Need to Know Test - Nurs 225 FINAL
84. ____ looking up at the ceiling A. extension B. abduction C. supination D. protraction E. plantar flexion
A. extension
1. A patient visits the clinic and complains of wrist pain. To perform Phalen's test for Carpal tunnel syndrome, the nurse should ask the client to: a. move the hand inward with the wrists straight b. place both palms on the examination table c. Dorsiflex the carpal d. Place the backs of both hands against each other
D. Place the backs of both hands against each other
86. _____ thrusting the jaw forward A. extension B. abduction C. supination D. protraction E. plantar flexion
D. protraction
Vocabulary: Match the definition with its medical vocabulary word. (Put on scantron) (#83-86) 83. ____ movement when pointing the toe to the ground A. extension B. abduction C. supination D. protraction E. plantar flexion
E. plantar flexion
92. What are the 2 recommended patient identifiers?
Full name and date of birth
95. Write the questions that you would ask to determine if the patient is oriented?
What year is it? Where are you? What is your name?
78. As the nurse palpates the radial pulse, the pulse is difficult to locate, disappears with slight pressure, is thready and irregular. This pulse would be graded as? a. 0 b. +1 c. +2 d. +3
b. +1
19. It is recommended that males do a self testicular exam by monthly. Testicular cancer is most common for which age group? a. 10 to 15 years b. 15 to 39 years c. 40 to 55 years d. Over 50
b. 15 to 39 years
12. Following self-testicular examination, the client should report which of the following findings to a health professional? a. One testicle being lower than the other b. Any non-tender mass c. Periodic non sexual erections d. Palpation of the epididymis
b. Any non-tender mass
13. Papanicolaou (Pap) smear is a screening test for which condition? a. Abdominal aneurysm b. Cervical cancer c. Gonorrhea d. Ovarian cancer
b. Cervical cancer
20. When the nurse was interviewing a patient, she asked these questions. Which is an example of a "closed-ended" question/statement? a. "Describe your relationship with your children." b. "Tell me what you eat in a normal day". c. "Are you allergic to any medications?" d. "What is your typical day like?"
c. "Are you allergic to any medications?"
2. The nurse needs to assess the right middle lobe of the lung. Where should the nurse place the stethoscope? a.posterior thoracic wall, right of mid-scapular line b.right tenth intercostal space posteriorly c.right sixth intercostal space anteriorly at the mid-clavicular line d.left second intercostal space, right of mid-axillary line
c.right sixth intercostal space anteriorly at the mid-clavicular line
82. Which statement made by the nurse during the health assessment implies a judgmental attitude? a. "How often do your adult children visit?" b. "Your husband's death must have been difficult for you." c. "How do you feel about getting older?" d. "You ought to quit smoking."
d. "You ought to quit smoking."
73. When documenting a normal apical impulse, how would the nurse document the location? a. 2nd intercostal space, left sternal border b. 3rd intercostal space, left axillary line c. 4th intercostal space, left sternal border d. 5th intercostal space, left mid-clavicular line
d. 5th intercostal space, left mid-clavicular line
91. BP ____
SBP < 120 DBP < 80
94. What is the rationale for the sequence of the abdominal exam?
So as not to stir up sounds that aren't usually present. If pain is present you would want to palpate last
96. When doing a cardiac assessment, the nurse asks the client to assume three positions. What are these positions? Also state the reasons for using these positions.
Supine - 30 degrees to complete the general exam of neck vessels and precordium including inspection, palpation, percussion and auscultation Sitting - leaning forward for auscultating certain abnormal sounds Left Lateral - if having difficulty palpating the apical impulse and for auscultating certain abnormal sounds ease
99. In the diagrams below, draw and label the chest landmarks:
Mid-Sternal Line (middle) Right Mid-clavicular line
90. R _______
10-20
89. P _______
50-95
Give the normal ranges for vital signs in adults (#88-91) 88. T (oral). ______
96.4-99.1
97. Draw a circle in each correct location and name the site where you place the stethoscope for traditional areas of auscultation of the precordial landmarks. Be sure to use the chest landmarks when naming the site & location. (see picture of ribs)
Aortic - Right 2nd Intercostal space-sternal boarder Pulmonic - Left 2nd IC space-sternal border Erb's - Left 3rd IC space-sternal border Tricuspid - 4th or 5th IC space - sternal border Mitral - 5th IC space - mid-clavicular line
85. _____ movement of a body part away from the midline A. extension B. abduction C. supination D. protraction E. plantar flexion
B. abduction
100. In the diagrams below, draw and label the chest landmarks:
Left Anterior Axillary (closest to front) Left Mid-axillary (between the two) Left Posterior Axillary (closest to back)
Answer the following on the test booklet. You must have ALL of the components of the question correct in order to get credit. There is NO partial credit. 87. What does PERRLA stand for________________
