. lying supine with arms at sides b. leaning forward with hands outstretched c. sitting with hands pushing onto hips d. one arm at side, other arm elevated

Breasts and Regional Lymphatics 7. A bimanual technique may be the preferred approach for a woman: a. who is pregnant b. who is having the first breast examination by a healthcare provider c. with pendulous breasts d. who has felt a change in the breast during self-exam

Breasts and Regional Lymphatics 8. During the exam of a 70 year old man, you note gynecomastia. You would: a. refer for a biopsy b. refer for a mammogram c. review medications for drugs that have gynecomastia as a side effect d. proceed with exam. This is normal part of aging process

Breasts and Regional Lymphatics 11. Which of the following women should not be referred to a physician for further evaluation? a. a 26-year-old with multiple nodules palpated in each breast b. a 48-year-old who has a 6-month history of reddened and sore left nipple and areolar area c. a 25-year-old with asymmetric breasts and inversion of nipples since adolescence d. a 64-year-old with ulcerated area at tip of right nipple; no masses, tenderness, or lymph nodes palpated

Breasts and Regional Lymphatics 17. The breasts of a neonate may be large and very visible, secreting clear or white fluid. What is the basis of this finding? a. It may be due to birth trauma. b. The fluid is colostrum, which is typically seen as a precursor to milk. c. The cause is maternal estrogen, which crossed the placenta. d. This often occurs with premature thelarche.

Heart and neck vessels 1. The precordium is: a. a synonym for the mediastinum. b. the area on the chest where the apical impulse is felt. c. the area on the anterior chest overlying the heart and great vessels. d. a synonym for the area where the superior and inferior venae cavae return unoxygenated venous blood to the right side of the heart.

Heart and neck vessels 13. The stethoscope bell should be pressed lightly against the skin so that: a. chest hair doesn't simulate crackles. b. high-pitched sounds can be heard better. c. it does not act as a diaphragm. d. it does not interfere with amplification of heart sounds.

Heart and neck vessels 14. A murmur heard after S1 and before S2 is classified as: a. diastolic (possibly benign). b. diastolic (always pathologic). c. systolic (possibly benign). d. systolic (always pathologic).

Peripheral Vascular System and Lymphatics 14. Brawny edema is: a. acute in onset. b. soft. c. nonpitting. d. associated with diminished pulses.

orthopnea

can't lay flat bc have fluid in lungs (cardiac patients)

During an examination, the nurse notices that a patient's legs turn white when they are raised above the patient's head. The nurse should suspect:

chronic arterial insufficiency. ANS: C Pages: 499-525. Elevational pallor (marked) indicates arterial insufficiency. See Chapter 20.

The nurse documents that a patient has coarse, thickened skin and brown discoloration over the lower legs. Pulses are present. This finding is probably the result of:

chronic venous insufficiency. ANS: D Pages: 499-525. Chronic venous insufficiency would present as firm brawny edema, coarse thickened skin, normal pulses, and brown discoloration. See Chapter 20.

clubbing

congenital cyanotic heart disease, lung cancer, and pulmonary diseases. feels spongy.

A 45-year-old male has come to the clinic for an abdominal assessment. Upon percussion, you note an area of dullness above the right costal margin of about 10 cm. You would:

consider this a normal finding and proceed with the examination.

pulmonary edema

coughing up pink, frothy sputum indicates...

Tb, pneumonia

coughing up rust colored sputum means you've got...

1. Vaginal lubrication is provided during intercourse by: a. the labia minora. b. sebaceous follicles. c. Skene's glands. d. Bartholin's glands

15. The nurse is assessing a patient with possible cardiomyopathy and assesses the hepatojugular reflux. If heart failure is present, then the nurse should see which finding while pushing on the right upper quadrant of the patient's abdomen, just below the rib cage? (5 pts) A. An impulse will be visible at the fourth or fifth intercostal space, at or inside the midclavicular line. B. The jugular veins will rise for a few seconds and then recede back to the previous level if the heart is working properly. C. The jugular veins will not be detected during this maneuver. D. The jugular veins will remain elevated as long as pressure on the abdomen is maintained.

2. A 45-year-old man is in the clinic for a physical examination. During the abdominal assessment, the nurse percusses the abdomen and notices an area of dullness above the right costal margin of about 10 cm. The nurse should: (5 pts) A. ask additional history questions regarding his alcohol intake B. describe this as an enlarged liver and refer him to a physician C. document the presence of hepatomegaly D. consider this a normal finding and proceed with the examination

20. A patient with pleuritis has been admitted to the hospital and complains of pain with breathing. What other key assessment finding would the nurse expect to find upon auscultation? (5 pts) A. wheezing B. stridor C. crackles D. friction rub

3. A woman has come for an examination because of a missed menstrual period and a positive home pregnancy test. Examination reveals a cervix that appears cyanotic. This is referred to as: a. Goodell sign. b. Hegar sign. c. Tanner sign. d. Chadwick sign

3. H.T. has come to the clinic for a follow-up visit. Six months ago, he was started on a new medication. The class of medication is most likely to cause impotence as a side effect; therefore medication classes explored by the nurse are: a. antipyretics. b. bronchodilators. c. corticosteroids. d. antihypertensives

4. After a myocardial infarction, the hospitalized client is taught to move his legs while resting in bed. The expected outcome of this excercise is to: (5 pts) A. decrease the likelihood of pressure ulcer formation B. prepare the client for ambulation C. promote urinary and intestinal elimination D. prevent a blood clot from forming

4. Hyperactive bowel sounds are: a. high pitched. b. rushing. c. tinkling. d. all of the above.

4. The nurse is performing a cardiac assessment on a 65-year-old patient 3 days after her myocardial infarction. Heart sounds are normal when she is supine, but when she is sitting and leaning forward, the nurse hears a high-pitched, scratchy sound with the diaphragm of the stethoscope at the apex. It disappears on inspiration. The nurse suspects: (5 pts) A. ventricular hypertophy resulting from muscle damage B. increased cardiac output C. another myocardial infarction D. inflammation of the precordium

5. A patient has been admitted to the emergency department with a possible medical diagnosis of pulmonary embolism. The nurse expects to see which assessment findings related to this condition? (5 pts) A. diffuse infiltrates with areas of dullness upon percussion B. absent or decreased breath sounds C. productive cough of thin, forthy sputum D. chest pain that is worse with deep inspiration, dyspnea

5. The nurse wants to assess for jugular vein distension, and places the stethoscope as shown below. What should the nurse do next? (5 pts) A. continue to listen for bruit with the diaphragm B. palpate the artery in the upper one third of the neck C. instruct the client to take a deep breath, exhale and hold it briefly D. remove the stethoscope to observe the client's neck

6. A woman has come for health care complaining of a thick, white discharge with intense itching. These symptoms are suggestive of: a. atrophic vaginitis. b. trichomoniasis. c. chlamydia. d. candidiasis

6. During palpation of the testes, the normal finding would be: a. firm to hard, and rough. b. nodular. c. 2 to 3 cm long by 2 cm wide and firm. d. firm, rubbery, and smooth

6. During the cardiac auscultation the nurse hears a sound occurring immediately after S2 at the second left intercostal space. To further assess this sound, what should the nurse do? (5 pts) A. Ask the client to hold his breath while the nurse listens again B. Have the client turn to the left side while the nurse listens with the bell C. No further assessment is needed because the nurse knows it is an S3 D. Watch the patient's respirations while listening for effect on the sound.

6. The nurse is listening to the breath sounds of a patient with severe asthma. Air passing through narrowed bronchioles would produce which of these adventitious sounds? (5 pts) A. rales B. bronchophony C. rhonchi D. wheezing

7. The range of normal liver span in the right midclavicular line in the adult is: a. 2-6 cm. b. 4-8 cm. c. 8-14 cm. d. 6-12 cm.

7. To prepare the vaginal speculum for insertion, the examiner: a. lubricates it with a water-soluble lubricant. b. lubricates it with petrolatum. c. warms it under the light, then inserts it into the vagina. d. lubricates it with warm water

7. Which client is at greatest risk for the development of venous disease? (5 pts) A. person who smokes a pack of cigarettes daily B. elderly person taking an anticoagulant medication C. woman in her second month of pregnancy D. client who has been on bed rest for 4 days

8. The left upper quadrant (LUQ) contains the: a. liver. b. appendix. c. left ovary. d. spleen.

9. During transillumination of a scrotum, you note a nontender mass that transilluminates with a red glow. This finding is suggestive of: a. scrotal hernia. b. scrotal edema. c. orchitis. d. hydrocele

9. Striae, which occur when the elastic fibers in the reticular layer of the skin are broken after rapid or prolonged stretching, have a distinct color when of long duration. This color is: a. pink. b. blue. c. purple-blue. d. silvery white

Thorax and Lungs 8. After examining a patient, you make the following notation: Increased respiratory rate, chest expansion decreased on left side, dull to percussion over left lower lobe, breath sounds louder with fine crackles over left lower lobe. These findings are consistent with a diagnosis of: a. bronchitis. b. asthma. c. pleural effusion. d. lobar pneumonia.

A young swimmer comes to you complaining of a very sore shoulder. He was running at the pool, slipped on some wet concrete, and tried to catch himself with his outstretched hand. He landed on his outstretched hand and has not been able to move his shoulder since. You suspect:

dislocated shoulder.

A 59-year-old patient has been diagnosed with prostatitis and is being seen at the clinic for complaints of burning and pain during urination. He is experiencing:

dysuria

13. The first physical sign associated with puberty in boys is: a. height spurt. b. penis lengthening. c. sperm production. d. pubic hair development. e. testes enlargement

vesicle

elevated cavity, less than 1 cm. blister. ex-varicella

bronchitis

if PT is only coughing in the am, it indicates

respiratory infection

if the cough is continuous, it indicates..

linea nigra

increased pigment along the midline of the abdomen - seen with pregnant women.

cyanosis

indicates hypoxemia. occurs with shock, cardiac arrest, heart failure, chronic bronchitis, and congenital heart disease

Thorax and lungs 19. lateral right d. fifth ______

intercostal

16. Black, non tarry stools may be caused by ingesting what kind of supplements?

iron

PND (paroxymal nocturnal dyspnea)

is a medical symptom wherein people with congestive heart failure develop difficulties breathing after laying flat. commonly occurs several hours after a person with heart failure has fallen asleep. resolves quickly once a person awakens and sits upright. Sign of severe heart failure.

Thorax and lungs What configuration of the thorax presents as an exaggerated posterior curvature of the thoracic spine?

kyphosis

polycyclic

lesions actually grow together.

confluent

lesions run together like hives

patch

macules larger than 1 cm.

endocrine

males: absent/sparse genital hairs suggest ______ dysfunction in females, hirsutism indicates it.

An 85-year-old man has come in for a physical examination, and the nurse notices that he uses a cane. When documenting general appearance, the nurse should document this information under the section that covers:

mobility. ANS: B Page: 764. Use of assistive devices would be documented under the mobility section. The other responses are all other categories of the general appearance section of the health history.

Heart and neck vessels 22. _____: muscular wall of heart

myocardium

Quiz 5: A patient states during the interview that she noticed a new lump in the shower a few days ago. It was on her left breast near her axilla. The nurse should plan to:

palpate the unaffected breast first. ANS:B Page: 398 If the woman mentions a breast lump she has discovered herself, the nurse should examine the unaffected breast first to learn a baseline of normal consistency for this individual.

plaque

papules coalesce to form surface elevation wider than 1 cm. psoriasis

While examining a 75-year-old woman, the nurse notices that the skin over her right breast is thickened and the hair follicles are exaggerated. This condition is known as:

peau d'orange. ANS:C Page: 404. This condition is known as peau d'orange. Lymphatic obstruction produces edema, which thickens the skin and exaggerates the hair follicles. The skin has a pig-skin or orange-peel look, and this condition suggests cancer.

Thorax and lungs 24. What configuration of the thorax presents with a forward protrusion of the sternum with ribs sloping back at either side?

pectus carinatum

The nurse has just recorded a positive obturator test on a patient who has abdominal pain. This test is used to confirm a(n):

perforated appendix. ANS: C Pages: 527-564. A perforated appendix irritates the obturator muscle, producing pain. See Chapter 21.

16. What color stools result from localized bleeding in the lower GI tract and around the anus (like in hemorrhoids)?

red

paronychia

red, swollen tender inflammation of the nail folds. usually bacterial (acute) or fungal (chronic) infections.

PaO2

reflects the ability of the lungs to oxygenate the blood. Used to evaluate O2 therapy >80%

A patient is complaining of pain in his joints that is worse in the morning, is better after he has moved around for awhile, and then gets worse again if he sits for long periods of time. You suspect that he may have:

rheumatoid arthritis.

Heart and neck vessels RBC from liver to body tissue Liver to _____ atrium via inferior vena cava, through _____ valve to right ventricle. Through ____ valve to _____ artery Picks up oxygen in lungs. Returns to _____ atrium. To ___ ventricle via mitral valve. Through ____ valve to aorta and out to the body

right, tricuspid pulmonic, pulmonary left, left aortic

Mr. P. is able to flex his right arm forward without difficulty or pain, but is unable to abduct his arm because of pain and muscle spasms; you suspect:

rotator cuff lesions.

Tb, pneumonia

rust colored sputum indicates...

