200 quizzes

A malignant skin lesion will have different colors, irregular borders and asymmetrical. true false

true

A nurse is assessing a client for gait abnormalities. The nurse asks the client to walk across the room. True False

true

A tympanic temperature is slightly higher than an oral temperature. true false

true

Abnormal lung sounds are called adventitious breath sounds. True False

true

Abnormalities of the retinal vessels can provide information about disease progression in diabetes and hypertension. true false

true

An example of a health disparity is the higher incidence of diabetes is greater in African American cultures compared to the white American culture. True False

true

Diabetes mellitus can be a modifiable risk factor for prevention of coronary heart disease. True False

true

Erectile dysfunction in men is a common early manifestation of venous disease. True False

true

Fissures are linear cracks in the skin. true false

true

Health screenings are a major part of secondary health promotion. true false

true

Kussmaul respirations are a type of hyperventilation associated with diabetic ketoacidosis. True False

true

Normal respirations with an equal rate and depth is called Eupnea. true false

true

Presence of tingling and or pain while placing the backs of both hands together while flexing her wrists 90-degrees with finger pointed down and wrist dangling is a sign of carpal tunnel syndrome. True False

true

Pustule is a vesicle that is filled with cloudy fluid. true false

true

The greater the exposure of your eyes to ultraviolet radiation from the sun, the greater the risk for the development of cataracts and macular degeneration. true false

true

The leading causes of chronic illnesses in the middle adult years are rheumatoid arthritis, obesity, alcoholism, and depression True Falae

true

The nurse is palpating the snuff box and knows the anatomical position is at the back of the wrist and extended thumb. True False

true

The nurse should auscultate bowel sounds at least one minute per quadrant. True False

true

The overall impression of a client gives the nurse the opportunity to "see" the patient knowingly or unknowingly, may mask it. true false

true

Toddlers can understand self as separate from others and have a beginning perception of body images. True False

true

When assessing fremitus on a client, avoid palpating the breast tissue. Breast tissue dampens the vibrations. True False

true

When using a Doppler to assess for peripheral pulses, you would expect to hear a whooshing sound that represents the peripheral pulse. True False

true

______________ refers to the skin's elasticity and how quickly the skin recoils

turgor

_________ are typically painless and occur in the lower leg or medial ankle.

venous ulcers

The movement of air in and out of the lung is _____________.

ventilation

The subarachnoid space is filled with cerebrospinal fluid formed in the _________ of the brain

ventricles

Elevated, irregular and transient areas of dermal edema. Can be seen in allergic reactions ________________________

wheels

While auscultating a 65-year-old male's heart rate and rhythm, the nurse detects an irregular pattern. The nurse should: a. refer the client to a physician b. assess the client for signs and symptoms of diminished P2 c. document this as a normal finding d. schedule the client for an ECG

a. refer client to a physician

The nurse is teaching a health education class on male reproductive anatomy and asks the students to identify the site of sperm production. Which structure, if identified by the group, would indicate to the nurse that the teaching was successful? a. testes b. seminal vesicles c. scrotum d. prostate gland

a. testes

The nurse is assessing the breasts of a Caucasian woman who has just been diagnosed with Paget disease. What would the nurse expect to find? a. Orange-peel skin b. Nipple retraction c. Dark pink areola d. Red and scaling on the areola

d. red and scaling on the areola

The nurse is preparing to inspect a woman's breasts for retraction and dimpling. Which position would be most appropriate? a. Standing b. Supine c. Semi-Fowler d. Sitting

d. sitting

The nurse is creating a diagram that illustrates the components of the male reproductive system. Which structure would be inappropriate for the nurse to include as an accessory gland? a. seminal vesicles b. prostate gland c. cowper's glands d. vas deferens

d. vas deferens

The average heart rate of a child _________ as age increases.

decreases

Normal respirations are called _________________ and range from 12-20 breaths per minute.

eupnea

n exaggerated thoracic curve that can lead to unsteady gait is ______________

kyphosis

The chronic disease is present but the person does not experience the symptoms _____________

remission

The nurse is assessing a client's breasts. When assessing the area of the breast most vulnerable to breast cancer, where should the nurse assess? a. Upper inner quadrant b. Lower inner quadrant c. Upper outer quadrant d. Lower outer quadrant

c. upper outer quadrant

These abnormal lung sounds are low pitched with bubbling, moist sounds. _________

crackles

Remission is when a chronic disease is present, but the person does not experience symptoms True False

true

Respirations greater than 24 breaths per minute. ______________

tachypnea

During palpation of the client's abdomen, the nurse feels a prominent, nontender, pulsating 6-cm mass above the umbilicus. What action should the nurse take? a. Refer the client to an oncologist b. Provide a dietician consult for the client c. Counsel the client regarding hernia repair d. Stop palpating and get medical assistance

d. Stop palpating and get medical assistance

The mnemonic used for further assessing pain is a. AVPU b. COLDSPA c. Pain d. Wongbaker faces

b. COLDSPA

________________ is usually the first symptom of peripheral artery disease.

intermittent claudications

The nurse is assessing the level of consciousness of a patient and uses the AVPU mnemonic to guide the assessment the nurse will elicit a __________ when the patient does not respond verbally.

painful stimuli

A itching type skin rash is called ______________

urticaria

The nursing student is assessing bowel sounds on a client returning from the operating room, the nursing student needs further instruction when stating a. The bowel sounds will be hyperactive when assessing because of the IV fluids infusing. b. The bowel sounds will be absent for the first few hours depending on the procedure. c. The colon will require 3-5 days to recover. d. The stomach takes 24-48 hours to resume motility.

a. The bowel sounds will be hyperactive when assessing because of the IV fluids infusing.

The ________ nervous system maintains the internal homeostasis of the body and incorporates the sympathetic and parasympathetic nervous system.

autonomic

The __________ nerve innervates the tongue muscles that promote the movement of food and enable talking.

hypoglossal

Chronic swelling and thickening of the metacarpophalangeal joints with finger deviation toward the ulnar side is seen in _____________

chronic rheumatoid arthritis

Encouraging patients to seek routine dental and vision care is what type of health promotion __________________

secondary

The nurse documents "Romberg test positive" on a client's medical record. The nurse would expect the patient to sway from side to side. True False

true

The psoas sign and obturator sign if positive can be a sign of appendicitis. True False

true

isceral pain occurs when hollow organs become distended or when the capsules of solid organs become stretched. True False

true

You are palpating your patient's thyroid gland. When you ask the patient to swallow, the gland moves ___________.

up

A 2-year-old grabs a handful of cake from the table and stuffs it in his mouth. According to Freud, what part of the mind is the child satisfying? a. Id b. Superego c. Ego d. Unconscious

a. Id

Which of the following actions produce the S2 heart sound? a. closing of the aortic and pulmonic valves b. opening of the aortic and pulmonic valves c. closing of the mitral and tricuspid valves d. opening of the mitral and tricuspid valves

a. closing of the aortic and pulmonic valves

Assessment of a client's lower extremities reveals unilateral edema of the right foot and ankle. What would the nurse do next? a. Compare measurements of both extremities. b. Perform the Allen test. c. Check for bilateral varicosities. d. Palpate the femoral pulses.

a. compare measurements of both extremities

The cerebrum is divided into right and left hemispheres, which are joined together by the a. corpus callosum. b. diencephalon. c. medulla oblongata. d. pons.

a. corpus callosum.