Pupils Equal, Round, and Reactive to Light and Accommodation
93. Create and label the 4 quadrants of the abdomen?
RLQ - I RUQ - II LUQ - III LLQ - IV
98. On the figure below, label seven sites where a pulse is commonly taken .
Top to bottom: Corotid Brachial Radial Femoral Popliteal Posterior Tibialis Dorsalis Pedis
51. A patient has tested 20/40 on the distant visual acuity test using a Snellen chart. The nurse knows that the: a. 20 means the distance the person is standing from the chart b. 20 means the number of choices c. 40 means the distance the chart is from the person d. 40 means the 4th line from the top of the chart
a. 20 means the distance the person is standing from the chart
21. The apex of each lung is located at the a. Area slightly above the clavicle b. Area below the diaphragm c. Level of the sixth rib d. Left oblique fissure
a. Area slightly above the clavicle
23. Which of the following questions should be used to assess whether a patient is experiencing hesitancy? a. Do you have difficulty starting your stream of urine? b. How often do you void? c. Do you experience the need to void immediately? d. Do you have difficulty controlling your urine?
a. Do you have difficulty starting your stream of urine?
53. The Romberg test evaluates: a. Equilibrium b. bone conduction c. air conduction d. swallowing
a. Equilibrium
81. With a normal Babinski response (plantar reflex) the adult individual a. Flexes toes when the outer border of the sole of the foot is stroked b. Blinks eyes repeatedly after being tapped on the forehead c. Puckers the lips when the side of the mouth is tapped d. Dorsiflexes the foot
a. Flexes toes when the outer border of the sole of the foot is stroked
68. When testing shoulder abduction, ask the patient to: a. Lift both arms out to the side b. Extend hands behind back c. Put hands on waist d. Contract forearms
a. Lift both arms out to the side
64. Which is an important consideration in auscultating the lungs? a. Listen at each site for at least one respiratory cycle. b. Have the patient breathe quietly through the nose c. Listen to the bases of the lung first d. Listen to the anterior thorax first
a. Listen at each site for at least one respiratory cycle.
15. How do you test for stereognosis? With patient's eyes closed: a. Place a familiar object in hand and ask patient to identify it b. Write a number on the palm of the hand and ask patient to identify it c. Touch the patient in the same area on both sides of body and ask patient to identify locations. d. Move toes or fingers up or down. Ask patient to tell you the direction of movement
a. Place a familiar object in hand and ask patient to identify it
69. Which is the back-lying position used for examination of the abdomen (with small pillow under head and one under knees)? a. Supine position b. Sitting position c. Sim's position d. Prone position
a. Supine position
24. The American Nurses Association (ANA) Standards of Care address which of the following? a. The nursing process b. Code of ethics c. Professional behavior d. Social policy statement
a. The nursing process
65. While auscultating for bowel sounds in a 35 year old man, you note a series of intermittent, soft clicks and gurgles that occur at a rate of 5-30/minute. These findings are: a. Within normal limits b. Minor variations but abnormal c. Age related variations d. An abnormal situation
a. Within normal limits
75. Upon inspecting the patient's skin you notice he has a rash on his arms and chest. There is a clear liquid draining from the red, raised lesions. How would you safely proceed with examination? a. apply gloves b. ask the patient to palpate his own lesions c. wash your hands immediately after palpating the lesions d. wear goggles with the gown and mask
a. apply gloves
55. When evaluating lymph nodes in the neck, you note that they are soft bilaterally. "Soft" is describing what characteristic of lymph nodes? a. consistency b. delimitation c. mobility d. shape.
a. consistency
62. When considering a nutritional assessment, the nurse is aware that the most common anthropometric measurements include: a. height and weight. b. leg circumference. c. biceps skinfold thickness. d. hip and waist measurement.
a. height and weight.