Thorax and lungs What configuration of the thorax presents with a lateral S shaped curvature of the thoracic and lumbar spine?

scoliosis

When assessing the scrotum of a male patient, you note the presence of multiple firm, nontender, yellow 1-cm nodules. These are most likely:

sebaceous cysts.

biots/ataxic

seen in stroke, trauma, brain injury PTs

hypothyroidism

skin feels rough, dry and flaky

hyperthyroidism

skin feels smoother and softer, like velvet

onychomycosis

slow, persistent fungal infection of nails, common in old. green, thick, nail crumbles.

macule

solely a color change. <1cm. freckles.

nodule

solid, elevated, larger than 1 cm. xanthoma

When performing a scrotal assessment, you note that the scrotal contents transilluminate and show a red glow. Based on this finding you would:

suspect the presence of serous fluid in the scrotum.

pain

the eight critical characteristics of ____ symptoms reported in the history are: P = provocative or palliative; Q = quality or quantity; R = region or radiation; S = severity scale; T = timing; and U = understand patient's perception.

A professional tennis player comes in complaining of a sore elbow. You suspect that he has tenderness at:

the medial and lateral epicondyle.

you will feel (more/less) vibrations in a pt with pneumonia/fluid in lungs

You are examining Mr. O., and when you ask him to bend forward from the waist, you notice lateral tilting; when you raise his leg straight up, he complains of a pain going down his buttock into his leg. You suspect:

herniated nucleus pulposus.

zosteriform

herpes, does it run along a nerve route, meningitis, ck pox, shingles.

SOB

higher than 20 resp/min indicates ____

discrete

individual lesions

During the interview your patient reveals that she has some vaginal discharge. She is worried that it may be a sexually transmitted disease. Your most appropriate response to this would be:

"I'd like some information about the discharge. What color is it?"

ephelides

"freckles" - small, flat macules of brown melanin pigment that occur on sun-exposed skin

The vas deferens is: A. a narrow tunnel inferior to the inguinal ligament. B. a narrow tunnel superior to the inguinal ligament. C. the joining of the vas deferens with the seminal vesicle. D. a muscular duct continuous with the epididymis.

D. a muscular duct continuous with the epididymis.

A deep recess formed by the peritoneum between the rectum and the cervix is called: A. Chadwick's sign. B. a cystocele. C. a rectocele. D. a rectouterine pouch.

D. a rectouterine pouch.

During the performance of the McMurray test, the examiner hears and feels a click, which is an indication of: A. a torn cruciate ligament. B. subluxation of the knee. C. dislocation of the femoral head. D. a torn meniscus

D. a torn meniscus

During a mental status assessment, the nurse asks about the patient's first job. What is the nurse trying to test? 1 Orientation 2 Attention span 3 Recent memory 4 Remote memory

During an examination of a 3-year-old child, the nurse notices a bruit over the left temporal area. The nurse should: a. Continue the examination because a bruit is a normal finding for this age. b. Check for the bruit again in 1 hour. c. Notify the parents that a bruit has been detected in their child. d. Stop the examination, and notify the physician.

A patient asks, "Where is that thing I use to read the newspaper?" and the nurse figures out that the patient wants glasses. Which thought process abnormality is this an example of? 1 Perseveration 2 Confabulation 3 Circumlocution 4 Circumstantiality

A patient in whom a seizure disorder was recently diagnosed plans to continue a career as a pilot. At this time in the interview, the nurse begins to question the patient's: A. thought process. B. judgment. C. perception. D. intellect.

19. The nurse should use which test to check for large amounts of fluid around the patella? A) Ballottement B) Tinel sign C) Phalen's test D) McMurray's test

A) Ballottement Ballottement of the patella is reliable when larger amounts of fluid are present. The Tinel's sign and the Phalen's test are used to check for carpal tunnel syndrome. The McMurray's test is used to test the knee for a torn meniscus. Pages: 590-591

A 55-year-old man is in the clinic for a yearly check-up. He is worried because his father died of prostate cancer. The nurse knows that which tests should be done at this time? Select all that apply. A) Blood test for prostate-specific antigen B) Urinalysis C) Transrectal ultrasound D) Digital rectal examination E) Prostate biopsy

A) Blood test for prostate-specific antigen D) Digital rectal examination Prostate cancer is typically detected by testing the blood for prostate-specific antigen (PSA) or by a digital rectal exam (DRE). It is recommended that both PSA and DRE be offered to men yearly, beginning at age 50 years. If the PSA is elevated, then further lab work or a transrectal ultrasound (TRUS) and biopsy may be recommended.

The nurse is examining a patient who tells the nurse, I sure sweat a lot, especially on my face and feet but it doesn't have an odor. The nurse knows that this condition could be related to: A. eccrine glands B. apocrine glands C. disorder of the stratum corneum D. disorder of the stratum germinativum.

A. eccrine glands

13. The nurse is checking the range of motion in a patient's knee and knows that the knee is capable of which movement(s)? A) Flexion and extension B) Supination and pronation C) Circumduction D) Inversion and eversion

A) Flexion and extension The knee is a hinge joint, permitting flexion and extension of the lower leg on a single plane. The knee is not capable of the other movements listed. Page 572

The nurse is preparing for a certification course in skin care and needs to be familiar with the various lesions that may be identified on assessment of the skin. Which of the following definitions are correct? Select all that apply. A) Petechiae: Tiny punctate hemorrhages, 1 to 3 mm, round and discrete, dark red, purple, or brown in color B) Bulla: An elevated, circumscribed lesion filled with turbid fluid (pus) C) Papule: A hypertrophic scar D) Vesicle: Also known as a friction blister E) Nodule: Solid, elevated, hard or soft, larger than 1 cm

A) Petechiae: Tiny punctate hemorrhages, 1 to 3 mm, round and discrete, dark red, purple, or brown in color D) Vesicle: Also known as a friction blister E) Nodule: Solid, elevated, hard or soft, larger than 1 cm An elevated, circumscribed lesion filled with turbid fluid (pus) is a pustule. A hypertrophic scar is a keloid. A bulla is larger than 1 cm and contains clear fluid; a papule is solid, elevated, but less than 1 cm.

Mr. Walker is a 56-year-old man who comes to the ambulatory health center for a routine health assessment. On examination, you note hepatomegaly, which is: A. enlargement of the liver. B. bowel protrusion through abdominal musculature. C. inflammation of the peritoneum. D. a burning sensation in the upper abdomen.

A. enlargement of the liver.

The nurse is reviewing the changes that occur with menopause. Which of these are changes associated with menopause? A) Uterine and ovarian atrophy along with thinning vaginal epithelium B) Ovarian atrophy, increased vaginal secretions, and increasing clitoral size C) Cervical hypertrophy, ovarian atrophy, and increased acidity of vaginal secretions D) Vaginal mucosa fragility, increased acidity of vaginal secretions, and uterine hypertrophy

A) Uterine and ovarian atrophy along with thinning vaginal epithelium The uterus shrinks because of its decreased myometrium. The ovaries atrophy to 1 to 2 cm and are not palpable after menopause. The sacral ligaments relax, and the pelvic musculature weakens, so the uterus droops. The cervix shrinks and looks paler with a thick glistening epithelium. The vaginal epithelium atrophies, becoming thinner, drier, and itchy. The vaginal pH becomes more alkaline, and secretions are decreased. This results in a fragile mucosal surface that is at risk for bleeding and vaginitis.

12. A patient tells the nurse that she is having a hard time bringing her hand to her mouth when she eats or tries to brush her teeth. The nurse knows that for her to move her hand to her mouth, she must perform which movement? A) flexion. B) abduction. C) adduction. D) extension.

A) flexion. Flexion, or bending a limb at a joint, would be required to move the hand to the mouth. Extension is straightening a limb at a joint. Moving a limb toward the midline of the body is called adduction; abduction is moving a limb away from the midline of the body. Pages: 566-567

A nurse notices that a patient has ascites, which indicates the presence of: A) fluid. B) feces. C) flatus. D) fibroid tumors.

A) fluid. Ascites is free fluid in the peritoneal cavity, and occurs with heart failure, portal hypertension, cirrhosis, hepatitis, pancreatitis, and cancer. REF: Pages: 543-544

The nurse is caring for a black child who has been diagnosed with marasmus. The nurse would expect to find the: A) hair to be less kinky and to be a copper-red color. B) head to be larger than normal, with wide-set eyes. C) skin on the hands and feet to be scaly and tender. D) lymph nodes in the groin to be enlarged and tender.

A) hair to be less kinky and to be a copper-red color. The hair of black children with severe malnutrition (e.g., marasmus) frequently changes not only in texture but in color—the child's hair becomes less kinky and assumes a copper-red color. The other findings are not present with marasmus.

An older man is concerned about his sexual performance. The nurse knows that in the absence of disease, a withdrawal from sexual activity later in life may be due to: A) side effects of medications. B) decreased libido with aging. C) decreased sperm production. D) decreased pleasure from sexual intercourse.

A) side effects of medications. In the absence of disease, a withdrawal from sexual activity may be due to side effects of medications such as antihypertensives, antidepressants, or sedatives. The other options are not correct.

During an examination, the nurse finds that a patient has excessive dryness of the skin. The best term to describe this condition is: A) xerosis. B) pruritus. C) alopecia. D) seborrhea.

A) xerosis.

The nurse is assessing a patient who is admitted with possible delirium. Which of these are manifestations of delirium? Select all that apply. a. Develops over a short period. b. Person is experiencing apraxia. c. Person is exhibiting memory impairment or deficits. d. Occurs as a result of a medical condition, such as systemic infection. e. Person is experiencing agnosia.

A, C, D

A patient has come in for an examination and states, I have this spot in front of my ear lobe on my cheek that seems to be getting bigger and is tender. What do you think it is? The nurse notes swelling below the angle of the jaw and suspects that it could be an inflammation of his: a. Thyroid gland. b. Parotid gland. c. Occipital lymph node. d. Submental lymph node.

Jesse Carter, a student nurse, has been assigned to teach fourth-graders about hygiene. She decides that her teaching module will cover the oil-producing glands. Which of the following will Jesse include while discussing the skin's sebaceous glands? A. The sebaceous glands produce sebum, a protective oily substance that prevents water loss from the skin. B. Dry skin results from the loss of oil and is treated by moisturizers. C. Sebaceous glands are located everywhere on the skin; they are most abundant in the scalp, forehead, face, and chin. D. All of the above.

A. The sebaceous glands produce sebum, a protective oily substance that prevents water loss from the skin.

Nocturia is: A. an advanced and fixed foreskin too tight to retract over the glans. B. awakening in the night with a need to urinate. C. a circumscribed collection of serous fluid in the tunica vaginalis surrounding the testes. D. a prolonged, painful erection of the penis without sexual desire.

B. awakening in the night with a need to urinate.

Mr. Shea is a 51-year-old patient who presents with complaints of a skin lesion. On examination, you note a linear skin lesion that runs along a nerve route. Which of the following terms best describes this lesion? A. Zosteriform B. Annular C. Dermatome D. Shingles

A. Zosteriform

A hydrocele is: A. a circumscribed collection of serous fluid in the tunica vaginalis surrounding the testes. B. a meatus opening on the dorsal side of the glans or shaft. C. an acute inflammation of the testes. D. awakening in the night with a need to urinate.

A. a circumscribed collection of serous fluid in the tunica vaginalis surrounding the testes.

Epispadias is: A. a meatus opening on the dorsal side of the glans or shaft. B. a circumscribed collection of serous fluid in the tunica vaginalis surrounding the testes. C. undescended testes. D. an acute inflammation of the testes.

A. a meatus opening on the dorsal side of the glans or shaft.

Undescended testes are called: A. cryptorchidism. B. phimosis. C. orchitis. D. a varicocele.

A. cryptorchidism.

SaO2

ABGs measure ____: nl. >95%

The spermatic cord is most commonly described as: A. combining the vas deferens and seminal vesicle. B. the vas deferens approximated with other vessels. C. a muscular duct continuous with the epididymis. D. a narrow tunnel superior to the inguinal ligament.

B. the vas deferens approximated with other vessels.

Adnexa is/are: A. an absence of menstruation. B. uterine accessory organs. C. a membranous fold of tissue partly closing the vaginal orifice. D. painful intercourse.

B. uterine accessory organs.

Inflammation of the vagina is known as: A. salpingitis. B. vaginitis. C. cystocele. D. dyspareunia.

B. vaginitis.

When assessing the tongue of an adult, the nurse knows that an abnormal finding would be: a. Smooth glossy dorsal surface. b. Thin white coating over the tongue. c. Raised papillae on the dorsal surface. d. Visible venous patterns on the ventral surface.

ANS: A The dorsal surface of the tongue is normally roughened from papillae. A thin white coating may be present. The ventral surface may show veins. Smooth, glossy areas may indicate atrophic glossitis (see Table 16-5).

During an assessment of a patients family history, the nurse constructs a genogram. Which statement best describes a genogram? a. List of diseases present in a persons near relatives b. Graphic family tree that uses symbols to depict the gender, relationship, and age of immediate family members c. Drawing that depicts the patients family members up to five generations back d. Description of the health of a persons children and grandchildren

During an assessment of a 20-year-old patient with a 3-day history of nausea and vomiting, the nurse notices dry mucosa and deep vertical fissures in the tongue. These findings are reflective of: a. Dehydration. b. Irritation by gastric juices. c. A normal oral assessment. d. Side effects from nausea medication.