Lesions that are well defined with sharp borders are described as a. Circumscribed b. Diffuse c. Clustered d. Linear

a. circumscribed

Which of the following data from the health history of a 42 year old male should be further evaluated as a possible risk for hearing loss? a. "I watch TV in the evenings with my wife and children." b. "When I was younger I wore an earring." c. "My primary hobby is carpentry work." d. "I have been an accountant for 16 years for an insurance agency."

c. "My primary hobby is carpentry work."

Which pulse amplitude is considered normal? a. 0 b. 1+ c. 2+ d. 3+

c. 2+

The nurse has asked a client if she has noticed any lumps or swelling in her breasts. The client responds "yes." What would the nurse ask next? a. "Have any of the other women in your family had this happen?" b. "Has there been any corresponding change in your breast size?" c. "Does the lump change over the course of your menstrual cycle?" d. "What do you think is causing this change?"

c. "Does the lump change over the course of your menstrual cycle?"

Which question would be most important to ask when obtaining the nursing health history of a male client with extensive peripheral vascular disease? a. "What dietary supplements do you take?" b. "When was your last prostate exam for cancer?" c. "Have you experienced a change in your usual sexual activity?" d. "Have you had an electrocardiogram recently?"

c. "Have you experienced a change in your usual sexual activity?"

Which of the following most accurately defines "illness"? a. the inability to carry out normal activities of living b. a pathologic change in mind body structure and function c. the response of a person to a disease d. achieving maximum potential and quality of life.

c. the response of a person to a disease

Which female reproductive tract structure would the nurse describe to a group of young women as containing rugae that enable it to dilate during labor and birth? a. cervix b. fallopian tube c. vagina d. vulva

c. vagina

A high school nurse is counseling parents of teenagers who are beginning high school. All of these topics would be discussion topics except. a. The influence of peer groups b. The dangers of bullying behavior c. Water safety d. Eating disorders recognition e. Risk taking behavior dangers

c. water safety

______ hearing loss is related to something blocking or impairing the passage of vibrations to the inner ear.

conductive

The systolic reading of a blood pressure represents the ___________ of the ventricles.

contraction

Growth is an increase in body size, structure, and function, whereas ____________ is an orderly pattern of changes in structure, thoughts, feelings, or behaviors resulting from maturation, experiences, and learning.

development

The last sound you hear when assessing the blood pressure is called _____________.

diastolic

A history of smoking cigarettes is a cardiac disease risk factor. Name two other risk factors that should be explored when taking a health history for the cardiovascular system?

diet family history

Regular pattern characterized by varying depth and rate of respirations follow by periods of apnea. ___________________________

hyperventilations

The nurse is assessing a 12-year-old girl who has had her first menses. When reviewing the client's history, which event would the nurse expect to have most likely occurred last? a. evidence of pubic hair b. breast bud development c. growth spurt d. onset of menses

d. onset of menses

The nurse is performing an assessment of a client admitted to the emergency department in status asthmaticus. The nurse should carefully inspect which part of the body in an effort to differentiate central cyanosis from peripheral cyanosis? a. nail beds b. sclerae c. palms d. oral mucosa

d. oral mucosa

Which of the following statements about pleural friction rub is not true? a. It is identified as a creaking, grating sound. b. It can be a symptom of serious lung disease. c. Asking the patient to cough has no effect on the sound. d. The sound originates in the alveoli.

d. the sound originates in the alveoli

According to Erickson's theory of psychosocial development, the school-aged stage is characterized by the theme of _____________ versus inferiority.

industry

When lymph node enlargement exceeds 1 cm., the client is said to have ________.

lymphadenopathy

Impaired ROM and neck pain associated with fever, chills and headaches could be indicative of ___________

meningitis

After teaching a group of adolescent girls about female reproductive development, the nurse determines that teaching was successful when the girls state that menarche is defined as a woman's first a. sexual experience b. full hormonal cycle c. menstrual period d. sign of breast development

menstrual period

A pulse strength of 2+ is considered ___________ when assessing the radial pulse.

normal

Your client's head is symmetrical and proportionate to her body size. You would document this assessment using the descriptive term _______________________.

normocephalic

List one of the mechanisms the body uses to return blood from the periphery to the heart.

one way valves

Dry, shiny, hairless shins are signs of _____________________.

peripheral vascular disease

Low pitched, dry, grating sound much like crackles heard on inspiration and expiration. _____________________

pleural friction rub

_______ refers to the gradual hearing loss common after the age of 50 years.

presbycusis

Encouraging teenagers in a sex education to practice abstinence or to practice safe sex practices is what type of health promotion ______________

primary

High pitched musical sound heard primarily with expiration. ________________

rhonchi

Unequal leg lengths are associated with ___________

scoliosis

The rotation of the hand where the palm is up _________________

supination

The ___________ ("fight-or-flight" system) is activated during stress and elicits responses such as decreased gastric secretions, bronchial dilatation, increased pulse rate, and pupil dilation.

sympathetic nervous system

The referral of a woman to a support group after removal of a breast because of cancer is what type of health promotion ______________

tertiary

A nurse usually begins the hands-on physical examination by taking vital signs. true false

true

A person's economic status can affect their health outcomes. True False

true

Bowel sounds normally occur every 5-15 seconds. True False

true

By the end of infancy, birth weight usually triples and body length usually increases by 50%. True False

true

Diet, exercise, and immunizations are three examples of primary health promotion. True False

true

Epitrochlear nodes are located in the upper arm near the elbow. True False

true

Heart murmurs can be classified on the basis of their timing in the cardiac cycle as systolic or diastolic. True False

true

Medications can decrease the smell and taste in older people. true false

true

Older clients may experience coldness and color changes of their lower extremities instead of intermittent claudication when diagnosed with peripheral vascular disease. True False

true

One of the causes of a pericardial friction rub can be a regurgitant flow of blood through an incompetent heart valve. True False

true

The buccal mucosa should appear pink in light skinned clients and pigmentation increased in dark skinned clients. true false

true

The diastolic reading of a blood pressure is the resting phase of the ventricles. true false

true

The ascending colon, ureter and fallopian tube is located in the _______________. Use only abbreviations.