11. In teaching a patient how to determine total body fat at home, the nurse includes instructions to obtain measurements of: a. height and weight. b. frame size and weight. c. waist and hip circumferences. d. mid upper arm circumference and arm span.
a. height and weight. Body mass index, calculated by using height and weight measurements, is a practical marker of optimal weight for height and an indicator of obesity.
38. To test for back and leg pain, you should do which of the following: a. in supine position with leg raised to point of pain, dorsiflex the foot b. in prone position, deeply palpate the lower back c. in side lying position, bend the knee on the affected side d. standing, have the patient bend over to the point of pain
a. in supine position with leg raised to point of pain, dorsiflex the foot
72. While assessing the ankles and feet, you palpate for edema. The normal response when pressure is released is a. instant rebound b. skin indents c. feels spongy d. one ankle is larger than the other
a. instant rebound
14. During the assessment of the neck you determine that the lymph nodes are soft, move from side to side, and are non-tender. Your evaluation is which of the following? a. it is normal b. it may represent malignancy c. it is a result of aging d. it is a sign of chronic infection
a. it is normal
74. A person who is drowsy or asleep most of the time, capable of making spontaneous movements, can be aroused with gentle shaking, and responds to their name, is described as a. lethargic b. obtunded c. stuporous d. semicomatose
a. lethargic
8. An adolescent asks the nurse about a "bump" on his neck. The nurse observes a raised, red, solid mass, 0.3 cm (1/8") by 0.2 cm (7/16"). The nurse should record this as which skin lesion? a. papule b. macule c. nodule d. pustule
a. papule
4. When palpating the pulses in the feet, the nurse notices that his/her fingers leave a lasting depression in the skin. This is called a. pitting edema b. lymphedema c. orthostatic edema d. 4 + edema
a. pitting edema
42. When performing the Romberg test, it is important to place your arms around the person without touching in order to a. prevent a fall. b. test perpherial vision. c. determine presence of tinnitus. d. assess body circumference.
a. prevent a fall.
66. Which non-verbal behavior by the nurse facilitates communication? a. sitting when the patient is in bed b. reading the interview questions c. maintaining physical distance d. note taking
a. sitting when the patient is in bed
59. While assessing the breasts of a female patient, the nurse should explain to the patient that most breast tumors occur in which quadrant: a. upper outer b. lower inner c. upper inner d. lower outer
a. upper outer
34. Before beginning the physical assessment of a patient, the nurse should first a. wash hands with soap and water b. determine whether the client is anxious c. ask the client to remove all clothing d. request a family member to be present
a. wash hands with soap and water
26. The OBN states that 'A registered nurse shall maintain the confidentiality of patient information." This means which of the following? a. will discuss only with health care team members b. will share only with the nursing staff and instructor c. will not tell anyone d. will not discuss unless directly asked by others.
a. will discuss only with health care team members
30. A patient's weekly blood pressure readings for 2 months have ranged between 124/84 and 136/88 mm Hg, with an average reading of 126/86 mm Hg. The nurse knows that this blood pressure falls within which blood pressure category? a. Normal blood pressure b. Pre-hypertension c. Stage I hypertension d. Stage 2 hypertension
b. Pre-hypertension According to the JNC-VII guidelines, prehypertension blood pressure readings are systolic 120-139 mm Hg or diastolic 50-89 mm Hg.
27. When auscultating the heart of a normal adult, how many heart sounds would the nurse expect to hear? a. One b. Two c. Three d. Four
b. Two
37. When inspecting the breasts which finding would be reason for further evaluation? a. areolas that are dark brown b. a retracted left nipple c. smooth breast tissue d. linear striae on outer aspects
b. a retracted left nipple
17. An older woman visits the clinic complaining of dysuria. The woman says "what is wrong with me?" The nurse should explain to her that this is most likely due to which of the following? a. atrophy of the vaginal mucosa b. bladder infection c. decreased volume of urine d. change in vaginal pH
b. bladder infection
28. Dyspareunia associated with menopause is related to which of the following? a. decrease in libido b. decrease in vaginal secretions c. increase in size of clitoris d. increase expansion of the vaginal vault
b. decrease in vaginal secretions
47. Which of the following is likely to cause dullness in the abdomen? a. kidney stones b. feces c. flatus d. bruit
b. feces
71. A normal response to striking the triceps tendon with the reflex hammer is a. forearm pronation and slight elbow flexion. b. forearm extends slightly at elbow. c. forearm flexes at the elbow. d. plantar flexion.
b. forearm extends slightly at elbow.