ANS: A Dry mouth occurs with dehydration or fever. The tongue has deep vertical fissures.

A patient in her first trimester of pregnancy is diagnosed with rubella. Which of these statements is correct regarding the significance of this in relation to the infants hearing? a. Rubella may affect the mothers hearing but not the infants. b. Rubella can damage the infants organ of Corti, which will impair hearing. c. Rubella is only dangerous to the infant in the second trimester of pregnancy. d. Rubella can impair the development of CN VIII and thus affect hearing.

The nurse is performing an oral assessment on a 40-year-old Black patient and notices the presence of a 1 cm, nontender, grayish-white lesion on the left buccal mucosa. Which one of these statements is true? This lesion is: a. Leukoedema and is common in dark-pigmented persons. b. The result of hyperpigmentation and is normal. c. Torus palatinus and would normally be found only in smokers. d. Indicative of cancer and should be immediately tested.

ANS: A Leukoedema, a grayish-white benign lesion occurring on the buccal mucosa, is most often observed in Blacks.

The nurse is assessing a patient with a history of intravenous drug abuse. In assessing his mouth, the nurse notices a dark red confluent macule on the hard palate. This could be an early sign of: a. Acquired immunodeficiency syndrome (AIDS). b. Measles. c. Leukemia. d. Carcinoma.

ANS: A Oral Kaposi's sarcoma is a bruiselike, dark red or violet, confluent macule that usually occurs on the hard palate. It may appear on the soft palate or gingival margin. Oral lesions may be among the earliest lesions to develop with AIDS.

The salivary gland that is the largest and located in the cheek in front of the ear is the _________ gland. a. Parotid b. Stensen's c. Sublingual d. Submandibular

ANS: A The mouth contains three pairs of salivary glands. The largest, the parotid gland, lies within the cheeks in front of the ear extending from the zygomatic arch down to the angle of the jaw. The Stensen's duct (not gland) drains the parotid gland onto the buccal mucosa opposite the second molar. The sublingual gland is located within the floor of the mouth under the tongue. The submandibular gland lies beneath the mandible at the angle of the jaw.

During an assessment of an infant, the nurse notes that the fontanels are depressed and sunken. The nurse suspects which condition? a. Rickets b. Dehydration c. Mental retardation d. Increased intracranial pressure

The nurse is performing an assessment on a 21-year-old patient and notices that his nasal mucosa appears pale, gray, and swollen. What would be the most appropriate question to ask the patient? a. "Are you aware of having any allergies?" b. "Do you have an elevated temperature?" c. "Have you had any symptoms of a cold?" d. "Have you been having frequent nosebleeds?"

ANS: A With chronic allergies, the mucosa looks swollen, boggy, pale, and gray. Elevated body temperature, colds, and nosebleeds do not cause these mucosal changes.

Which of these assessment findings would the nurse expect to see when examining the eyes of a black patient?

ANS: A dark retinal background There is an ethnically based variability in the color of the iris and in retinal pigmentation, with darker irides having darker retinas behind them.

A patient comes into the emergency department after an accident at work. A machine blew dust into his eyes and he was not wearing safety glasses. The nurse examines his corneas by shining a light from the side across the cornea. What findings would suggest that he has suffered a corneal abrasion?

ANS: A shattered look to the light rays reflecting off the cornea A corneal abrasion causes irregular ridges in reflected light, which produce a shattered look to light rays. There should be no opacities in the cornea. The other responses are not correct.

An elevated cavity containing free fluid that is less than 1 cm in diameter is a(n): A. wheal. B. vesicle. C. bulla. D. edema.

B. vesicle.

A term for the female external genitalia is: A. vagina. B. vulva. C. clitoris. D. hymen.

B. vulva.

Peripheral Vascular System and Lymphatics 2. The organs that aid the lymphatic system are: a. liver, lymph nodes, and stomach. b. pancreas, small intestine, and thymus. c. spleen, tonsils, and thymus. d. pancreas, spleen, and tonsils.

During an assessment the nurse notices that an elderly patient has tears rolling down his face from his left eye. Closer examination shows that the lower lid is loose and rolling outward. The patient complains of his eye feeling "dry and itchy." Which action by the nurse is correct?

ANS: Assess for other signs of ectropion. The condition described is known as ectropion, and it occurs in aging due to atrophy of elastic and fibrous tissues. The lower lid does not approximate to the eyeball, and, as a result, the puncta cannot siphon tears effectively, and excessive tearing results. Ptosis is drooping of the upper eyelid. These are not signs of a foreign body in the eye or basal cell carcinoma.

The nurse is reviewing causes of increased intraocular pressure. Which of these factors determines intraocular pressure?

ANS: Amount of aqueous produced and resistance to its outflow at the angle of the anterior chamber Intraocular pressure is determined by a balance between the amount of aqueous produced and resistance to its outflow at the angle of the anterior chamber. The other responses are incorrect.

The nurse is examining a patient's retina with an ophthalmoscope. Which finding is considered normal?

ANS: An optic disc that is a yellow-orange color The optic disc is located on the nasal side of the retina. It is a creamy yellow-orange to pink color, and the edges are distinct and sharply demarcated, not blurred. A pigmented crescent is black, and it is due to the accumulation of pigment in the choroid.

During an oral examination of a 4-year-old Native-American child, the nurse notices that her uvula is partially split. Which of these statements is accurate? a. This condition is a cleft palate and is common in Native Americans. b. A bifid uvula may occur in some Native-American groups. c. This condition is due to an injury and should be reported to the authorities. d. A bifid uvula is palatinus, which frequently occurs in Native Americans.

ANS: B Bifid uvula, a condition in which the uvula is split either completely or partially, occurs in some Native-American groups.

A 40-year-old patient who has just finished chemotherapy for breast cancer tells the nurse that she is concerned about her mouth. During the assessment the nurse finds areas of buccal mucosa that are raw and red with some bleeding, as well as other areas that have a white, cheesy coating. The nurse recognizes that this abnormality is: a. Aphthous ulcers. b. Candidiasis. c. Leukoplakia. d. Koplik spots.

ANS: B Candidiasis is a white, cheesy, curdlike patch on the buccal mucosa and tongue. It scrapes off, leaving a raw, red surface that easily bleeds. It also occurs after the use of antibiotics or corticosteroids and in persons who are immunosuppressed. (See Table 16-4 for descriptions of the other lesions.)

When examining the mouth of an older patient, the nurse recognizes which finding is due to the aging process? a. Teeth appearing shorter b. Tongue that looks smoother in appearance c. Buccal mucosa that is beefy red in appearance d. Small, painless lump on the dorsum of the tongue

ANS: B In the aging adult, the tongue looks smoother because of papillary atrophy. The teeth are slightly yellowed and appear longer because of the recession of gingival margins.

A woman who is in the second trimester of pregnancy mentions that she has had "more nosebleeds than ever" since she became pregnant. The nurse recognizes that this is a result of: a. A problem with the patient's coagulation system. b. Increased vascularity in the upper respiratory tract as a result of the pregnancy. c. Increased susceptibility to colds and nasal irritation. d. Inappropriate use of nasal sprays.

ANS: B Nasal stuffiness and epistaxis may occur during pregnancy as a result of increased vascularity in the upper respiratory tract.

The primary purpose of the ciliated mucous membrane in the nose is to: a. Warm the inhaled air. b. Filter out dust and bacteria. c. Filter coarse particles from inhaled air. d. Facilitate the movement of air through the nares.

ANS: B The nasal hairs filter the coarsest matter from inhaled air, whereas the mucous blanket filters out dust and bacteria. The rich blood supply of the nasal mucosa warms the inhaled air.

The nurse is using an otoscope to assess the nasal cavity. Which of these techniques is correct? a. Inserting the speculum at least 3 cm into the vestibule b. Avoiding touching the nasal septum with the speculum c. Gently displacing the nose to the side that is being examined d. Keeping the speculum tip medial to avoid touching the floor of the nares

ANS: B The correct technique for using an otoscope is to insert the apparatus into the nasal vestibule, avoiding pressure on the sensitive nasal septum. The tip of the nose should be lifted up before inserting the speculum.

The nurse is palpating the sinus areas. If the findings are normal, then the patient should report which sensation? a. No sensation b. Firm pressure c. Pain during palpation d. Pain sensation behind eyes

ANS: B The person should feel firm pressure but no pain. Sinus areas are tender to palpation in persons with chronic allergies or an acute infection (sinusitis).

In assessing the tonsils of a 30 year old, the nurse notices that they are involuted, granular in appearance, and appear to have deep crypts. What is correct response to these findings? a. Refer the patient to a throat specialist. b. No response is needed; this appearance is normal for the tonsils. c. Continue with the assessment, looking for any other abnormal findings. d. Obtain a throat culture on the patient for possible streptococcal (strep) infection.

ANS: B The tonsils are the same color as the surrounding mucous membrane, although they look more granular and their surface shows deep crypts. Tonsillar tissue enlarges during childhood until puberty and then involutes.

While obtaining a health history, a patient tells the nurse that he has frequent nosebleeds and asks the best way to get them to stop. What would be the nurse's best response? a. "While sitting up, place a cold compress over your nose." b. "Sit up with your head tilted forward and pinch your nose." c. "Just allow the bleeding to stop on its own, but don't blow your nose." d. "Lie on your back with your head tilted back and pinch your nose."

ANS: B With a nosebleed, the person should sit up with the head tilted forward and pinch the nose between the thumb and forefinger for 5 to 15 minutes.

While performing an assessment of the mouth, the nurse notices that the patient has a 1-cm ulceration that is crusted with an elevated border and located on the outer third of the lower lip. What other information would be most important for the nurse to assess? a. Nutritional status b. When the patient first noticed the lesion c. Whether the patient has had a recent cold d. Whether the patient has had any recent exposure to sick animals

ANS: B With carcinoma, the initial lesion is round and indurated, but then it becomes crusted and ulcerated with an elevated border. Most cancers occur between the outer and middle thirds of the lip. Any lesion that is still unhealed after 2 weeks should be referred.

During an assessment, a patient mentions that "I just can't smell like I used to. I can barely smell the roses in my garden. Why is that?" For which possible causes of changes in the sense of smell will the nurse assess? Select all that apply. a. Chronic alcohol use b. Cigarette smoking c. Frequent episodes of strep throat d. Chronic allergies e. Aging f. Herpes simplex virus I

ANS: B, D, E The sense of smell diminishes with cigarette smoking, chronic allergies, and aging. Chronic alcohol use, a history of strep throat, and herpes simplex virus I are not associated with changes in the sense of smell.

The nurse is teaching a health class to high-school boys. When discussing the topic of using smokeless tobacco (SLT), which of these statements are accurate? Select all that apply. a. One pinch of SLT in the mouth for 30 minutes delivers the equivalent of one cigarette. b. Using SLT has been associated with a greater risk of oral cancer than smoking. c. Pain is an early sign of oral cancer. d. Pain is rarely an early sign of oral cancer. e. Tooth decay is another risk of SLT because of the use of sugar as a sweetener. f. SLT is considered a healthy alternative to smoking.

ANS: B, D, E One pinch of SLT in the mouth for 30 minutes delivers the equivalent of three cigarettes. Pain is rarely an early sign of oral cancer. Many brands of SLT are sweetened with sugars, which promotes tooth decay. SLT is not considered a healthy alternative to smoking, and the use of SLT has been associated with a greater risk of oral cancer than smoking.

During ocular examinations, the nurse keeps in mind that movement of the extraocular muscles is:

ANS: Stimulated by cranial nerves III, IV, and VI. Movement of the extraocular muscles is stimulated by three cranial nerves: III, IV, and VI.

The nurse is assessing a patient in the hospital who has received numerous antibiotics and notices that his tongue appears to be black and hairy. In response to his concern, what would the nurse say? a. "We will need to get a biopsy to determine the cause." b. "This is an overgrowth of hair and will go away in a few days." c. "Black, hairy tongue is a fungal infection caused by all the antibiotics you have received." d. "This is probably caused by the same bacteria you had in your lungs."

ANS: C A black, hairy tongue is not really hair but the elongation of filiform papillae and painless overgrowth of mycelial threads of fungus infection on the tongue. It occurs after the use of antibiotics, which inhibit normal bacteria and allow a proliferation of fungus.

During an examination of the eye, the nurse would expect what normal finding when assessing the lacrimal apparatus?

ANS: The absence of drainage from the puncta when pressing against the inner orbital rim There should be no swelling, redness, or drainage from the puncta when it is pressed. Regurgitation of fluid from the puncta, when pressed, indicates duct blockage. The lacrimal glands are not functional at birth.

The nurse is assessing a 3 year old for "drainage from the nose." On assessment, a purulent drainage that has a very foul odor is noted from the left naris and no drainage is observed from the right naris. The child is afebrile with no other symptoms. What should the nurse do next? a. Refer to the physician for an antibiotic order. b. Have the mother bring the child back in 1 week. c. Perform an otoscopic examination of the left nares. d. Tell the mother that this drainage is normal for a child of this age.

ANS: C Children are prone to put an object up the nose, producing unilateral purulent drainage with a foul odor. Because some risk for aspiration exists, removal should be prompt.