RLQ

The duodenum, the liver and the right ureter is located in the _____________. Use only abbreviations.

RUQ

A 32 year old woman has a 4 day history of a sore throat and difficulty swallowing. The nurse observes tonsils covered with yellow patches, and the tonsils are so large they fill the entire oropharynx and appear to be touching each other. The nurse documents: a. "Tonsils yellow and swollen." b. "Enlarged tonsils 4+ with yellow exudate." c. Strep infection to tonsils with 3 + swelling." d. "1+ edema of tonsils with pus."

b. "Enlarged tonsils 4+ with yellow exudate."

The nurse palpates a pulse of 72 bpm and irregular. How should the nurse follow-up with this finding. _____________

assess apical pulse

n some cases, an auditory, visual, or motor sensation called an _______ forewarns the client that a seizure is about to occur.

aura

You are auscultating the lungs of an adult patient on the medical unit. You note that over the posterior lower lobes you hear low-pitched, soft breath sounds, with inspiration being longer than expiration. You know that these are: a. sounds normally auscultated over the trachea. b. bronchial breath sounds and are normal in that location. c. vesicular breath sounds and are normal in that location. d. bronchovesicular breath sounds and are normal in that location.

c. vesicular breath sounds and are normal in that location

Characteristics of respiration include rate, rhythm, and ___________.

depth

A blood pressure of 105/75 mmHg is normal for an average adult. true flase

true

Percussion is assessing the tone in the abdomen and should elicit tympany as a normal finding. True False

true

Receding and ischemic gums with worn tooth surfaces are normal findings as a person ages true false

false

The ballottement test is used to inspect the clients knee when there is a suspect ligament tear. True False

false

The nurse should ask the client to smile and puff her cheeks when assessing cranial nerve XII. True False

false

When testing muscle strength, a client has difficulty moving her right arm against resistance. The nurse would defer further testing of the arm. True False

false

When testing sensory function of the Trigeminal Nerve (CN V), the nurse would assess light touch and pain. True False

false

When the aortic valve of the heart fails, pooling of the blood or venous stasis occurs. True False

false

The _________ connects the superficial vein with the deep veins.

perforator veins

The ABCDE features are used to assess what type of skin alteration. _________

skin cancer

The ovary and descending and sigmoid colon are located in the _______________. Use only abbreviations.

LLQ

The spleen, pancreas and transverse descending colon is located in the ________. Use only abbreviations.

LUQ

Match the assessment finding with the cause/symptom: 1. blue/dark red tympanic membrane 2. acute otitis media 3. perforated tympanic membrane 4. scarred tympanic membrane a. white spots and streaks indicate scarring from infection b. red, bulging membrane or absent light reflex c. blood behind eardrum due to trauma d. rupture from increased pressure such as untreated infection or trauma

1. Blue/Dark Red Tympanic Membrane- c. Blood behind eardrum due to trauma 2. Acute Otitis Media- b. Red, bulging membrane or absent light reflex 3. Perforated Tympanic Membrane- d. Rupture from increased pressure such as untreated infection or trauma 4. Scarred Tympanic Membrane- a. White spots and streaks indicate scarring from infection

Red raised areas that are normal signs of aging. ______________

cherry angiomas

The nurse is assessing a patient that is admitted to the medical surgical floor. The skin assessment reveals a redness in the patient's sacral area. The nurse needs to describe this wound for charting. Identify 3 assessments included in her charting.

Measurements See if the sacrum blanches after taking pressure off Pain of patient

The abbreviation PERRLA is commonly used when nurses and physicians in a variety of health care settings examine the pupils of the eye. Write out what the letters stand for in the blank provided.

P- pupils E- equal R- round R- reactive L- light A- accommodation

When the nurse is assessing a client's mental status as part of the neurological examination, which question would be most appropriate to ask? a. "Can you tell me where you are right now?" b. "Do you feel like crying often?" c. "Do you have a history of psychotic disorder?" d. "Can you tell me about your mood today?"

a. "Can you tell me where you are right now?"

While interviewing a teenage male client, the nurse reviews the various structures of the male genitalia. The client asks, "So what does this epididymis do?" What would the nurse include in the response? a. "It allows sperm to mature." b. "It transports sperm away from the testes." c. "It separates the testes from the scrotal wall." d. "It produces sperm and male sex hormones."

a. "It allows sperm to mature."

During assessment of the precordium, you detect the presence of a heave. Which of the following is the most accurate description of your finding? a. A lifting of the cardiac area observed over the left lower sternal border. b. A laterally displaced apical impulse c. Palpation of a fine vibration over the precordium d. None of the above

a. A lifting of the cardiac area observed over the left lower sternal border.

During the assessment of a patient who has developed cheilosis, you expect to find: a. Fissuring and cracking at the corners of the mouth b. Marked erythema of the hard and soft palates c. White plaques on the lateral borders of the buccal mucosa d. Raised painless lesions on the gingiva

a. Fissuring and cracking at the corners of the mouth

The nurse caring for infants in a hospital nursery knows that newborns continue to grow and develop according to individual growth patterns and developmental levels. Which terms describe these patterns? Select all that apply a. Orderly b. Simple c. Sequential d. Unpredictable e. Individualized

a. Orderly c. sequential e. individualized

A woman reports a sudden onset of spontaneous nipple discharge. What would the nurse do next? a. Refer the client for cytologic study of the discharge. b. Observe the breast for eversion of the nipples c. Reassure the woman that this is a result of hormonal fluctuations. d. Collect a sample for culture and sensitivity of testing.

a. Refer the client for cytologic study of the discharge.

A nurse is working with a client who is the victim of a shooting. The client has an increased pulse rate and pupil dilation and is clearly in stress. The nurse recognizes the "fight-or-flight" response in this client and understands that this represents an activation of which of the following? a. Sympathetic nervous system b. Parasympathetic nervous system c. Central nervous system d. Somatic nervous system

a. Sympathetic nervous system

The nurse is performing a routine assessment of a male client who has an artificial arm as a result of a plane crash several years earlier. How should the nurse best understand the client's health? a. Despite the loss of his limb, the client may consider himself to be healthy b. The client may be well, but his loss of limb means that he is unhealthy c. The loss of his limb prevents the client from achieving wellness, though he may be healthy. d. Because of the client's injury many years ago, it does not have a bearing on his health and wellness.