48. When the nurse asks the question, "Have you ever been hospitalized for a serious illness or injury?" The nurse should document this under which heading? a. biographic data b. past health history c. family health history d. review of systems
b. past health history
43. In percussing the thorax, the sound representing normal lung tissue is a. hyperresonance b. resonance c. dull d. flat
b. resonance
49. According to the Ohio Board of Nursing, a student in an RN program is held to which standard? a. higher standard than an RN b. same standard as an RN c. lower standard than an RN d. there is no standard for student nurses
b. same standard as an RN
3. The patient is admitted with right-sided hemiparesis. Which of the following would be the most appropriate episodic assessment? a. taking vital signs on the left side b. testing the strength of hands c. checking the left patellar reflex d. asking the patient what year it is
b. testing the strength of hands
54. During an interview, a woman says, "I have decided that I can no longer allow my children to live with their father's violence. I just can't seem to leave him though." Which response is the least non-judgmental? a. "That's too bad-- children need both parents." b. ."If you're afraid for your children, why can't 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."
c. "It sounds as if you might be afraid of how your husband will respond." This statement is not based on one's inference or conclusion. It links events, makes associations, or implies cause. Interpretation also ascribes feelings and helps the person understand his or her own feelings in relation to the verbal message.
29. Which data collected by the nurse is documented under objective data? a. Religion b. Occupation c. Appearance d. Ethnicity
c. Appearance
57. You are discussing the need for a flu shot with a woman who is 30 years old. She says, "I really think it is important for everyone who can to get flu shots in order to prevent needless deaths." This reflects which time orientation? a. Past b. Current c. Future d. Present
c. Future
18. Which of the following is not one of the Ohio Board of Nursing (OBN) Standards for promoting patient safety? a. Name tags b. Communicate and document promptly c. Maintain personal boundaries d. Promote a safe environment
c. Maintain personal boundaries
79. On the diagram below, which letter is indicating the occipital lymph node(s)? (the one behind the one directly behind the ear) a. b. c. d.
c. Occipital lymph node
32. When using alcohol-based hand rub for hand hygiene, it is important to remember which of the following? a. It can be used in all situations just like soap and water. b. You need to apply about 10-20 ml (about a tablespoon) of the product. c. You need to rub your hands until they are completely dry. d. Wipe any excess product with a dry paper towel.
c. You need to rub your hands until they are completely dry.
31. Orthostatic hypotension is best described as a. a drop of 20 mm of pressure from prone to supine position b. an increase of at least 10mm in systolic pressure when standing c. a drop of 20 mm of Hg from supine to standing position d. an increase of 10 mm in the pulse deficit
c. a drop of 20 mm of Hg from supine to standing position
25. When asking the patient "A rolling stone catches no moss.", you are assessing which of the following? a. concentration b. judgment c. abstract reasoning d. perceptual ability
c. abstract reasoning
67. The rationale for standard precautions is that a. one does not want to discriminate between patients. b. it is the law. c. all patients are considered infected. d. it reduces nosocomial infections.
c. all patients are considered infected.
80. The patient is complaining of abdominal pain in the area just below the sternum. This area is called a. Supraumbillica b. infrasternal c. epigastric d. left outer quadrant
c. epigastric
9. The nurse hears a low-pitched, dry, grating sound at the lung bases during inspiration and expiration of a patient with pneumonia. The nurse would document what type of lung sound? a. vesicular b. wheeze c. friction rub d. fine crackles
c. friction rub
52. What is the correct sequence of the four assessment techniques when examining the abdomen? a. inspect, percuss, palpate, auscultate b. auscultate, inspect, palpate percuss c. inspect, auscultate, percuss, palpate d. palpate, inspect, auscultate, percuss
c. inspect, auscultate, percuss, palpate
10. Mr. J. says "I have to get up 3-4 times a night to urinate in the bathroom". This is called? a. enuresis b. bradyuria c. nocturia d. dysuria
c. nocturia
50. The nurse can best encourage a patient's verbalization by using which technique? a. sharing own experiences b. direct questions c. open ended questions d. active listening
c. open ended questions
36. The nurse can best encourage a patient's verbalization of a topic by using which technique? a. sharing own experiences b. direct questions c. open-ended questions d. active listening
c. open-ended questions