During an assessment of a 26 year old at the clinic for "a spot on my lip I think is cancer," the nurse notices a group of clear vesicles with an erythematous base around them located at the lip-skin border. The patient mentions that she just returned from Hawaii. What would be the most appropriate response by the nurse? a. Tell the patient she needs to see a skin specialist. b. Discuss the benefits of having a biopsy performed on any unusual lesion. c. Tell the patient that these vesicles are indicative of herpes simplex I or cold sores and that they will heal in 4 to 10 days. d. Tell the patient that these vesicles are most likely the result of a riboflavin deficiency and discuss nutrition.

ANS: C Cold sores are groups of clear vesicles with a surrounding erythematous base. These evolve into pustules or crusts and heal in 4 to 10 days. The most likely site is the lip-skin junction. Infection often recurs in the same site. Recurrent herpes infections may be precipitated by sunlight, fever, colds, or allergy.

Peripheral Vascular System and Lymphatics 12. Intermittent claudication is: a. muscular pain relieved by exercise. b. neurologic pain relieved by exercise. c. muscular pain brought on by exercise. d. neurologic pain brought on by exercise.

Immediately after birth, the nurse is unable to suction the nares of a newborn. An attempt is made to pass a catheter through both nasal cavities with no success. What should the nurse do next? a. Attempt to suction again with a bulb syringe. b. Wait a few minutes, and try again once the infant stops crying. c. Recognize that this situation requires immediate intervention. d. Contact the physician to schedule an appointment for the infant at his or her next hospital visit.

ANS: C Determining the patency of the nares in the immediate newborn period is essential because most newborns are obligate nose breathers. Nares blocked with amniotic fluid are gently suctioned with a bulb syringe. If obstruction is suspected, then a small lumen (5 to 10 Fr) catheter is passed down each naris to confirm patency. The inability to pass a catheter through the nasal cavity indicates choanal atresia, which requires immediate intervention.

A 92-year-old patient has had a stroke. The right side of his face is drooping. The nurse might also suspect which of these assessment findings? a. Epistaxis b. Rhinorrhea c. Dysphagia d. Xerostomia

ANS: C Dysphagia is difficulty with swallowing and may occur with a variety of disorders, including stroke and other neurologic diseases. Rhinorrhea is a runny nose, epistaxis is a bloody nose, and xerostomia is a dry mouth.

When examining the nares of a 45-year-old patient who has complaints of rhinorrhea, itching of the nose and eyes, and sneezing, the nurse notices the following: pale turbinates, swelling of the turbinates, and clear rhinorrhea. Which of these conditions is most likely the cause? a. Nasal polyps b. Acute sinusitis c. Allergic rhinitis d. Acute rhinitis

ANS: C Rhinorrhea, itching of the nose and eyes, and sneezing are present with allergic rhinitis. On physical examination, serous edema is noted, and the turbinates usually appear pale with a smooth, glistening surface. (See Table 16-1 for descriptions of the other conditions.)

A patient comes into the clinic complaining of facial pain, fever, and malaise. On examination, the nurse notes swollen turbinates and purulent discharge from the nose. The patient also complains of a dull, throbbing pain in his cheeks and teeth on the right side and pain when the nurse palpates the areas. The nurse recognizes that this patient has: a. Posterior epistaxis. b. Frontal sinusitis. c. Maxillary sinusitis. d. Nasal polyps.

ANS: C Signs of maxillary sinusitis include facial pain after upper respiratory infection, red swollen nasal mucosa, swollen turbinates, and purulent discharge. The person also has fever, chills, and malaise. With maxillary sinusitis, dull throbbing pain occurs in the cheeks and teeth on the same side, and pain with palpation is present. With frontal sinusitis, pain is above the supraorbital ridge.

During an oral assessment of a 30-year-old Black patient, the nurse notices bluish lips and a dark line along the gingival margin. What action would the nurse perform in response to this finding? a. Check the patient's hemoglobin for anemia. b. Assess for other signs of insufficient oxygen supply. c. Proceed with the assessment, knowing that this appearance is a normal finding. d. Ask if he has been exposed to an excessive amount of carbon monoxide.

ANS: C Some Blacks may have bluish lips and a dark line on the gingival margin; this appearance is a normal finding.

A mother is concerned because her 18-month-old toddler has 12 teeth. She is wondering if this is normal for a child of this age. The nurse's best response would be: a. "How many teeth did you have at this age?" b. "All 20 deciduous teeth are expected to erupt by age 4 years." c. "This is a normal number of teeth for an 18 month old." d. "Normally, by age 2 years, 16 deciduous teeth are expected."

ANS: C The guidelines for the number of teeth for children younger than 2 years old are as follows: the child's age in months minus the number 6 should be equal to the expected number of deciduous teeth. Normally, all 20 teeth are in by 2 years old. In this instance, the child is 18 months old, minus 6, equals 12 deciduous teeth expected.

The projections in the nasal cavity that increase the surface area are called the: a. Meatus. b. Septum. c. Turbinates. d. Kiesselbach plexus.

ANS: C The lateral walls of each nasal cavity contain three parallel bony projections: the superior, middle, and inferior turbinates. These increase the surface area, making more blood vessels and mucous membrane available to warm, humidify, and filter the inhaled air.

The nurse notices that the mother of a 2-year-old boy brings him into the clinic quite frequently for various injuries and suspects there may be some child abuse involved. During an inspection of his mouth, the nurse should look for: a. Swollen, red tonsils. b. Ulcerations on the hard palate. c. Bruising on the buccal mucosa or gums. d. Small yellow papules along the hard palate.

ANS: C The nurse should notice any bruising or laceration on the buccal mucosa or gums of an infant or young child. Trauma may indicate child abuse from a forced feeding of a bottle or spoon.

The nurse is assessing an 80-year-old patient. Which of these findings would be expected for this patient? a. Hypertrophy of the gums b. Increased production of saliva c.Decreased ability to identify odors d. Finer and less prominent nasal hair

ANS: C The sense of smell may be reduced because of a decrease in the number of olfactory nerve fibers. Nasal hairs grow coarser and stiffer with aging. The gums may recede with aging, not hypertrophy, and saliva production decreases.

A patient has been diagnosed with strep throat. The nurse is aware that without treatment, which complication may occur? a. Rubella b. Leukoplakia c. Rheumatic fever d. Scarlet fever

ANS: C Untreated strep throat may lead to rheumatic fever. When performing a health history, the patient should be asked whether his or her sore throat has been documented as streptococcal.

A 10 year old is at the clinic for "a sore throat that has lasted 6 days." Which of these findings would be consistent with an acute infection? a. Tonsils 1+/1-4+ and pink; the same color as the oral mucosa b. Tonsils 2+/1-4+ with small plugs of white debris c. Tonsils 3+/1-4+ with large white spots d. Tonsils 3+/1-4+ with pale coloring

ANS: C With an acute infection, tonsils are bright red and swollen and may have exudate or large white spots. Tonsils are enlarged to 2+, 3+, or 4+ with an acute infection.

A patient has a normal pupillary light reflex. The nurse recognizes that this reflex indicates that:

ANS: Constriction of both pupils occurs in response to bright light. The pupillary light reflex is the normal constriction of the pupils when bright light shines on the retina. The other responses are not correct.

The nurse is assessing a patient's eyes for the accommodation response and would expect to see which normal finding?

ANS: Convergence of the axes of the eyes The accommodation reaction includes pupillary constriction and convergence of the axes of the eyes. The other responses are not correct.

11. When inspecting the anterior chest of an adult, the nurse should include which assessment? (5 pts) A. symmetric chest expansion B. diaphragmatic excursion C. the presence of breath sounds D. the shape and configuation of the chest wall

During an interview, the nurse notes that the patient gets up several times to wash her hands even though they are not dirty. This behavior is an example of: a. Social phobia b. Compulsive disorder c. Generalized anxiety disorder d. Posttraumatic stress disorder

A 32-year-old woman is at the clinic for "little white bumps in my mouth." During the assessment, the nurse notes that she has a 0.5 cm white, nontender papule under her tongue and one on the mucosa of her right cheek. What would the nurse tell the patient? a. "These spots i ndicate an infection such as strep throat." b. "These bumps could be indicative of a serious lesion, so I will refer you to a specialist." c. "This condition is called leukoplakia and can be caused by chronic irritation such as with smoking." d. "These bumps are Fordyce granules, which are sebaceous cysts and are not a serious condition."

ANS: D Fordyce granules are small, isolated white or yellow papules on the mucosa of the cheek, tongue, and lips. These little sebaceous cysts are painless and are not significant. Chalky, white raised patches would indicate leukoplakia. In strep throat, the examiner would see tonsils that are bright red, swollen, and may have exudates or white spots.

A pregnant woman states that she is concerned about her gums because she has noticed they are swollen and have started bleeding. What would be an appropriate response by the nurse? a. "Your condition is probably due to a vitamin C deficiency." b. "I'm not sure what causes swollen and bleeding gums, but let me know if it's not better in a few weeks." c. "You need to make an appointment with your dentist as soon as possible to have this checked." d. "Swollen and bleeding gums can be caused by the change in hormonal balance in your system during pregnancy."

ANS: D Gum margins are red and swollen and easily bleed with gingivitis. A changing hormonal balance may cause this condition to occur in pregnancy and puberty.

The nurse is nearing the end of an interview. Which statement is appropriate at this time? a. Did we forget something? b. Is there anything else you would like to mention? c. I need to go on to the next patient. Ill be back. d. While Im here, lets talk about your upcoming surgery.

The nurse is obtaining a health history on a 3-month-old infant. During the interview, the mother states, "I think she is getting her first tooth because she has started drooling a lot." The nurse's best response would be: a. "You're right, drooling is usually a sign of the first tooth." b. "It would be unusual for a 3 month old to be getting her first tooth." c. "This could be the sign of a problem with the salivary glands." d. "She is just starting to salivate and hasn't learned to swallow the saliva."

ANS: D In the infant, salivation starts at 3 months. The baby will drool for a few months before learning to swallow the saliva. This drooling does not herald the eruption of the first tooth, although many parents think it does.

The nurse is reviewing the development of the newborn infant. Regarding the sinuses, which statement is true in relation to a newborn infant? a. Sphenoid sinuses are full size at birth. b. Maxillary sinuses reach full size after puberty. c. Frontal sinuses are fairly well developed at birth. d. Maxillary and ethmoid sinuses are the only sinuses present at birth.

ANS: D Only the maxillary and ethmoid sinuses are present at birth. The sphenoid sinuses are minute at birth and develop after puberty. The frontal sinuses are absent at birth, are fairly well developed at age 7 to 8 years, and reach full size after puberty.

While obtaining a health history from the mother of a 1-year-old child, the nurse notices that the baby has had a bottle in his mouth the entire time. The mother states, "It makes a great pacifier." The best response by the nurse would be: a. "You're right. Bottles make very good pacifiers." b. "Using a bottle as a pacifier is better for the teeth than thumb-sucking." c. "It's okay to use a bottle as long as it contains milk and not juice." d. "Prolonged use of a bottle can increase the risk for tooth decay and ear infections."

ANS: D Prolonged bottle use during the day or when going to sleep places the infant at risk for tooth decay and middle ear infections.

The nurse is performing a functional assessment on an 82-year-old patient who recently had a stroke. Which of these questions would be most important to ask? a. Do you wear glasses? b. Are you able to dress yourself? c. Do you have any thyroid problems? d. How many times a day do you have a bowel movement?

The tissue that connects the tongue to the floor of the mouth is the: a. Uvula. b. Palate. c. Papillae. d. Frenulum.

ANS: D The frenulum is a midline fold of tissue that connects the tongue to the floor of the mouth. The uvula is the free projection hanging down from the middle of the soft palate. The palate is the arching roof of the mouth. Papillae are the rough, bumpy elevations on the tongue's dorsal surface.

During a checkup, a 22-year-old woman tells the nurse that she uses an over-the-counter nasal spray because of her allergies. She also states that it does not work as well as it used to when she first started using it. The best response by the nurse would be: a. "You should never use over-the-counter nasal sprays be cause of the risk of addiction." b. "You should try switching to another brand of medication to prevent this problem." c. "Continuing to use this spray is important to keep your allergies under control." d. "Using these nasal medications irritates the lining of the nose and may cause rebound swelling."

ANS: D The misuse of over-the-counter nasal medications irritates the mucosa, causing rebound swelling, which is a common problem.

The nurse is performing an assessment. Which of these findings would cause the greatest concern? a. Painful vesicle inside the cheek for 2 days b. Presence of moist, nontender Stensen's ducts c. Stippled gingival margins that snugly adhere to the teeth d. Ulceration on the side of the tongue with rolled edges

ANS: D Ulceration on the side or base of the tongue or under the tongue raises the suspicion of cancer and must be investigated. The risk of early metastasis is present because of rich lymphatic drainage. The vesicle may be an aphthous ulcer, which is painful but not dangerous. The other responses are normal findings.

A 72-year-old patient has a history of hypertension and chronic lung disease. An important question for the nurse to include in the health history would be: a. "Do you use a fluoride supplement?" b. "Have you had tonsillitis in the last year?" c. "At what age did you get your first tooth?" d. "Have you noticed any dryness in your mouth?"

ANS: D Xerostomia (dry mouth) is a side effect of many drugs taken by older people, including antidepressants, anticholinergics, antispasmodics, antihypertensives, antipsychotics, and bronchodilators.

During an ophthalmoscopic examination of the eye, the nurse notices areas of exudate that look like "cotton wool" or fluffy gray-white cumulus clouds. This finding indicates which possible problem?