a. despite the loss of his limb, the client may consider himself to be healthy

What factor should a nurse include when discussing risk factors about breast cancer for a group of women? a. Early menarche b. One or more pregnancies before age 20 c. Consumption of a high-protein diet d. Early menopause

a. early menarche

A nurse caring for elderly patients in a long-term care facility encourages an older adult to reminisce about her past life events. This life review, according to Erikson, is demonstrating what developmental stage of the later adult years? a. Ego integrity b. Generativity c. Intimacy d. Initiative

a. ego integrity

A school nurse who is teaching a health course at the local high school is presenting information on human development and sexuality. When talking about the role of hormones in sexual development, which hormone does the nurse teach the class is the most important for developing and maintaining the female reproductive organs? a. estrogen b. progesterone c. androgens d. follicle-stimulating hormone

a. estrogen

A nurse caring for older adults in a long-term care facility knows that several physical changes occur in the aging adult. Which characteristics best describe these changes? Select all that apply. a. Fatty tissue is redistributed b. The skin is drier and wrinkles appear c. Cardiac output increases d. Muscle mass increases e. Hormone production increases f. Visual and hearing acuity diminishes

a. fatty tissue is redistributed b. the skin is drier and wrinkles appear f. visual and hearing acuity diminishes

During the physical exam, the nurse notes a very tender and painful, reddened, hot, and swollen metatarsophalangeal joint of the great toe. What would the nurse suspect? a. gouty arthritis b. rheumatoid arthritis c. degenerative joint disease d. Plantar fasciitis.

a. gouty arthritis

The roof of the mouth is divided into two parts known as the: a. Hard and soft palates b. Anterior and posterior palates c. Frontal and ethmoid arches d. Superior lingual and ethmoid arches

a. hard and soft palette

A client has large, pendulous breasts. What would be most appropriate to ensure better access while examining the client's breasts for retraction and dimpling? a. Have the client stand and lean forward b. Have the client lie on her side c. Have the client sit and then learn forward d. Have the client lie flat on her back

a. have the client sit and then lean forward

An adult client tells the nurse that his father died of a coronary attack at the age of 60. The nurse should explain to the client that one of the risk factors for heart disease is: a. high serum level of low-density lipoproteins b. low protein diets c. diets that are high in omega-3 vitamins d. high serum level of high-density lipoproteins

a. high serum level of low-density lipoproteins

A nurse is giving a talk to a local community group on health promotion and illness prevention. The nurse explains the different levels of promotion. Which of the following does the nurse include when talking about primary promotions? Select all that apply a. immunization clinics b. screenings for blood pressure c. recommending mammograms for women d. teaching about a healthy diet

a. immunization clinics d. teaching about a healthy diet

What phrase best describes health? a. Individually defined by each person b. Experienced by each person in exactly the same way c. The opposite of illness d. The absence of a disease

a. individually defined by each person

Which of the following is correct use of the stethoscope to auscultate breath sounds? a. Listen to at least one full respiration in each location. b. Listen as the patient inhales, then move your stethoscope to the next location during exhalation. c. Have the patient breath in and out rapidly. d. To protect modesty, you can auscultate through a hospital gown.

a. listen to at least one full respiration in each location

A nurse is conducting a class for a group of teenage girls about female reproductive anatomy and physiology. Which structures would the nurse include as an external female reproductive organ? Select all that apply. a. mons pubis b. labia c. vagina d. clitoris e. uterus

a. mons pubis b. labia d. clitoris

A nurse is providing a client with instructions on how to perform self-examination of the skin. The nurse would encourage the client to perform this examination at which frequency? a. monthly b. bi-monthly c. quarterly d. daily

a. monthly

A 14-year-old student tells the school nurse that he has been having trouble reading his school books since school began because "the print is blurry". Based on this history, the nurse suspects that he may have developed: a. Myopia b. Hyperopia c. Presbyopia d. Glaucoma

a. myopia

The nurse is preparing to examine an adult's distant visual acuity using a Snellen chart. The nurse should: a. Position the client 20 feet away from the chart. b. Ask the client to remove his glasses. c. Ask the client to read each line with both eyes open. d. Instruct the client to begin reading from the bottom of the chart.

a. position the client 20 feet away from the chart

The assessment reveals that an older adult client has osteomalacia. What would be most important to include in the clients teaching plan? a. practice risk prevention for fractures. b. keep exercise to a minimum to decrease pain c. minimize movement to maintain joint stability d. treat secondary arthritis proactively.

a. practice risk prevention for fractures.

While assessing the lungs of an adult client, the nurse plans to auscultate for voice sounds using Bronchophony. What is the expected normal finding? a. The voice is muffled. b. The voice may be heard and the actual "99" phrase is distinguishable c. Over areas of consolidation, the sound is louder d. The words are easily understood and louder over areas of increased density.

a. the voice is muffled

The normal tone elicited by percussion of the abdomen is termed a. Tympanic b. Resonance c. Dull d. Hyperresonance

a. tympanic

The nurse is preparing to palpate the breasts of a female client. Which technique should the nurse utilize during this aspect of assessment? a. Use the flat pads of three fingers. b. Use the fingertips of both hands. c. Gently pinch the skin between two fingers d. Use the palm of one hand

a. use the flat pads of three fingers

The nurse's inspection of a Caucasian client's lower extremities reveals a brownish coloration to the client's ankles and shins. The nurse should perform further assessments that address what health problem? a. Venous insufficiency b. Peripheral edema c. Coronary artery disease d. Raynaud phenomenon

a. venous insufficiency

A 42-year-old client says she does not perform breast self-examination because she believes that mammograms are more thorough. Which response by the nurse would be most appropriate? a. "You should do the examination. It's the best way to detect breast cancer early." b. "Be sure to have your breasts checked by a doctor and have a mammogram every year." c. "Mammograms don't always detect the lumps that you might feel." d. "Once you hit age 50, you really won't have a choice about doing them."

b. "Be sure to have your breasts checked by a doctor and have a mammogram every year."

Based on Erikson's theory, middle adults who do not achieve their developmental tasks may be considered to be in stagnation. Which statement is one example of this finding? a. "I am helping my parents move into an assisted-living facility." b. "I spend all of my time going to the doctor to be sure I am not sick." c. "I have enough money to help my son and his wife when they need it." d. "I earned this gray hair and I like it."

b. "I spend all of my time going to the doctor to be sure I am not sick."

During the health history, a young male client asks the nurse why his scrotum rises and relaxes. The nurse would include which statement when responding to the client? a. "When the temperature is warm, it causes the scrotum to rise." b. "The cremasteric reflex controls the rise and relaxation of the scrotum." c. "When the scrotum is in a relaxed state, it has many rugae." d. "When the temperature is colder, the scrotum relaxes."

b. "The cremasteric reflex controls the rise and relaxation of the scrotum."

Where on the tympanic membrane does the cone of light reflect in the right ear? a. 4 o'clock b. 5 o'clock c. 6 o'clock d. 7 o'clock

b. 5 o'clock

When evaluating a client's risk for cerebrovascular accident, which client would the nurse identify as being at highest risk? a. 42-year-old Caucasian woman who smokes b. 68-year-old African American male with hypertension c. 55-year-old Caucasian male who has two beers a week d. 35-year-old African American who has sleep apnea

b. 68-year-old African American male with hypertension

The nurse examines a patient's auditory canal and tympanic membrane with an otoscope. Which of the following is considered an abnormal finding? a. The presence of cerumen. b. A yellow or amber color to the tympanic membrane. c. The presence of a cone of light. d. A shiny, translucent tympanic membrane.

b. A yellow or amber color to the tympanic membrane.