16. During an interaction with the family of a critically ill patient, the nurse uses silence as a therapeutic technique. This technique allows the family to: a. communicate with the patient b. regain composure c. organize their thoughts d. decrease anxiety
c. organize their thoughts
5. The pimple like lesions across the chin of an adolescent are called? a. cysts b. papules c. pustules d. vesicles
c. pustules
76. A woman complains that when she laughs or sneezes she leaks a little urine. This is called a. cystitis b. dysuria c. stress incontinence d. urethral hyperplasia
c. stress incontinence
77. A respiratory rate of 32 per minute is called a. shortness of breath b. apnea c. tachypnea d. bradypnea
c. tachypnea
60. Which action by the nurse correctly applies the principles of standard precautions? a. washing the hands between examination of each body part b. discarding a safety pin used to assess sensory perception in the trash can c. wearing gloves to palpate the tongue and buccal membranes d. wearing gown, gloves, and mask during the physical exam
c. wearing gloves to palpate the tongue and buccal membranes
41. The nurse is preparing to perform a musculoskeletal examination on an adult patient. The patient tells you, the nurse, that he has a limitation in ROM of his left elbow. To further assess you should do which of the following? a. Go through all ROM quickly to minimize pain. b. Firmly move the joint to the point of pain then take it just beyond to stretch the muscle. c. Instruct the patient to take the joint as far as he can, then you move it to the normal position. d. Anchor the joint with one hand while the other slowly moves it to its limit.
d. Anchor the joint with one hand while the other slowly moves it to its limit.
39. The OBN states that the nurse shall not engage in seductive or sexual behavior with a patient. The basis of this is that the patient is presumed to be a. Married b. Not interested in sex since he is sick c. Infected d. Incapable of giving free and full consent
d. Incapable of giving free and full consent
44. In preparing a woman for a pelvic exam, which position is she placed in? a. Supine b. Prone c. Sim's d. Lithotomy
d. Lithotomy
7. When you ask the patient to push his feet against your hands, you are assessing which of the following? a. Homan's sign b. Length of feet c. Range of motion d. Muscle strength
d. Muscle strength
70. The name of the position in the picture is called what? (face down on stomach) a. Trendelenburg b. Supine c. Dorsal recumbent d. Prone
d. Prone
6. During the musculoskeletal examination, the person is asked to bend forward at the waist to evaluate which condition? a. Lordosis b. Kyphosis c. Gibbus d. Scoliosis
d. Scoliosis
58. You are planning to teach Mary Doe, a 20-year-old college student how to perform a self-breast examination. Which of the following will assist the palpation? a. Palpating the breasts in a circular pattern b. Squeezing the nipple of each breast with thumb and forefinger c. Keeping a bra on d. Start in a sitting position
d. Start in a sitting position
45. The proper technique for washing hands includes which of the following? a. Washing with hot water. b. Keep the hands higher than wrists. c. Start with the right hand, then do the left. d. Washing for at least 15 seconds.
d. Washing for at least 15 seconds.
61. If the thyroid gland is palpable, where is it located? a. above the thyroid cartilage. b. over the thyroid cartilage c. lateral to the sternomastoid muscle d. below the cricoid cartilage.
d. below the cricoid cartilage.
63. As one ages the systolic and diastolic readings both increase. This is due to a. decreased peripheral vascular resistance b. increased cardiac output c. increased blood viscosity d. decreased elasticity in the arteries
d. decreased elasticity in the arteries
33. The nurse preparing to interview a client knows it is important to do which of the following first: a. make inferences b. determine client strengths. c. identify health problems. d. establish rapport
d. establish rapport
56. Identify the correct order for using the physical assessment skills in most cases. a. auscultation, percussion, inspection, palpation b. percussion, inspection, auscultation, palpation c. inspection, palpation, auscultation, percussion d. inspection, palpation, percussion, auscultation
d. inspection, palpation, percussion, auscultation
40. An African American client has areas of raised and enlarged scar tissue. The nurse recognizes this as a. crusts b. vitiligo c. birthmark d. keloids
d. keloids
35. The normal response for capillary refill test is: a. less than 1 second b. greater than 4 seconds c. greater than 2 seconds d. less than 3 seconds
d. less than 3 seconds
46. When the examiner asks the person to repeat a series of unrelated numbers, what is being evaluated? a. Judgment b. ability to learn c. computation d. memory
d. memory
22. Which is the best position for listening to a patient's breathe sounds? a. prone b. supine c. left lateral d. sitting upright
d. sitting upright