ANS: Diabetes Soft exudates or "cotton wool" areas look like fluffy gray-white cumulus clouds, They occur with diabetes, hypertension, subacute bacterial endocarditis, lupus, and papilledema of any cause. These exudates are not found with hyperthyroidism, glaucoma, or hypotension.

When examining a patient's eyes, the nurse recalls that stimulation of the sympathetic branch of the autonomic nervous system:

ANS: Elevates the eyelid and dilates the pupil. Stimulation of the sympathetic branch of the autonomic nervous system dilates the pupil and elevates the eyelid. Parasympathetic nervous system stimulation causes the pupil to constrict. The muscle fibers of the iris contract the pupil in bright light to accommodate for near vision. The ciliary body controls the thickness of the lens.

When examining the eye, the nurse notices that the patient's eyelid margins approximate completely. The nurse recognizes that this assessment finding:

ANS: Is expected. The palpebral fissure is the elliptical open space between the eyelids, and, when closed, the lid margins approximate completely, which is a normal finding.

A patient's vision is recorded as 20/30 when the Snellen eye chart is used. The nurse interprets these results to indicate that:

ANS: The patient can read at 20 feet what a person with normal vision can read at 30 feet. The top number indicates the distance the person is standing from the chart; the denominator gives the distance at which a normal eye can see.

1, 2

After performing the Four Unrelated Words Test for a patient, the nurse concludes that the patient has Alzheimer dementia. What must be the word recall score of this patient? Select all that apply. 1. 0 2. 1 3. 2 4. 3 5. 4

Although a full mental status examination may not be required for every patient, the health care provider must address the four main components during a health history and physical examination. The four components are: A. memory, attention, thought content, and perceptions. B. language, orientation, attention, and abstract reasoning. C. appearance, behavior, cognition, and thought processes. D. mood, affect, consciousness, and orientation.

During a skin assessment, the nurse notices that a Mexican-American patient has skin that is yellowish-brown; however, the skin on the hard and soft palate is pink and the patient's scleras are not yellow. From this finding, the nurse could probably rule out: a. Pallor b. Jaundice c. Cyanosis d. Iron deficiency

Urticaria (hives)

An example of a primary lesion is a(n): urticaria. ucler. erosion. port-wine stain.

An older adult: A. experiences a 10-point decrease in intelligence. B. has diminished recent and remote memory recall. C. has a slower response time. D. has difficulty with problem solving.

A mother brings her newborn in for an assessment and asks, Is there something wrong with my baby? His head seems so big. Which statement is true regarding the relative proportions of the head and trunk of the newborn? a. At birth, the head is one fifth the total length. b. Head circumference should be greater than chest circumference at birth. c. The head size reaches 90% of its final size when the child is 3 years old. d. When the anterior fontanel closes at 2 months, the head will be more proportioned to the body.

A patient comes to the clinic complaining of neck and shoulder pain and is unable to turn her head. The nurse suspects damage to CN ______ and proceeds with the examination by _____________. a. XI; palpating the anterior and posterior triangles b. XI; asking the patient to shrug her shoulders against resistance c. XII; percussing the sternomastoid and submandibular neck muscles d. XII; assessing for a positive Romberg sign

A patient comes to the emergency department after a boxing match, and his left eye is swollen almost shut. He has bruises on his face and neck. He says he is worried because he cant see well from his left eye. The physician suspects retinal damage. The nurse recognizes that signs of retinal detachment include: a. Loss of central vision. b. Shadow or diminished vision in one quadrant or one half of the visual field. c. Loss of peripheral vision. d. Sudden loss of pupillary constriction and accommodation.

The nurse is performing the diagnostic positions test. Normal findings would be which of these results? a. Convergence of the eyes b. Parallel movement of both eyes c. Nystagmus in extreme superior gaze d. Slight amount of lid lag when moving the eyes from a superior to an inferior position

The nurse is preparing to conduct a mental status examination. Which statement is true regarding the mental status examination? a. A patient's family is the best resource for information about the patient's coping skills. b. Gathering mental status information during the health history interview is usually sufficient. c. Integrating the mental status examination into the health history interview takes an enormous amount of extra time. d. To get a good idea of the patient's level of functioning, performing a complete mental status examination is usually necessary.

The nurse keeps in mind that a thorough skin assessment is very important because the skin holds information about a person's: A) support systems. B) circulatory status. C) socioeconomic status. D) psychological wellness.

B) circulatory status. The skin holds information about the body's circulation, nutritional status, and signs of systemic diseases as well as topical data on the integument itself.

A 70-year-old patient tells the nurse that he has noticed that he is having trouble hearing, especially in large groups. He says that he cant always tell where the sound is coming from and the words often sound mixed up. What might the nurse suspect as the cause for this change? a. Atrophy of the apocrine glands b. Cilia becoming coarse and stiff c. Nerve degeneration in the inner ear d. Scarring of the tympanic membrane

The nurse is listening to bowel sounds. Which of these statements is true of bowel sounds? A) They are usually loud, high-pitched, rushing, tinkling sounds. B) They are usually high-pitched, gurgling, irregular sounds. C) They sound like two pieces of leather being rubbed together. D) They originate from the movement of air and fluid through the large intestine.

B) They are usually high-pitched, gurgling, irregular sounds. Bowel sounds are high-pitched, gurgling, cascading sounds that occur irregularly from 5 to 30 times per minute. They originate from the movement of air and fluid through the small intestine. REF: Pages: 539-540

The nurse is assessing a patient who has liver disease for jaundice. Which of these assessment findings is indicative of true jaundice? A) Yellow patches in the outer sclera B) Yellow color of the sclera that extends up to the iris C) Skin that appears yellow when examined under low light D) Yellow deposits on the palms and soles of the feet where jaundice first appears

B) Yellow color of the sclera that extends up to the iris The yellow sclera of jaundice extends up to the edge of the iris. Calluses on the palms and soles of the feet often look yellow but are not classified as jaundice. Do not confuse scleral jaundice with the normal yellow subconjunctival fatty deposits that are common in the outer sclera of dark-skinned persons. Pages: 213-214

A semiconscious woman is brought to the emergency department after she was found on the floor in her kitchen. Her face, nail beds, lips, and oral mucosa are a bright cherry-red color. The nurse suspects that this coloring is due to: A) polycythemia. B) carbon monoxide poisoning. C) carotenemia. D) uremia.

B) carbon monoxide poisoning. A bright cherry-red coloring in the face, upper torso, nail beds, lips, and oral mucosa appears in cases of carbon monoxide poisoning.

After completing an assessment of a 60-year-old man with a family history of colon cancer, the nurse discusses with him early detection measures for colon cancer. The nurse should mention the need for a(n): A) annual proctoscopy. B) colonoscopy every 10 years. C) fecal test for blood every 6 months. D) digital rectal examinations every 2 years.

B) colonoscopy every 10 years. Early detection measures for colon cancer include a digital rectal examination performed annually after age 50 years, a fecal occult blood test annually after age 50 years, sigmoidoscopy every 5 years or colonoscopy every 10 years after age 50 years; and a PSA blood test annually for men over 50 years old, except black men beginning at age 45 years (American Cancer Society, 2006).

An older patient has been diagnosed with pernicious anemia. The nurse knows that this condition could be related to: A) increased gastric acid secretion. B) decreased gastric acid secretion. C) delayed gastrointestinal emptying time. D) increased gastrointestinal emptying time.

B) decreased gastric acid secretion. Gastric acid secretion decreases with aging, and this may cause pernicious anemia (because it interferes with vitamin B12 absorption), iron deficiency anemia, and malabsorption of calcium. REF: Page: 531

The nurse knows that during an abdominal assessment, deep palpation is used to determine: A) bowel motility. B) enlarged organs. C) superficial tenderness. D) overall impression of skin surface and superficial musculature.

B) enlarged organs. With deep palpation, the nurse should notice the location, size, consistency, and mobility of any palpable organs and the presence of any abnormal enlargement, tenderness, or masses. REF: Pages: 546-547

A patient has hypoactive bowel sounds. The nurse knows that a potential cause of hypoactive bowel sounds is: A) diarrhea. B) peritonitis. C) laxative use. D) gastroenteritis.

B) peritonitis. Diminished or absent bowel sounds signal decreased motility from inflammation as seen with peritonitis, with paralytic ileus after abdominal surgery, or with late bowel obstruction. REF: Page: 561

The structure that secretes a thin, milky alkaline fluid to enhance the viability of sperm is the: A) Cowper's gland. B) prostate gland. C) median sulcus. D) bulbourethral gland.

B) prostate gland. In men, the prostate gland secretes a thin milky alkaline fluid that enhances sperm viability. The Cowper's glands (also known as bulbourethral glands) secrete a clear, viscid mucus. The median sulcus is a groove dividing the lobes of the prostate gland and does not secrete fluid.

A 40-year-old woman reports a change in mole size, accompanied by color changes, itching, burning, and bleeding over the past month. She has a dark complexion and has no family history of skin cancer, but she has had many blistering sunburns in the past. The nurse would: A) tell the patient to watch the lesion and report back in 2 months. B) refer the patient because of the suspicion of melanoma on the basis of her symptoms. C) ask additional questions regarding environmental irritants that may have caused this condition. D) suspect that this is a compound nevus, which is very common in young to middle-aged adults.

B) refer the patient because of the suspicion of melanoma on the basis of her symptoms. The ABCD danger signs of melanoma are asymmetry, border irregularity, color variation, and diameter. In addition, individuals may report a change in size, development of itching, burning, bleeding, or a new-pigmented lesion. Any of these signs raise suspicion of malignant melanoma and warrant immediate referral. Pages: 212-213

During an examination, a patient states that she was diagnosed with open-angle glaucoma 2 years ago. The nurse assesses for characteristics of open-angle glaucoma. Which of these are characteristics of open-angle glaucoma?Select all that apply. a. Patient may experience sensitivity to light, nausea, and halos around lights. b. Patient experiences tunnel vision in the late stages. c. Immediate treatment is needed. d. Vision loss begins with peripheral vision. e. Open-angle glaucoma causes sudden attacks of increased pressure that cause blurred vision. f. Virtually no symptoms are exhibited.

B, D, F

The nurse is assessing a 1 month old infant at his well baby checkup. Which assessment findings are appropriate for this age? (Select all that apply). A. head circumference equal to chest circumference B. head circumference greater than chest circumference C. head circumference less than chest circumference D. fontanels firm and slightly concave E. absent tonic neck reflex F. nonpalpable cervical lymph nodes

B, D, F

A functional assessment is primarily concerned with gathering information related to: A. range of motion. B. activities of daily living. C. transcultural variations. D. developmental capabilities.

B. activities of daily living.

Phimosis is: A. undescended testes. B. an advanced and fixed foreskin too tight to retract over the glans. C. hard, subcutaneous plaques associated with painful bending of the erect penis. D. a prolonged, painful erection of the penis without sexual desire.

B. an advanced and fixed foreskin too tight to retract over the glans.

Mrs. Landers is a 53-year-old patient with rheumatoid arthritis. On examination, which of the following would you expect to find due to this type of arthritis? A. Dislocation B. Painful motion C. Increased ROM D. Muscle spasms

B. Painful motion

The term used to describe the shape of a lesion as being circular is: A. scaphoid. B. annular. C. confluent. D. zosteriform.

B. annular.

A patient comes to the clinic complaining of neck and shoulder pain and is unable to turn her head. The nurse suspects damage to CN ___ and proceeds with the examination by ________. A. XI; palpating the anterior and posterior triangles B. XI; asking the patient to shrug her shoulders against resistance C. XII; percussing the sternocleidomastoid and submandibular neck muscles D. XII; assessing for positive Romberg sign

B. XI; asking the patient to shrug her shoulders against resistance the major neck muscles are sternomastoid and trapezius. they are innervated by CN XI, spinal accessory. the innervated muscles assist with head rotation and head flexion, movement of the shoulders, and extension and turning of the head

Pyrosis is: A. an inflammation of the peritoneum. B. a burning sensation in the upper abdomen. C. a congenital narrowing of the pyloric sphincter. D. an abnormally sunken abdominal wall.

B. a burning sensation in the upper abdomen.

A red, round, superficial ulcer with serous discharge, which is a possible sign of syphilis, is called: A. cystitis. B. a chancre. C. hypospadias. D. phimosis.

B. a chancre.

The spleen is: A. a soft, lobulated gland behind the stomach. B. a soft mass of lymphatic tissue on the posterolateral wall. C. a bean-shaped, retroperitoneal gland. D. None of the above.

B. a soft mass of lymphatic tissue on the posterolateral wall.

Splenomegaly is defined as a(n): A. outflow obstruction of the stomach. B. abnormal enlargement of the spleen. C. enlargement of the liver. D. sunken abdominal wall.

B. abnormal enlargement of the spleen.

The nurse has just completed a lymph node assessment on a 60 year old healthy female patient. The nurse knows that most lymph nodes in healthy adults are normally: A. shotty B. nonpalpable C. large, firm, and fixed to the tissue D. rubbery, discrete, and mobile

B. nonpalpable

Borborygmi is/are: A. a midline longitudinal ridge in the abdomen. B. normal hyperperistaltic bowel sounds. C. an inflammation of the peritoneum. D. obesity.