A client's bladder is distended. At which location should the nurse begin palpating? a. At the umbilicus b. At the symphysis pubis c. In the right lower quadrant d. In the left lower quadrant

b. At the symphysis pubis

While auscultating the apical pulse of a 16-year-old, you note an irregular rhythm. His heart rate speeds up slightly with inspiration and slows slightly with expiration. What would be your best response? a. Assess the client's caffeine intake b. Auscultate for a systolic murmur at the 4th ICS, left sternal border c. Understand that this is a common finding in young adults d. Repeat the apical pulse assessment at the end of your exam

b. Auscultate for a systolic murmur at the 4th ICS, left sternal border

While inspecting the lower extremities of a client, the nurse observes an ulcer. What would lead the nurse to suspect that the ulcer is the result of arterial insufficiency? Select all that apply. a. Irregular border b. Deep c. Circular in shape d. Moderate leg edema e. Client reports of severe pain

b. Deep c. Circular in shape e. Client reports of severe pain

The nurse is performing the Allen test on a client who has a diagnosis of peripheral vascular disease. What action should the nurse take after a positive Allen test? a. Document the absence of dorsalis pedis or posterior tibial pulses. b. Document the lack of patency in the ulnar and/or radial arteries. c. Attempt to palpate the popliteal pulse with the client's leg in a dependent position. d. Corroborate the finding by assessing capillary refill in the client's great toes.

b. Document the lack of patency in the ulnar and/or radial arteries.

A client has sought care because of chronic constipation. During the health history interview, the nurse should address what potential contributing factor? a. Excessive fat and sugar intake b. Overuse of laxatives c. Obesity d. Inadequate abdominal muscle tone

b. Overuse of laxatives

The direction of blood flow through the heart is best described by which of the following? a. Vena cava → right atrium → right ventricle → lungs → pulmonary artery → left atrium → left ventricle b. Right atrium → right ventricle →pulmonary artery →lungs→ pulmonary vein→ left atrium→ left ventricle c. Aorta →right atrium→ right ventricle→ lungs→ pulmonary vein→ left atrium→ left ventricle→ vena cava d. Right atrium→ right ventricle→ pulmonary vein→ lungs →pulmonary artery→ left atrium→ left ventricle

b. Right atrium → right ventricle →pulmonary artery →lungs→ pulmonary vein→ left atrium→ left ventricle

The nurse is planning a presentation to a group of adults on the topic of strokes. Which of the following should the nurse plan to include in the teaching plan? a. Strokes are the number one cause of death in the United States. b. Smoking and high cholesterol levels are risk factors for STROKE. c. Clients who smoke while taking oral contraceptives are not at higher risk. d. Postmenopausal women taking estrogen are at greater risk for STROKE.

b. Smoking and high cholesterol levels are risk factors for STROKE.

A nursing instructor is observing a nursing student assess a client's capillary refill. Which action by the student indicates the proper technique? a. Student gently compresses the wrist area on the side of the thumb. b. Student compresses the client's nail bed until it blanches. c. Student applies firm pressure to the hand, noting any indentation. d. Student asks the client to turn hands slowly over and back.

b. Student compresses the client's nail bed until it blanches.

The nurse is assessing the gastrointestinal system of an 81-year-old client. What age related change should the nurse consider when collecting and analyzing assessment data? a. The client is more vulnerable to impaired nutrition due to decreased appetite. b. The client derives less nutritional value from food because of decreased enzyme production. c. The client's liver will be significantly larger than that of a younger client. d. The client will have greater bowel motility than a younger adult.

b. The client derives less nutritional value from food because of decreased enzyme production.

With which of the following patients would it be most appropriate to use games during the assessment, such as having the patient "blow out" the light on the penlight? a. an infant b. a preschool child c. a school-age child d. an adolescent

b. a preschool child

A nurse is describing the structure and function of the reproductive system to an adolescent health class. How would the nurse describe the secretion of the seminal vesicles? a. mucus-like b. alkaline c. acidic d. semen

b. alkaline

The nurse is preparing to auscultate a female adult client's carotid arteries. The nurse should plan to a. place the diaphragm of the stethoscope over the carotid artery b. ask the client to hold her breath c. use palpation to locate the arteries before auscultation d. ask the client to breathe in and out normally

b. ask the client to hold her breath

When inspecting a client's inguinal area for bulging, what would be most appropriate for the nurse to have the client do? a. Bend forward from the waist b. Bear down as if having a bowel movement c. Hold his breath after exhaling d. Lie supine and draw his knees to his chest

b. bear down as if having a bowel movement

During the health interview, the nurse asks a client at what age she began menstruating. This question addresses a risk factor for what health problem? a. Mastitis b. Breast cancer c. Benign breast disease d. Paget disease

b. breast cancer

The nurse is assessing a 13-year-old girl. Which event would the nurse expect to have occurred first? a. evidence of pubic hair b. development of breast buds c. onset of menses d. growth spurt

b. development of breast buds

Which of the following is an abnormality of the tongue caused exclusively by antibiotic therapy and is characterized as a yellow, brown, or black tongue with elongated papillae? a. Leukoplakia b. Hairy leukoplakia c. Kaposi's sarcoma d. Candida albicans

b. hairy leukoplakia

A nurse has been invited to be a guest speaker for a female high school health class about the menstrual cycle and reproduction. When describing the hormones involved in the menstrual cycle, a nurse identifies which hormone is responsible for initiating the cycle? a. estrogen b. luteinizing hormone c. progesterone d. prolactin

b. luteinizing hormone

A _________________ is characterized by turbulent blood flow which creates a swooshing or blowing sound over the precordium during auscultation. a. bruit b. murmur c. thrill d. atrial gallop

b. murmur

While assessing the scrotum of an adult client, the nurse notes thin and rugated scrotal skin with little hair dispersion. How would the nurse document this finding? a. Reiter syndrome b. Normal findings c. Effects of chemotherapy d. Gonorrhea

b. normal findings

The nurse is preparing an outline for a class on the physiology of the male sexual response. Which event would the nurse identify as occurring first? a. sperm emission b. penile vasodilation c. psychological release d. ejaculation

b. penile vasodilation

To adequately inspect the ear canal of an adult client, the nurse should do which of the following prior to inserting the otoscope? a. Require that earrings be removed from earlobes. b. Pull the pinna up and back. c. Use a cotton tipped applicator to remove cerumen. d. Have the client lie down to promote comfort.

b. pull the pinna up and back

A client says that an object placed in the hand is a pair of scissors when the object is a paper clip. Which aspect of the client's neurologic system should the nurse identify as being compromised? a. Motor b. Sensory c. Position sense d. Responsiveness

b. sensory

The pediatric nurse encourages parents of hospitalized infants and toddlers to stay with their child to help decrease what potential problem? a. Problems with attachment b. Separation anxiety c. Risk for injury d. Failure to thrive

b. separation anxiety

Which of these assessment techniques is an assessment for Cranial Nerve II? a. Corneal light reflex b. Six cardinal gazes c. Cover - uncover test d. Confrontation

b. six cardinal gazes

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 parents aren't in view.

b. stoop down to her level and ask her about the toy she is holding

The nurse is assessing the genitalia of an older adult client. What would the nurse document as a normal finding? a. Decrease in size of the testes b. Testes hanging lower in the scrotum c. Abundant pubic hair d. Bulging in the inguinal area

b. testes hanging lower in scrotum

When taking a health history for a client, which factor should the nurse identify as placing the client at increased risk for breast cancer? a. The client smokes six to eight cigarettes per day b. The client had her first child at age 38 c. The client breast-fed her child for a full year d. The client has a low body mass index

b. the client had her first child at age 38

A nurse is utilizing the Braden Scale for Predicting pressure sore risk during the admission assessment of an older adult client. What assessment parameter will the nurse evaluate when using this scale? a. the client's current medication regimen b. the client's ability to change position c. the pigmentation of the clients skin d. the client's history of integumentary disorders

b. the client's ability to change position

Which of the following observations indicates use of accessory muscles for breathing? a. Pain over the intercostal spaces. b. The tripod position. c. Diaphragmatic excursion. d. Unequal fremitus.

b. the tripod position

It is important for the nurse to avoid taping the skin of an older adult patient due to a decrease in which integumentary factor? a. Vitamin D production b. Thickness of the epidermis c. Dermal blood flow d. Epidermal permeability

b. thickness of the epidermis

The student is planning a lecture about the cranial nerves. The student nurse should include the pairs of cranial nerves in her lest and where each exit. How many pairs of cranial nerves exit from the brain? a. Ten b. Twelve c. Six at base of brain, 6 in the thoracic spinal canal d. Sixteen

b. twelve

What is the best way to palpate the lymph nodes in the neck? a. Using the index and middle fingers gently compress the nodes between your fingers and the sternocleidomastoid muscle. b. Using gentle pressure, compare lymph nodes that occur bilaterally with two hands. c. Gently grasp each node between your thumb and forefinger as you systematically palpate each node. d. Using firm pressure, palpate with two hands to compare the two sides.

b. using gentle pressure, compare lymph nodes that occur bilaterally with two hands

A nurse is completing a continuing education program about the male and female reproductive organs. After reviewing the information, the nurse demonstrates understanding of the information by identifying which structures as male accessory organs? Select all that apply. a. testes b. vas deferens c. bulbourethral glands d. prostate gland e. penis

b. vas deferens c. bulbourethral glands d. prostate gland

When examining a newborn male infant, the nurse notes that neither testicle is descended. How would the nurse document this finding? a. Epididymitis b. Orchitis c. Cryptorchidism d. Varicocele

c. Cryptorchidism

When assessing deep tendon reflexes in an elderly client what finding would the nurse anticipate? a. Normal reaction time b. Increased reaction time c. Decreased reaction time d. Absent

c. Decreased reaction time

When palpating a female client's axillae, which action is most appropriate? a. Have the client hold the arm of the side being examined slightly away from the body. b. Tell the client to raise her arm on the side being examined up over her head. c. Hold the client's elbow of the side being examined with one hand. d. Have the client lean forward from the waist with arms outstretched.

c. Hold the client's elbow of the side being examined with one hand.

A group of students is preparing for their clinical experience, during which they are required to demonstrate the techniques for assessing the abdomen. The students demonstrate understanding of the proper sequence when they demonstrate the techniques in which order? a. Palpate, percuss, inspect, auscultate b. Auscultate, inspect, palpate, percuss c. Inspect, auscultate, percuss, palpate d. Percuss, inspect, auscultate, palpate

c. Inspect, auscultate, percuss, palpate

The nurse is beginning the physical exam of a male client's genitalia. The nurse is sitting on a stool in front of the client. In which position would it be best to place the client? a. Lying supine b. Kneeling c. Standing d. Sitting

c. standing

The nurse is percussing the costovertebral angle of the client. The nurse is assessing which area of the patient a. The gallbladder in the RUQ b. The appendices in the RLQ c. The posterior kidneys d. The thoracic cavity.

c. The posterior kidneys

What is a normal finding for an older client when assessing lung sounds? a. The pectus excavatum is present due to lack of subcutaneous fat. b. There is a forward protrusion of the sternum called pectus carinatum. c. The sternum and ribs are more prominent because of loss of subcutaneous fat. d. The chest will be Barrel-like due to emphysema.

c. The sternum and ribs are more prominent because of loss of subcutaneous fat.

During a cardiac examination, the nurse can best hear the S1 heart sound by placing the stethoscope at the a. base of the heart b. pulmonic valve area c. apex of the heart d. second left intercostal space

c. apex of the heart

The nurse is preparing to auscultate the posterior thorax of an adult female. The nurse should: a. place the bell of the stethoscope firmly on the posterior chest wall. b. auscultate from the base of the lungs to the apices. c. Ask the client to breathe deeply through her mouth. d. Ask the client to breathe through her nose.

c. ask the client to breathe deeply through her mouth

During an assessment of an older patient, the nurse detects a bruit over the right carotid artery. The nurse should explain to the client that a bruit is a. something to watch but seldom serious in older adults b. a faint wheezing sound heard on expiration c. associated with occlusive arterial disease d. heard only when the artery is almost totally occluded

c. associated with occlusive arterial disease

While inspecting the penis of a client, the nurse suspects herpes progenitalis based on which assessment finding? a. Red, oval ulcerations b. Hardened nodules on the glans c. Clear vesicles that erupt d. Painless, fleshy papules

c. clear vesicles that erupt

The nurse is assessing a patient with several skin lesions that are grouped together. How will the nurse describe the group of lesions? a. Diffuse b. Circumscribed c. Clustered d. Linear

c. clustered

A nurse suspects intra-abdominal bleeding in a client who was recently involved in a motor vehicle accident. Which finding would most likely lead the nurse to this suspicion? a. Tenderness on palpation b. Diastasis recti c. Cullen sign d. Tympany on percussion

c. cullen sign

A client complains of scrotal pain, and the nurse elicits a positive Prehn sign. The nurse would refer the client for treatment of what condition? a. Strangulated hernia b. Tortuous vericocele c. Epididymitis d. Scrotal mass

c. epididymitis

After teaching a group of adolescents about female reproductive anatomy, the nurse determines that the teaching was successful when the adolescents identify which structure as the site of fertilization? a. vagina b. uterus c. fallopian tubes d. vestibule

c. fallopian tubes

Which of the following is not one of the six general types of risk factors in regard to increasing an individual's chances for illness and injury? a. Age b. Environment c. Gender d. Lifestyle

c. gender

If you hear abnormal breath sounds when auscultating, you should? a. Further assess the respiratory rate, depth and rhythm b. Notify the respiratory therapist for a breathing treatment c. Have the patient cough to see if this abnormal breath sounds go away d. Document your findings and notify the physician.