B. normal hyperperistaltic bowel sounds.

The nurse is assessing a patient who has liver disease for jaundice. Which of these assessment findings is indicative of true jaundice? A. yellow patches in the outer sclera B. yellow color of the sclera that extends up to the iris C. skin that appears yellow when examined under low light D. yellow deposits on the palms and soles of the feet where jaundice first appers

B. yellow color of the sclera that extends up to the iris. The yellow sclera of jaundice extends up to the edge of the iris. calluses on the palms and soles of the feet are often yellow but are not classified as jaundice. scleral jaundice should not be confused with the normal yellow subconjunctival fatty deposits that are common in the outer sclera of dark-skinned persons

During an annual physical exam, a 43-year-old patient states that she doesn't perform monthly breast self-examinations (BSE). She tells the nurse that she believes that mammograms "do a much better job than I ever could to find a lump." The nurse should explain to her that:

BSEs may detect lumps that appear between mammograms. ANS:A Pages: 389-391. The monthly practice of breast self-examination, along with clinical breast examination and mammograms are complementary screening measures. Mammography can reveal cancers too small to be detected by the woman or by the most experienced examiner. However, interval lumps may become palpable between mammograms.

A black patient is in the intensive care unit because of impending shock after an accident. The nurse expects to find what characteristics in this patient's skin? a. Ruddy blue. b. Generalized pallor. c. Ashen, gray, or dull. d. Patchy areas of pallor.

A mother asks when her newborn infants eyesight will be developed. The nurse should reply: a. Vision is not totally developed until 2 years of age. b. Infants develop the ability to focus on an object at approximately 8 months of age. c. By approximately 3 months of age, infants develop more coordinated eye movements and can fixate on an object. d. Most infants have uncoordinated eye movements for the first year of life.

A patient has had three pregnancies and two live births. The nurse would record this information as gravida _____, para _____, AB _____. A) 2; 2; 1 B) 3; 2; 0 C) 3; 2; 1 D) 3; 3; 1

C) 3; 2; 1 Gravida is number of pregnancies. Para is number of births. Abortions are interrupted pregnancies, including elective abortions and spontaneous miscarriages.

black patient is in the intensive care unit because of impending shock after an accident. The nurse would expect to find what characteristics in this patient's skin? A) Ruddy blue B) Generalized pallor C) Ashen, gray, or dull D) Patchy areas of pallor

C) Ashen, gray, or dull Pallor due to shock (decreased perfusion and vasoconstriction) in black-skinned people will cause the skin to appear ashen, gray, or dull. See Table 12-2.

14. The nurse is explaining the mechanism of the growth of long bones to a mother of a toddler. Where does lengthening of the bones occur? A) Bursa B) Calcaneus C) Epiphyses D) Tuberosities

C) Epiphyses Lengthening occurs at the epiphyses, or growth plates. The other options are not correct. Page: 573

A patient has been diagnosed with schizophrenia. During a recent interview, he shows the nurse a picture of a man holding a decapitated head. He describes this picture as horrifying but then laughs loudly at the content. This behavior is a display of: a. Confusion b. Ambivalence c. Depersonalization d. Inappropriate affect

16. A patient is complaining of pain in his joints that is worse in the morning, is better after he has moved around for awhile, and then gets worse again if he sits for long periods of time. The nurse should assess for other signs of what problem? A) Tendinitis B) Osteoarthritis C) Rheumatoid arthritis D) Intermittent claudication

C) Rheumatoid arthritis Rheumatoid arthritis is worse in the morning when arising. Movement increases most joint pain, except in rheumatoid arthritis, in which movement decreases pain. The other options are not correct. Page 574-575

A newborn infant is in the clinic for a well-baby check. The nurse observes the infant for the possibility of fluid loss because of which of these factors? A) Subcutaneous fat deposits are high in the newborn. B) Sebaceous glands are overproductive in the newborn. C) The newborn's skin is more permeable than that of the adult. D) The amount of vernix caseosa rises dramatically in the newborn.

C) The newborn's skin is more permeable than that of the adult. The newborn's skin is thin, smooth, and elastic and is relatively more permeable than that of the adult, so the infant is at greater risk for fluid loss. The subcutaneous layer in the infant is inefficient, not thick, and the sebaceous glands are present but decrease in size and production. Vernix caseosa is not produced after birth.

A patient is having difficulty in swallowing medications and food. The nurse would document that this patient has: A) aphasia. B) dysphasia. C) dysphagia. D) anorexia.

C) dysphagia. Dysphagia is a condition that occurs with disorders of the throat or esophagus and results in difficulty swallowing. Aphasia and dysphasia are speech disorders. Anorexia is a loss of appetite. REF: Pages: 532-533

17. The nurse suspects that a patient has carpal tunnel syndrome and wants to perform the Phalen's test. To perform this test, the nurse should instruct the patient to: A) dorsiflex the foot. B) plantarflex the foot. C) hold both hands back to back while flexing the wrists 90 degrees for 60 seconds. D) hyperextend the wrists with the palmar surface of both hands touching and wait for 60 seconds.

C) hold both hands back to back while flexing the wrists 90 degrees for 60 seconds. For the Phalen's test, the nurse should ask the person to hold both hands back to back while flexing the wrists 90 degrees. Acute flexion of the wrist for 60 seconds produces no symptoms in the normal hand. The Phalen's test reproduces numbness and burning in a person with carpal tunnel syndrome. The other actions are not correct for testing for carpal tunnel syndrome. Page: 587

The nurse notices that a patient has had a pale, yellow, greasy stool, or steatorrhea, and recalls that this is caused by: A) occult bleeding. B) absent bile pigment. C) increased fat content. D) ingestion of bismuth preparations.

C) increased fat content. Steatorrhea (pale, yellow, greasy stool) is caused by increased fat content in the stools, as in malabsorption syndrome. Occult bleeding and ingestion of bismuth products cause black stool, and absent bile pigment causes gray, tan stool.

A patient is complaining of a sharp pain along the costovertebral angles. The nurse knows that this symptom is most often indicative of: A) ovary infection. B) liver enlargement. C) kidney inflammation. D) spleen enlargement.

C) kidney inflammation. Sharp pain along the costovertebral angles occurs with inflammation of the kidney or paranephric area. The other options are not correct. REF: Pages: 542-543

While examining a patient, the nurse observes abdominal pulsations between the xiphoid and umbilicus. The nurse would suspect that these are: A) pulsations of the renal arteries. B) pulsations of the inferior vena cava. C) normal abdominal aortic pulsations. D) increased peristalsis from a bowel obstruction.

C) normal abdominal aortic pulsations. Normally, one may see the pulsations from the aorta beneath the skin in the epigastric area, particularly in thin persons with good muscle wall relaxation. REF: Pages: 538-539

18. The nurse is assessing a 1-week-old infant and is testing his muscle strength. The nurse lifts the infant with hands under the axillae and notices that the infant starts to "slip" between the hands. The nurse should: A) suspect a fractured clavicle. B) suspect that the infant may have a deformity of the spine. C) suspect that the infant may have weakness of the shoulder muscles. D) consider this a normal finding because the musculature of an infant this age is undeveloped.

C) suspect that the infant may have weakness of the shoulder muscles. An infant who starts to "slip" between the nurse's hands shows weakness of the shoulder muscles. An infant with normal muscle strength wedges securely between the nurse's hands. The other responses are not correct. Pages: 600-601

A physician has diagnosed a patient with purpura. After leaving the room, a nursing student asks the nurse what the physician saw that led to that diagnosis. The nurse should say, "The physician is referring to: A) that blue dilation of blood vessels in a star-shaped linear pattern on the legs." B) that fiery red, star-shaped marking on the cheek that has a solid circular center." C) that confluent and extensive patch of petechiae and ecchymoses on the feet." D) those tiny little areas of hemorrhage that are less than 2 mm, round, discrete, and dark red in color."

C) that confluent and extensive patch of petechiae and ecchymoses on the feet." Purpura is a confluent and extensive patch of petechiae and ecchymoses and a flat macular hemorrhage seen in generalized disorders such as thrombocytopenia and scurvy. The blue dilation of blood vessels in a star-shaped linear pattern on the legs describes a venous lake. The fiery red, star-shaped marking on the cheek that has a solid circular center describes a spider or star angioma. The tiny little areas of hemorrhage that are less than 2 mm, round, discrete, and dark red in color describes petechiae. Pages: 239-240

The nurse is performing percussion during an abdominal assessment. Percussion notes heard during the abdominal assessment may include: A) flatness, resonance, and dullness. B) resonance, dullness, and tympany. C) tympany, hyperresonance, and dullness. D) resonance, hyperresonance, and flatness.

C) tympany, hyperresonance, and dullness. Percussion notes normally heard during the abdominal assessment may include tympany, which should predominate because air in the intestines rises to the surface when the person is supine; hyperresonance, which may be present with gaseous distention; and dullness, which may be found over a distended bladder, adipose tissue, fluid, or a mass. REF: Pages: 539-540

Which of the following refers to the four layers of large, flat abdominal muscles? A. Linea alba B. Rectus abdominus C. Ventral abdominal wall D. None of the above

C. Ventral abdominal wall

Casey Galen, a student nurse, conducts a dermatology in-service for nurses and students assigned to a medical surgical floor at the local hospital. Casey covers skin changes indicative of prolonged sun exposure and shows slides of precancerous lesions. Which of the following is descriptive of a precancerous keratotic lesion? A. Raised, thickened areas of pigmentation, which look crusted, scaly, and warty B. A raised, thickened, crusted area of dark pigmentation that looks "stuck on" and greasy C. A raised, rough plaque of red-tan pigmentation with a silver-white scale D. A raised, thickened, dry area of decreased pigmentation with a tightly packed set of papules

C. A raised, rough plaque of red-tan pigmentation with a silver-white scale

Functions of the skin include: A. protection, prevention, perception, and production of vitamin D. B. temperature regulation, communication, and identification. C. All of the above. D. None of the above.

C. All of the above.

A herniated nucleus pulposus will produce which of the following results when an individual performs a straight leg-raising test? A. Numbness and tingling in the foot and ankle B. Limited ROM of the hip C. Back and leg pain D. Clicking sound when the knee is extended and externally rotated

C. Back and leg pain

Which of the following statements about sweat glands is correct? A. Sweat glands are located everywhere on the skin except the palms and soles. B. Sweat glands are eccrine glands that produce a thick, milky secretion and open into the hair follicles. C. Eccrine glands mature by the time an infant is 2 months old. D. All of the above

C. Eccrine glands mature by the time an infant is 2 months old.

Fluid within the bursa that results in synovial thickening is also described by which of the following terms? A. Subluxation B. Ankylosis C. Effusion D. Effleurage

C. Effusion

Mrs. Kinder brings her infant son in for a health assessment. On examination, you note polydactyly. An infant with polydactyly would be expected to manifest which of the following? A. Digits that are webbed together B. Digits that are nonfunctional C. Extra digits D. Digits with extra joints

C. Extra digits

Mrs. Bauer comes to your office with her 12-year-old daughter with a complaint of a lump in her groin. On examination you detect a hernia. Which of the following types of hernias is more common in females? A. Direct hernia B. Indirect hernia C. Femoral hernia D. Sliding hernia

C. Femoral hernia

Which is true about a newborn's umbilical cord? A. It contains two veins. B. It contains one artery. C. It contains two arteries. D. None of the above.

C. It contains two arteries.

Mr. Tucker is a 28-year-old patient who presents to your office with a concern that during an erection his penis is bent and painful. This clinical finding is caused by nontender, hard plaques on the surface of the penis known as: A. paraphimosis. B. phimosis. C. Peyronie disease. D. spermatocele.

C. Peyronie disease.

Mrs. Moyer comes to the ambulatory health center for a routine assessment. After her examination, you suspect rheumatoid arthritis. Which of the following characteristics differentiates rheumatoid arthritis from other MS conditions? A. Stiffness associated with RA occurs mostly at night. B. Pain associated with RA is worse at night. C. RA involves symmetric joints. D. Activity increases pain in the RA-affected joint.

C. RA involves symmetric joints.

A visitor from Poland who does not speak English seems to be somewhat apprehensive about the nurse examining his neck. He would probably be more comfortable with the nurse examining his thyroid from: A. behind with the nurses hand placed firmly around his neck B. the side with the nurses eyes averted toward the ceiling and thumbs on his neck C. The front with the nurses thumbs placed on either side of his trachea and his head tilted forward D. The front with the nurses thumbs placed on either side of this trachea and his head tilted backward

C. The front with the nurses thumbs placed on either side of his trachea and his head tilted forward

The divisions of the spinal vertebrae include which of the following? A. Cervical, thoracic, and scaphoid B. Scapular, clavicular, and lumbar C. Thoracic, lumbar, and coccygeal D. Cervical, lumbar, and iliac

C. Thoracic, lumbar, and coccygeal

Today is your last day of an emergency room (ER) rotation. A mother brings her 3-year-old child to the ER to be examined after a fall. The child is dressed in clothing that, although clean, is worn and wrinkled. The child sits quietly without fidgeting, arms in her lap, staring at the floor; she remains silent when you try to engage her. As her mother explains the circumstances of the fall and the resulting injuries, you wonder about the possibility of physical abuse. An x-ray is ordered to rule out fracture of the left arm. Which of the following physical findings might suggest abuse? A. An x-ray depicting a simple fracture of the left arm B. A skinned knee with torn pants midway down same leg C. Three bite marks on the right upper arm/shoulder area D. None of the above

C. Three bite marks on the right upper arm/shoulder area

Mr. Turner is a 43-year-old patient who presents for a yearly physical examination. On exam you note balanitis associated with phimosis. Which individual is this most likely to occur in? A. Newborn male infants B. Diabetic men C. Uncircumcised men D. Men exposed to radiation

C. Uncircumcised men

The nurse notices that a patients palpebral fissures are not symmetric. On examination, the nurse may find that damage has occurs with which CN? A. III B. V C. VII D. VIII

C. VII Facial muscles are mediated by CN VII; asymmetry of palpebral fissure may be attributable to damage to CN VII (Bell palsy)

A newborn infant is in the clinic for a well-baby checkup. The nurse observes the infant for the possibility of fluid loss because of which of these factors? A. subcutaneous fat deposits are high in the newborn B. sebaceous glands are overproductive in the newborn C.the newborns skin is more permeable than that of the adult D. the amount of vernix caseosa dramatically rises in the newborn.

C. the newborns skin is more permeable than that of the adult.

The nurse needs to palpate the temporomandibular joint for crepitation. This joint is located just below the temporal artery and anterior to the: A. hyoid bone B. vagus nerve C. tragus D. mandible

C. tragus

The joint is the functional unit of the musculoskeletal system and is the point at which: A. the tendon is attached to the bone. B. cartilage meets bone. C. two or more bones are joined. D. the bursa is interconnected with bone.

C. two or more bones are joined.

The sloughing of necrotic inflammatory tissue that causes a deep depression in the skin that extends into the dermis is called: A. gangrene. B. dermanecrosis. C. ulceration. D. maceration.

C. ulceration.

Cryptorchidism is: A. an advanced and fixed foreskin too tight to retract over the glans. B. a circumscribed collection of serous fluid in the tunica vaginalis surrounding the testes. C. undescended testes. D. hard, subcutaneous plaques associated with painful bending of the erect penis.

C. undescended testes.

An example of a primary lesion is a(n): A. erosion. B. ulcer. C. urticaria. D. port-wine stain.

C. urticaria.

Thorax and lungs 20. posterior apex b. Which vertebrae?

A 19-year-old woman comes to the clinic at the insistence of her brother. She is wearing black combat boots and a black lace nightgown over the top of her other clothes. Her hair is dyed pink with black streaks throughout. She has several pierced holes in her nares and ears and is wearing an earring through her eyebrow and heavy black makeup. The nurse concludes that: a. She probably does not have any problems. b. She is only trying to shock people and that her dress should be ignored. c. She has a manic syndrome because of her abnormal dress and grooming. d. More information should be gathered to decide whether her dress is appropriate.

A 20-year-old construction worker has been brought into the emergency department with heat stroke. He has delirium as a result of a fluid and electrolyte imbalance. For the mental status examination, the nurse should first assess the patient's: a. Affect and mood b. Memory and affect c. Language abilities d. Level of consciousness and cognitive abilities

A 23-year-old patient in the clinic appears anxious. Her speech is rapid, and she is fidgety and in constant motion. Which of these questions or statements would be most appropriate for the nurse to use in this situation to assess attention span? a. "How do you usually feel? Is this normal behavior for you?" b. "I am going to say four words. In a few minutes, I will ask you to recall them." c. "Describe the meaning of the phrase, 'Looking through rose-colored glasses.'" d. "Pick up the pencil in your left hand, move it to your right hand, and place it on the table."

A 26-year-old woman was robbed and beaten a month ago. She is returning to the clinic today for a follow-up assessment. The nurse will want to ask her which one of these questions? a. "How are things going with the trial?" b. "How are things going with your job?" c. "Tell me about your recent engagement!" d. "Are you having any disturbing dreams?"

The nurse is describing a scaphoid abdomen. To the horizontal plane, a scaphoid contour of the abdomen depicts a _____ profile. A) flat B) convex C) bulging D) concave

D) concave Contour describes the profile of the abdomen from the rib margin to the pubic bone; a scaphoid contour is one that is concave from a horizontal plane. See Figure 21-7. REF: Page: 536

Mrs. Gilder is a 32-year-old patient who presents to the office for a health assessment. On examination, you note a positive Chadwick's sign. This is: A. an aberrant growth of endometrial tissue. B. a cervical mucous plug. C. the absence of menstruation. D. a bluish discoloration of the cervix.

D. a bluish discoloration of the cervix.

You are conducting an in-service on aging skin for nurses and students assigned to a medical floor at the local hospital. Which of the following pieces of information is essential for your in-service to include? A. The loss of collagen increases the risk of shearing, tearing injuries. B. Thinning and flattening of the stratum corneum increases absorption of chemicals. C. Diminished vascularity and increased vascular fragility lead to senile purpura. D. All of the above

D. All of the above

Bowel sounds are: A. high pitched. B. air and fluid moving through the small intestine. C. irregular. D. All of the above.

D. All of the above.

Essential components of a patient history for dermatology disorders include: A. a previous history of skin disorders plus symptom analysis (or HPI) of current problems and allergies. B. self-care behaviors, occupation, and hobbies. C. prescribed medications, over-the-counter medications, herbs, and substance use. D. All of the above.

D. All of the above.

Jesse Carter, a student nurse, has been assigned to teach fourth-graders about hygiene. Part of her lesson will focus on the apocrine glands. Which of the following statements is true? A. The apocrine glands, a type of sweat gland, are mainly located in the axillae, anogenital area, nipples, and navel. B. These glands produce a thick, milky secretion and open into the hair follicles. C. The apocrine glands become active during puberty and decrease functioning in aging adults. D. All of the above.

D. All of the above.

Jesse Carter, a student nurse, has been assigned to teach fourth-graders about hygiene. She decides to begin the teaching module with a short lecture on the skin. Which of the following facts will Jesse include while discussing the skin's protective and adaptive properties? A. The skin regulates body temperature. Heat is stored in fat pads or released through sweating. B. The skin protects against infection. Normal skin flora fights off the invasion of microorganisms that can enter the body and cause infection. C. The skin is an organ of excretion. It removes a significant amount of metabolic wastes, which are the byproducts of cellular decomposition such as minerals and urea. D. All of the above.

D. All of the above.

Lichenification is/are: A. tightly packed sets of papules. B. thickening of the skin. C. due to prolonged, intense scratching. D. All of the above.

D. All of the above.

The right lower quadrant of the abdomen contains which of the following organs? A. Duodenum B. Liver C. Sigmoid colon D. Appendix

D. Appendix

Mrs. Stevens is a 43-year-old patient who presents with multiple complaints and a concern that her husband was diagnosed with syphilis. Which of the following is a sign of syphilis? A. Caruncle B. Cystocele C. Polyp D. Chancre

D. Chancre

Mr. Cook is a 53-year-old patient who comes to the clinic for routine follow-up for his chronic obstructive pulmonary disease (COPD). Which of the following is indicative of COPD? A. Acrocyanosis B. Circumoral cyanosis C. Pitting of nails D. Clubbing of nails

D. Clubbing of nails

Mr. Liggett is a 42-year-old patient who presents with a painful left testicle. On examination you note abnormal dilation and tortuosity of the veins along the spermatic cord. Which of the following conditions best describes this clinical finding? A. Varicocele B. Priapism C. Hypospadias D. Epididymitis

D. Epididymitis

The rotator cuff of the body is associated with which of the following joints? A. Radiocarpal joint B. Temporomandibular joint C. Acetabular joint D. Glenohumeral joint

D. Glenohumeral joint

Which of the following terms is used to describe the number of pregnancies? A. PAL B. Parosity C. Para D. Gravida

D. Gravida

Skeletal muscle is differentiated from other types of muscle by which of the following characteristics? A. It is involuntary in its activity. B. It is semivoluntary in nature. C. It is under contractual regulation. D. It is under voluntary control.

D. It is under voluntary control.

Jesse Carter, a student nurse, has been assigned to teach fourth-graders about hygiene. While preparing, Jesse adds information about the sweat glands. Which of the following will Jesse include while discussing this topic? A. There are two types of sweat glands: the eccrine and the sebaceous. B. The evaporation of sweat, which is a dilute saline solution, increases body temperature. C. Eccrine glands produce sweat and are mainly located in the axillae, anogenital area, and navel. D. Newborn infants do not sweat; they use compensatory mechanisms to control body temperature.

D. Newborn infants do not sweat; they use compensatory mechanisms to control body temperature.

The liver is: A. a soft, lobulated gland behind the stomach. B. a soft mass of lymphatic tissue on the postlateral wall. C. a bean-shaped, retroperitoneal gland. D. None of the above.

D. None of the above.

A 24-year-old man has scrotal pain and marked erythema. The examiner considers epididymitis. What finding is consistent with this problem? A. An uneven scrotal size and shape is observed. B. The patient has anorexia and nausea. C. The patient reports an acute onset of severe pain. D. Urinalysis shows elevated WBCs and bacteria.

D. Urinalysis shows elevated WBCs and bacteria.

Mr. Harrison is a 28-year-old patient who presents to your office urgently with a concern of a penile erection that has not subsided. Which of the following is a prolonged penile erection that is often painful (most cases are idiopathic)? A. Paraphimosis B. Phimosis C. Spermatocele D. Priapism

D. Priapism

Paraurethral glands are also called: A. Bartholin's glands. B. Hegar's sign. C. Chadwick's sign. D. Skene's glands.

D. Skene's glands.

A mother brings in her 2 month old daughter in for an examination and says, my daughter rolled over against the wall, and now I have noticed that she has this spot that is soft on the top of her head. Is something terribly wrong? The nurses best response would be: A. Perhaps that could be the result of your dietary intake during pregnancy B. Your baby may have craniosynostosis, a disease of the sutures of the brain C. The soft spot may be an indication of cretinism or congenital hypothyroidism D. The soft spot is normal, and actually allows for growth of the brain during the first year of your baby's life.

D. The soft spot is normal, and actually allows for growth of the brain during the first year of your baby's life.

Viscera is the term given to: A. bowel obstruction. B. the midline longitudinal ridge in the abdomen. C. a proximal part of the large intestine. D. internal organs.

D. internal organs.

During an assessment, the nurse finds that a 5-year-old child has distorted speech. The child misuses certain words and omits other words while speaking. Which disorder does the nurse expect in the child? 1 Echolalia 2 Dysarthria 3 Dysphonia 4 Neologism

During an assessment, the nurse finds that an adolescent patient's body mass index is 18.4. The patient's caregiver states that the patient is extremely afraid of weight gain and barely eats for 4 days a week. Which disorder does the nurse suspect in the patient? 1 Bulimia nervosa 2 Anorexia nervosa 3 Autism spectrum disorder 4 Oppositional defiant disorder

During an initial interview, the examiner asks, "Mrs. J., tell me what you do when your headaches occur." With this question, the examiner is seeking information about: A the patient's perception of the problem. B the frequency of the problem. C the severity of the problem. D aggravating or relieving factors

During an interview, the nurse asks an older adult patient to describe childhood teachers, first job, and important dates in life. Which cognitive function is the nurse assessing in the patient? 1 Orientation 2 Attention span 3 Recent memory 4 Remote memory

Overweight defined as BMI of ____ or greater

You are examining a 35-year-old female patient. You note that she has had two full-term pregnancies, both babies delivered vaginally. You observe the following upon internal examination: Cervical os is a horizontal slit with some healed lacerations. The cervix has some Nabothian cysts that are small, smooth, and yellow. In addition, you notice that the cervical surface is granular and red, especially around the os. Finally, you note the presence of stringy, opaque, odorless secretions. Which of these findings are abnormal?

The cervical surface is granular and red.

The mental status examination: A. should be completed at the end of the physical examination. B. will not be affected if the patient has a language impairment. C. is usually not assessed in children younger than 2 years of age. D. assesses mental health strengths and coping skills and screens for any dysfunction.

3, 4, 5

What information should the nurse obtain from the patient's health history while assessing the cognitive status of that patient? Select all that apply. 1 Dietary habits 2 Exercise habits 3 Educational levels 4 Current medication 5 Current health problems

What is the nurse assessing when using the Glasgow Coma Scale? 1 Memory, computation, and level of consciousness 2 Reading, writing, and knowing factual information 3 Level of consciousness and involuntary movement 4 Eye opening, verbal response, and motor response

What step of the nursing process includes data collection by health history, physical examination, and interview? a. Planning b. Diagnosis c. Evaluation d. Assessment

When assessing the pulse, which of the following are included? A Rate, rhythm, and force. B Rate, rhythm, tempo, and presence of skipped beats. C Rate, rhythm, force and strength. D Rate, rhythm, tempo

10. How sensitive to pressure are normal testes? a. somewhat b. not at all c. left is more sensitive than right d. only when inflammation is present

10. During percussion, the nurse knows that a dull percussion note elicited over a lung lobe most likely results from: (5 pts) A. shallow breathing B. increased density of lung tissue C. normal lung tissue D. decreased adipose tissue

10. Select the best description of the uterus. a. anteverted, round asymmetric organ b. pear-shaped, thick-walled organ flattened anteroposteriorly c. retroverted, almond-shaped asymmetric organ d. midposition, thick-walled oval organ

11. In placing a finger on either side of the cervix and moving it side to side, you are assessing: a. the diameter of the fallopian tube. b. cervical motion tenderness. c. the ovaries. d. the uterus

12. An adhesion of the prepuce to the head of the penis, making it impossible to retract, is: a. paraphimosis. b. phimosis. c. smegma. d. dyschezia

Breasts and Regional Lymphatics 10. During the examination of the breasts of a pregnant woman, you would expect to find: a. peau d'orange. b. nipple retraction. c. a unilateral, obvious venous pattern. d. a blue vascular pattern over both breasts.