c. have the patient cough to see if this abnormal breath sounds go away

A nurse is preparing a program on osteoporosis for a local women's group. What would the nurse cite as a risk factor? a. obesity b. multiparity c. history of smoking d. African American ethnicity

c. history of smoking

A nurse is testing the range of motion of the thoracic and lumbar spine. What would the nurse document as an abnormal finding? a. Flexion of 80 degrees b. lateral bending of 35 degrees c. hyperextension of 30 degrees d. rotation of 30 degrees

c. hyperextension of 30 degrees

Upon assessment of a 55 year old male who is a heavy smoker and drinker, the nurse observes a chalky, white, thick, raised patch on the lateral edges of his tongue. The lesion is firmly attached and does not scrape off. Which of the following conditions is described? a. Herpes simplex type 1 b. Candida albicans c. Leukoplakia d. Carcinoma of the tongue

c. leukoplakia

Chronic swelling and thickening of the metacarpophalangeal joints with finger deviation toward the ulnar side is seen in _____________. a. limitation of all shoulder motion b. chronic pain c. limited abduction d. sharp catches of pain with movement.

c. limited abduction

A nurse teaches a male client how to perform testicular self-examination. The nurse should instruct the client to perform the self-examination at which frequency? a. Weekly b. Bimonthly c. Monthly d. Quarterly

c. monthly

Which of the following statements related to palpation of lymph nodes in the adult is false? a. The client should be seated in an upright position. b. The submental nodes are easier to palpate with one hand. c. Nodes seen with metastatic cancer are typically palpable, hard, mobile, and unilateral. d. Healthy nodes most often cannot be palpated.

c. nodes seen with metastatic cancer are typically palpable, hard, mobile, and unilateral

A nursing instructor teaching classes in gerontology to nursing students discusses myths related to the aging of adults. Which statement is a myth about older adults? a. Most older adults live in their own homes. b. Healthy older adults enjoy sexual activity. c. Old age means mental deterioration. d. Older adults want to be attractive to others.

c. old age means mental deterioration

A client who reports "fluttering sensations in the chest" or "skipped heart beats" could be documented as experiencing a. syncope b. dyslipidemia c. palpitations d. dyspnea

c. palpitations

A nurse is teaching parents of toddlers how to spend quality time with their children. Which activity would be developmentally appropriate for this age group? a. Playing video games b. Playing peek-a-boo c. Playing in a sand box d. Playing board games

c. playing in a sandbox

An adult male client reports hesitancy when urinating. The nurse would further assess this client for which complication? a. Scrotal hernia b. Sexually transmitted infection c. Prostate enlargement d. Testicular tumor

c. prostate enlargement

After teaching a group of students about the bones and their functions, the instructor determines that the teaching was successful when the students state that blood cells are produced in which of the following? a. compact bone b. yellow marrow c. red marrow d. spongy bone

c. red marrow

The nurse is preparing to perform the Romberg test on an adult male client. The nurse should instruct the client to a. squat down as far as he is able to do so. b. keep his eyes open while he bends at the knees. c. stand erect with arms at the sides and feet together. d. touch the tip of his nose with his finger.

c. stand erect with arms at the sides and feet together.

The school nurse uses the principles and theories of growth and development when planning programs for high school students. According to Havighurst, what is a developmental task for this age group? a. Learning to relate emotionally to parents b. Developing a conscience, morality and a scale of values c. Achieving personal independence d. Achieving a masculine or feminine gender role

d. Achieving a masculine or feminine gender role

In your assessment of an adult, where would you expect to palpate the apical impulse? a. Third intercostal space at the left midclavicular line. b. Fourth intercostal space at the left sternal border. c. Fourth intercostal space at the left anterior axillary line. d. Fifth intercostal space at the left midclavicular line.

d. Fifth intercostal space at the left midclavicular line

The nurse is assessing the neurological status of an unconscious client. The nurse should use which assessment scale? a. Norton b. Braden c. Morse d. Glasgow

d. Glasgow

The nurse is auscultating a client's abdomen and is unable to discern any bowel sounds. How should the nurse proceed with assessment? a. Repeat auscultation in 4 to 6 hours. b. Palpate the client's abdomen to stimulate bowel motility. c. Perform abdominal percussion, and then repeat auscultation. d. Listen for 5 minutes before documenting an absence of bowel sounds.

d. Listen for 5 minutes before documenting an absence of bowel sounds.

The nurse is assessing the skin of an older patient. Which assessment finding needs follow up? a. Multiple liver spots on the arm b. Xerosis on the lower extremities c. Presence of cherry hemangiomas on the trunk d. One light brown lesion (6.5 cm) on the right scapula.

d. One light brown lesion (6.5 cm) on the right scapula.

Which of the following statements concerning S1 is true? a. S1 is louder than S2 at the base of the heart. b. S1 signals the onset of diastole. c. S1 coincides with the jugular vein pulsation. d. S1 is caused by the closure of the tricuspid and mitral valves.

d. S1 is caused by the closure of the tricuspid and mitral valves.

The nurse is conducting a musculoskeletal assessment of an older adult client. What aspect of the client's medical history requires the nurse to alter the usual sequence or content of this assessment? a. the client takes medications to treat hypertension b. the client suffered a fracture Humerus one year earlier c. the client has a diagnosis of type I diabetes d. The client had a total hip replacement 2 years ago.

d. The client had a total hip replacement 2 years ago.

When palpating a female client's axillae, which finding would the nurse document as normal? a. Node size is 1.2 cm. b. Nodes are fixed. c. Nodes are hard. d. Nodes are discrete.

d. nodes are discrete

The nurse's inspection of a client's extremities reveals a deep, circular, painful wound on the client's great toe. What should the nurse suspect as the etiology of the client's wound? a. Blood is returning from the client's toe more slowly than normal. b. There is a blockage or infection in the client's lymphatic system. c. There is a disruption in osmotic pressure in the client's extremities. d. The client's toe is receiving an inadequate supply of blood.

d. The client's toe is receiving an inadequate supply of blood.

An experienced nurse tells a younger nurse who is working in a retirement home that older adults are different and do not have the same desires, needs, and concerns as other age groups. The nurse also comments that most older adults have "outlived their usefulness." What is the term for this type of prejudice? a. Harassment b. Whistle blowing c. Racism d. Ageism

d. ageism

The patient reports indigestion (pyrosis). The nurse knows that this can be an indication of acute gastric disorders such as a. GERD b. hyperacidity c. peptic ulcer disease and stomach cancer d. all are an indication of pyrosis

d. all are an indication of pyrosis

After teaching a group of young women about breast self-examination, the nurse determines that the teaching was successful when the women state that they will palpate their breasts using which pattern? a. A semi-circular pattern b. A clockwise pattern c. A random pattern d. An up-and-down pattern

d. an up-and-down pattern

A nurse is preparing to examine a client's inguinal area. The nurse understands that this area is contained by which structure laterally? a. Symphysis pubis b. Inguinal ligament c. Inguinal canal d. Anterior superior iliac spine

d. anterior superior iliac spine

Which technique best describes how to assess the pupillary light reflex? a. Shine a penlight directly in front of the patient and inspect for pupillary constriction. b. Hold the penlight 12-15 inches from the nose. Ask the patient to focus on the light as you move the light closer to the eyes. Watch for constriction of the pupils. c. Ask the patient to follow your penlight in six visual fields and observe for bilateral pupil constriction. d. Ask the patient to focus on a distant object. Shine a light obliquely into one eye and observe the pupillary reaction.

d. ask the patient to focus on a distant object. Shine a light obliquely into one eye and observe the pupillary reaction

A public health nurse understands that health promotions should continue across the lifespan. When planning health promotion initiatives, when in the lifespan should health promotion begin? a. Adolescence b. School age c. Preschool d. Before birth

d. before birth

A dark skinned patient is admitted for pneumonia. What is the most accurate method to assess for cyanosis in this patient? a. Observe for shallow and rapid respirations b. Inspect the top of feet for discoloration c. Look in the eyes for discoloration d. Check the tongue and lips for a gray color.

d. check the tongue and lip for a gray color

The nurse is assessing an adolescent client and notes a 45-degree flexion of the cervical spine. What is the nurses most appropriate action? a. facilitate a referral for a medical follow up b. palpate the spinous process c. perform the Lasegue test d. continue the exam because this curve is a normal finding.

d. continue the exam because this curve is a normal finding.

A client complained of temporomandibular joint (TMJ) pain. What would the nurse most likely assess? a. joint dislocation b. History of fracture c. History of dental abscess d. difficulty chewing

d. difficulty chewing

Which term describes labored breathing? a. Apnea b. Tachypnea c. Bradypnea d. Dyspnea

d. dyspnea

The nurse noticed the blood pressure was elevated after the patient walked down the hall with physical therapy. What is the potential cause of this blood pressure reading? a. The patient has not taken their medication. b. The blood pressure reflects the pressure on the artery walls. c. The blood pressure is the contraction and relaxation of the atrium d. Exercise can elevate the blood pressure.

d. exercise can elevate the blood pressure

An older adult male client is admitted to the cardiac ICU after suffering a heart attack. Upon taking a history after the client is stable, the nurse charts that he weighs over 275 pounds, has a history of heart disease in his family, suffers with stress at work, drinks alcohol daily, and smokes two packs of cigarettes daily. All of the following are modifiable risk factors except. a. Alcohol intake b. Smoking c. Stress d. Family history

d. family history

During a client's vascular assessment, the nurse is palpating the pulse just under the client's inguinal ligament. The nurse is assessing which pulse? a. Temporal b. Brachial c. Popliteal d. Femoral

d. femoral

All of the following are high cardiac output states that can be associated with a physiologic murmur except: a. pregnancy b. dehydration c. anemia d. fever

d. fever

During a client's genitourinary exam, the nurse notes that the client's scrotum is enlarged and easily transilluminates. What should the nurse suspect? a. Tumor b. Hernia c. Varicocele d. Hydrocele

d. hydrocele

Upon inspection of the client, the nurse notices the client to be in the tripod position. The nurse understands that this position helps the client to: a. sit up better while having trouble breathing. b. So the patient is not fatigued while breathing. c. It does not do anything to help with breathing. d. To allow greater expansion of the lungs for breathing.

d. to allow greater expansion of the lungs for breathing

Which of the following is not a normal change of the ears with age? a. Presbycusis b. Hardened cerumen c. Cloudy tympanic membrane d. Tophi

d. tophi

A family history of cancer is considered a modifiable risk factor for illness. True False

false

According to your Fundamentals text, acute illnesses are the leading health problem in the world today. true false

false

After testing deep tendon reflexes, the nurse documents 2+. The nurse should evaluate further. True False

false

An apical pulse can be palpated at the apex of the heart between the 5th and 6th rib true flase

false

Axillary temperatures must be obtained on children under the age of 2 years. true false

false

Both S3 and S4 are best heard at the apex of the heart. True False

false

Bronchovesicular breath sounds are long in inspiration and short in expiration. True False

false

Capillary refills greater than 3 seconds should be documented as normal findings. True False

false

Dysphagia is painful swallowing and may place a patient at risk for aspiration. true false

false

Opacity/ties of the lens is an indication of conjunctivitis. true false

false

Papules are elevated lesions in the skin that are greater than 1 cm in diameter. true false

false

Percussion requires the nurse to palpate the thoracic cavity to identify possible consolidation within the lungs. True False

false

Referred pain is when the peritoneum becomes inflamed like in appendicitis. True False

false

Teaching, an independent function of professional nurse practice, is included as a primary nurse responsibility in all state nurse practice acts. true false

false

You are providing vision screening at a community health fair. One man has tested 20/15 for both eyes on the distant visual acuity test. The nurse correctly refers him to an optometrist. true false

false

__________ is characterized by a wide spread of musculoskeletal pain accompanied by fatigue, sleep, memory, and mood changes, or cognitive disorders.

fibromyalgia

According to Erickson's theory, the middle adult years are a period of _______________ versus stagnation, a time to reevaluate one's goals and accomplishments.

generativity

Women who begin menarche late or being menopause early are at greater risk for development of _______________

osteoporosis

Drooping of the upper eyelid is called _____________________.

ptosis

The difference between systolic and diastolic pressure is termed ___________ pressure.

pulse

A public health nurse is assessing the nutritional awareness of a group of women who are participating in a prenatal health class. What outcome would most clearly demonstrate that the women possess nutritional awareness a. The women demonstrate an understanding of the importance of a healthy diet b. The women are able to describe the importance of vitamin supplements during pregnancy c. The women can list the mineral nutrients that should be consumed daily d. The women can interpret the nutrition facts listed on food packaging.

the women demonstrate an understanding of the importance of a healthy diet