12. During an assessment, the nurse knows that expected findings in the normal adult lung include presence of: (5 pts) A. increased tactile fremitus and dull percussion tones B. muffled voice sounds and symmetrical tactile fremitus C. adventitious sounds and limited chest expansion D. absent voice sounds and hyperresonant percussion tones

12. When listening to heart sounds, the nurse knows that the valve closures that can be heard at the base of the heart are: (5 pts) A. aortic and pulmonic B. aortic and pulmonic C. tricuspid and aortic D. mitral and tricuspid

Heart and neck vessels 5. The second heart sound is the result of: a. opening of the mitral and tricuspid valves. b. closing of the mitral and tricuspid valves. c. opening of the aortic and pulmonic valves. d. closing of the aortic and pulmonic valves.

Breasts and Regional Lymphatics 13. Any lump found in the breast should be referred for further evaluation. A benign lesion will usually have 3 of the following characteristics. Which one is characteristic of a malignant lesion? a. soft b. well-defined margins c. freely movable d. irregular shape

When performing a genitourinary assessment on a 16-year-old boy, you notice a swelling in the scrotum that increases with increased intraabdominal pressure and decreases when he is lying down. The patient complains of pain when straining. This description is most consistent with:

an indirect inguinal hernia.

polycyclic

annular lesions grow together (psoriasis)

Heart and Neck vessels 16. S1 is best heard where in the heart? S2 is loudest where in the heart?

apex base

7. An adult patient with a history of allergies comes to the clinic complaining of wheezing and difficulty in breathing when working in his yard. The assessment findings include tachypnea, use of accessory neck muscles, prolonged expiration, intercostal retractions, decreased breath sounds, and expiratory wheezes. The nurse interprets that these assessment findings are consistent with: (5 pts)

asthma

Heart and neck vessels 19. _____: reservoir for holding blood

atrium

1. The nurse is preparing for a class on risk factors for hypertension, and reviews recent statistics. Which racial group has the highest prevalence of hypertension in the world? (5 pts) A. whites B. african-americans C. hispanics D. american indians

10. A client is suspected of having inflammation of the gallbladder, or cholecystitis. The nurse should conduct which of these techniques to assess for this condition? (5 pts) A. assess for rebound tenderness B. test for Murphy's sign C. obturator test D. iliopsoas test

12. The nurse is reviewing venous blood flow patterns. Which of these statements best describes the mechanism(s) by which venous blood returns to the heart? (5 pts) A. Contracting skeletal muscles milk blood distally toward the veins. B. Increased thoracic pressure and decreased abdominal pressure facilitate venous return to the heart. C. Intraluminal valves ensure unidirectional flow toward the heart. D. The high-pressure system of the heart helps to facilitate venous return.

13. Tenderness during abdominal palpation is expected when palpating: a. the liver edge. b. the spleen. c. the sigmoid colon. d. the kidneys

18. During an assessment of a 68-year-old man with a recent onset of right-sided weakness, the nurse hears a blowing, swishing sound with the bell of the stethoscope over the left carotid artery. This finding would indicate: (5 pts) A. fluid volume overload B. ventricular hypertrophy C. blood flow tubulence D. a valvular disorder

2. A 45-year-old man is in the clinic for a routine physical. During the history the patient states he's been having difficulty sleeping. "I'll be sleeping great and then I wake up and feel like I can't get my breath." The nurse's best response to this would be: (5 pts) A. "When was your last electrocardiogram?" B. "It's probably because it's been so hot at night." C. "Do you have any history of problems with your heart?" D. "Have you had a recent sinus infection or upper respiratory infection?"

2. The nurse is observing the auscultation technique of another nurse. The correct method to use when progressing from one auscultatory site on the thorax to another is ____ comparison.` (5 pts) A. top to bottom B. posterior to anterior C. side to side D. interspace by interspace

2. Which of the following may be noted through inspection of the abdomen? a. fluid waves and abdominal contour b. umbilical eversion and Murphy sign c. venous pattern, peristaltic waves, and abdominal contour d. peritoneal irritation, general tympany, and peristaltic waves

20. The nurse is assessing the apical pulse of a 3-month-old infant and finds that the heart rate is 135 beats per minute. The nurse interprets this result as: (5 pts) A. higher than expected, reflecting persistent tachycardia B. lower than expected C. normal for this age D. higher than expected, probably as a result of crying

Heart and neck vessels 3. The function of the pulmonic valve is to: a. divide the left atrium and left ventricle. b. guard the opening between the right atrium and right ventricle. c. protect the orifice between the right ventricle and the pulmonary artery. d. guard the entrance to the aorta from the left ventricle.

16. What color stools indicate the presence of occult blood (melena) from bleeding higher in the GI tract?

black

During a health history of a patient who complains of chronic constipation, the patient asks the nurse about high-fiber foods. The nurse relates that an example of a high-fiber food would be:

broccoli. ANS:A Pages: 712-713. High-fiber foods are either soluble type (i.e., beans, prunes, barley, broccoli) and insoluble type (i.e., cereals, wheat germ). The other examples are not considered high-fiber foods.

1. Select the sequence of techniques used during an examination of the abdomen. a. percussion, inspection, palpation, auscultation b. inspection, palpation, percussion, auscultation c. inspection, auscultation, percussion, palpation d. auscultation, inspection, palpation, percussion

1. The examiner is going to inspect and palpate for a hernia. During this examination, the man is instructed to: a. hold his breath during palpation. b. cough after the examiner has gently inserted the examination finger into the rectum. c. bear down when the examiner's finger is at the inguinal canal. d. relax in a supine position while the examination finger is inserted into the canal.

11. The findings from an assessment of a 70-year-old client with swelling in his ankles include jugular venous pulsations 5 cm above the sternal angle when the head of the bed is elevated to 45 degrees. The nurse knows this finding indicates: (5 pts) A. decreased fluid volume B. increased cardiac output C. elevated pressure related to heart failure D. narrowing of the jugular veins

Peripheral Vascular System and Lymphatics 3. Ms. T. has come for a prenatal visit. She complains of dependent edema, varicosities in the legs, and hemorrhoids. The best response is: a. "If these symptoms persist, we will perform an amniocentesis." b. "If these symptoms persist, we will discuss having you hospitalized." c. "The symptoms are caused by the pressure of the growing uterus on the veins. They are usual conditions of pregnancy." d. "At this time, the symptoms are a minor inconvenience. You should learn to accept them."

Peripheral Vascular System and Lymphatics 5. Inspection of a person's right hand reveals a red, swollen area. To further assess for infection, you would palpate the: a. cervical node. b. axillary node. c. epitrochlear node. d. inguinal node.

Thorax and Lungs 12. When examining for tactile fremitus, it is important to: a. have the patient breathe quickly. b. ask the patient to cough. c. palpate the chest symmetrically. d. use the bell of the stethoscope.

Thorax and Lungs 14. A pleural friction rub is best detected by: a. observation. b. palpation. c. auscultation. d. percussion.

Thorax and Lungs 5. Absence of diaphragmatic excursion occurs with: a. asthma. b. an unusually thick chest wall. c. pleural effusion or atelectasis of the lower lobes. d. age-related changes in the chest wall.

Thorax and Lungs 9. Upon examining a patient's nails, you note that the angle of the nail base is >160 degrees and that the nail base feels spongy to palpation. These findings are consistent with: a. adult respiratory distress syndrome. b. normal findings for the nails. c. chronic congenital heart disease and COPD. d. atelectasis.

13. The nurse is assessing a patient's apical impulse. Which of these statements is true regarding the apical impulse? (5 pts) A. it is palpable in all adults B. it should normally be palpable in the anterior axillary line C. it occurs with the onset of diastole D. its location may be indicative of heart size

14. A patient has a long history of chronic obstructive pulmonary disease. During the assessment, the nurse is most likely to observe which of these? (5 pts) A. increased tactile fremitus B. unequal chest expansion C. atrophied neck and trapezius muscles D. an anteroposterior-to-transverse diameter ratio of 1:1

15. A positive Blumberg sign indicates: a. a possible aortic aneurysm. b. the presence of renal artery stenosis. c. an enlarged, nodular liver. d. peritoneal inflammation

15. In the aging male, when does infertility occur? a. At age 60, with the sudden decline in sperm production. b. At approximately age 55 to 60, when testosterone levels are lower. c. When the male is not longer able to achieve an erection. d. There is no specific age; men may be fertile into their 80s and 90s

Breasts and Regional Lymphatics 1. The reservoirs for storing milk in the breast are: a. lobules b. alveoli c. Montgomery's glands d. lactiferous sinuses

10. The mother of a 3-month-old infant states that her baby has not been gaining weight. With further questioning, the nurse finds that the infant falls asleep after nursing and wakes up after a short amount of time, hungry again. What other information would the nurse want to have? (5 pts) A. sibling history of eating disorders B. amount of background noise when eating C. the infant's sleeping position D. presence of dyspnea or diaphoresis when sucking

When performing a genitourinary assessment, you note that the urethral meatus is positioned ventrally. This is:

called hypospadius.

Heart and neck vessels 16. S1 coincides with the pulse of the ____ artery and coincides with the ___ wave if the patient is on an ECG monitor.

carotid, R

During an examination, a patient has just successfully completed the finger-to-nose and the rapid-alternating-movements tests and is able to run each heel down the opposite shin. The nurse will conclude that the patient's ____ function is intact.

cerebellar ANS: D Pages: 769-770. The nurse should test cerebellar function of the upper extremities by using the finger-to-nose test or rapid-alternating-movements test. The nurse should test cerebellar function of the lower extremities by asking the person to run each heel down the opposite shin.

spoon (concave)

chronic iron deficiency anemia may show ______ nails. fatigue, exertional dyspnea, rapid pulse, dizziness, and impaired mental function also accompany severe anemias.

Heart and neck vessels 6. The examiner has estimated the jugular venous pressure. Identify the finding that is abnormal. a. patient elevated to 30 degrees, internal jugular vein pulsation at 1 cm above sternal angle b. patient elevated to 30 degrees, internal jugular vein pulsation at 2 cm above sternal angle c. patient elevated to 40 degrees, internal jugular vein pulsation at 1 cm above sternal angle d. patient elevated to 45 degrees, internal jugular vein pulsation at 4 cm above sternal angle

Peripheral Vascular System and Lymphatics 10. A 54-year-old woman with five children has varicose veins of the lower extremities. Her most characteristic sign is: a. reduced arterial circulation. b. blanching, deathlike appearance of the extremities on elevation. c. loss of hair on feet and toes. d. dilated, tortuous superficial bluish vessels.

Peripheral Vascular System and Lymphatics 8. While reviewing a medical record, a notation of 4+ edema of the right leg is noted. The best description of this type of edema is: a. mild pitting, no perceptible swelling of the leg. b. moderate pitting, indentation subsides rapidly. c. deep pitting, leg looks swollen. d. very deep pitting, indentation lasts a long time.

Peripheral Vascular System and Lymphatics 6. To screen for deep vein thrombosis, you would: a. measure the circumference of the ankle. b. check the temperature with the palm of the hand. c. compress the dorsalis pedis pulse, looking for blood return. d. measure the widest point with a tape measure.

Thorax and Lungs 10. Upon examination of a patient, you note a coarse, low-pitched sound during both inspiration and expiration. This patient complains of pain with breathing. These findings are consistent with: a. fine crackles. b. wheezes. c. atelectatic crackles. d. pleural friction rub.

A patient's annual physical examination reveals a lateral curvature of the thoracic and lumbar segments of his spine; however, this curvature disappears with forward bending. This abnormality of the spine would be called:

functional scoliosis.

tinea capitis (ringworn)

grey, scaly, well defined areas of broken hairs accompany _______

Thorax and Lungs 17. base a. rests on the ____

diaphragm

Heart and neck vessels 18. ______: thin layer of endothelial tissue that lines the inner surface of the heart chambers and valves

endocardium

The nurse is discussing breast self-examination with a postmenopausal woman. The best time for postmenopausal women to perform breast self-examination is:

the same day every month. ANS: A Page: 398. Postmenopausal women are no longer experiencing regular menstrual cycles but need to continue to perform breast self-examination on a monthly basis. Choosing the same day of the month is a helpful reminder to perform breast self-examination.

The main reason auscultation precedes percussion and palpation of the abdomen is:

to prevent distortion of bowel sounds that might occur after percussion and palpation.

confluent (runs together)

urticaria is class'd as what shape?

Heart and neck vessels 21. ______: muscular pumping chamber

ventricle

hyperresonance

what kind of percussion sounds would you expect to hear in emphysema and pneumothorax?

Dull

what kind of percussion sounds would you expect to hear in pneumonia, pleural effusion, atelectasis, and tumors?

urticaria (hives)

wheals coalesce to form extensive reaction. pruritic.

secondary

when a lesion changes over time or changes bc of scratching or infection, it is________

primary

when a lesion develops on previously unaltered skin, it is______

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