nsg 250 test 1
41. During the history, the patient tells the nurse he has frequent nosebleeds and asks the best way to get them to stop. What would be the nurse's best response?
"Sit up with your head tilted forward and pinch your nose midway to the tip."
32. To enhance the physical environment of the interview the nurse:
Reduces noise by turning off televisions and radios
2. A nurse is caring for a client who has contact dermatitis of the neck and upper chest. Which of the following is an expected finding?
Report of exposure to a skin irritant.
23. While conducting an ear examination, the nurse knows that the normal tympanic membrane would appear:
Shiny and translucent with a pearl-gray color.
45. A client comes to the emergency department complaining of increasing eye pain, seeing halo's around lights and a decrease in peripheral vision. Which data would be essential to obtain for this patient?
The degree of intraocular eye pressure.
25. The nurse is examining a 2-year-old child and asks, "May I listen to your heart now?" Which critique of her technique is most accurate?
Children at this age like to say "no." The examiner should not offer a choice when there is none.
9. The nurse is reviewing the blood supply to the arm. The major artery supplying the arm is the _____ artery.
Brachial.
5. The patient who was just admitted is in acute pain, has not been sleeping well lately, and is having difficulty breathing. How should the nurse prioritize these problems?
Breathing, pain, sleep.
47. The nurse is examining a patient's ears and notices cerumen in the external canal. Which of these statements about cerumen is correct?
The purpose of cerumen is to protect and lubricate the ear
24. The nurse is reviewing the components of the nursing process. Which statement about nursing diagnoses is true?
They are clinical judgments about a person's response to an actual or potential health state.
6. While conducting an admission assessment, the nurse notes a draining ulceration on the patient's lower leg. Which intervention is appropriate?
Wash hands, put on gloves, continue with the examination of the ulceration and then proceed with the remainder of the exam.
18. A 17-year-old single mother is describing how difficult it is to raise a 2-year-old by herself. During the course of the interview she states, "I can't believe my boyfriend left me to do this by myself! What a terrible thing to do to me!" Which of the following responses of the nurse is the best example of expressing empathy?
"It must be so hard to face this all alone."
7. The visiting home health nurse has been assigned to care for a patient on a ongoing basis and is making an initial home visit with the patient who has many chronic medical problems. Which type of database is most appropriate to collect in this setting?
A complete health database because the nurse will be responsible for monitoring the patient's health over time.
11. A 6-month-old infant has been brought to the well-child clinic for a routine check-up. The child is currently sleeping. What should the nurse do first?
Auscultate the lungs and heart while the infant is still sleeping.
31. The reason for performing a palpated pressure prior to auscultating is to:
Avoid missing the auscultatory gap during auscultation and obtaining a false low blood pressure.
36. The nurse should measure rectal temperatures in which of these patients?
Comatose adult
16. 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:
Conducts vibrations of sound to the inner ear
12. A 68-year-old woman is in the eye clinic for an evaluation of her macular degeneration. Which of the following objective and subjective data does the nurse expect to find?
Difficulty with reading the paper, sewing and seeing the faces of her grandchildren. Examination findings indicate a loss of central vision with normal peripheral vision.
48. When performing a cultural assessment on a client, which of these questions would not be appropriate for the nurse to ask?
Does the patient require government assistance for health care expenses?
44. The nurse is assessing a patient's skin during an office visit. What is the best technique to use to best assess the patient's skin temperature? Use the:
Dorsal surface of the hand because the skin is thinner than on the palms
35. During an interview, the nurse states, "You mentioned shortness of breath. Tell me about that." Which verbal skill is used with this statement?
Facilitation
8. A school nurse is assessing a child for pediculosis capitis. Which of the following manifestations should the nurse recognize as an indication of this the condition?
Firmly attached white particles on the hair.
21. The six muscles that control eye movement are innervated by cranial nerves:
III, IV, VI.
43. A nurse in a clinic is caring for an older adult client who reports dry, flaky skin on her upper back. Which of the following is an intervention should the nurse complete?
Pinch up a fold of skin to check for turgor.
17. To perform an otoscopic examination on a 2 year old child, the nurse should:
Pull the pinna down and back.
34. The nurse is testing a patient's visual accommodation, which refers to which action?
Pupillary constriction when looking at a near object
30. The nurse is preparing to check the blood pressure of an obese patient using a standard-sized blood pressure cuff. The nurse would expect the reading to:
Yield a falsely high blood pressure.
3. The nurse interprets a Snellen score of 20/60 as:
The patient can read at 20 feet what a person with normal vision can read at 60 feet.
42. The nurse is performing a nasal assessment on a 12 year-old male. The nurse notes that his nasal mucosa appears pale, gray, and swollen with clear watery discharge. What would be the most appropriate question to ask the patient?
"Do you have any allergies?"
4. The nurse determines that the patient's condition is one of a "second-level' priority problem. Based on this determination this situation could be which of the following?
Abnormal laboratory values.
13. Acute otitis externa is a common infection among children and adults. Which describes a typical exam finding of otitis externa?
Erythema and edema of the EAC.
49. The nurse examines a patient who has been diagnosed with atherosclerosis and a higher than normal blood viscosity. Based on this information, the nurse can expect the blood pressure reading on this patient to be:
Higher than normal.
50. The nurse is assessing the vital signs of a 24-year-old marathon runner. The following vital signs have been documented: temperature: 97.8º F oral; pulse: 46 bpm; respirations: 12 breaths/minute; blood pressure: 100/70 (right upper arm). Which of the following statements is true?
These are within the range of normal vital signs for a healthy athletic adult.
10. A woman is discussing the problems she is having with her 2-year-old son. "He won't go to sleep at night and during the day he has several fits. I get so upset when that happens." An appropriate response by the nurse would be:
"You say that your son has several fits during the day. Tell me what you mean by this."
22. The mother of a 2-year-old is concerned because her son has had three ear infections in the past year. What would be the most appropriate response for the nurse to make?
"Your son's eustachian tube is shorter and wider than yours because of his age, which allows for infections to develop more easily."
15. One aspect of a culture's value orientation concerns the dimension of time. This specific cultural understanding may assist with discharge planning for the patient. An example of a person with "present time" value orientation would be:
A patient with a total hip replacement who has been unwilling to discuss or plan for needs at home or for getting prescriptions filled after discharge from the hospital.
26. When examining the aging adult the nurse should:
Arrange the sequence to allow as few position changes as possible.
20. During a follow-up visit, the nurse discovers that the patient has not been taking his insulin on a regular basis. The nurse asks, "Why haven't you taken your insulin as instructed?" Which statement is an appropriate evaluation of the nurse's response to the patient?
Asking "why" may put the patient on the defensive and harm any therapeutic relationship between the nurse and patient.
38. A 75-year-old male client has a history of hypertension and was recently changed to a new antihypertensive medication by his health care provider. He reports feeling dizzy at times. What is the best means to evaluate the client's blood pressure in this situation?
Assess blood pressure and pulse when the patient changes from the supine position to that of sitting and standing positions.
14. During a routine physical examination, a nurse observes a 1-cm (0.4-in) lesion on a client's chest. The lesion is raised and fresh-colored with pearly white borders. The nurse should recognize that this finding is suggestive of which of the following types of skin cancer.
Basal cell carcinoma
19. When taking a history from a newly admitted patient, the nurse notices that he is pausing often and looking at the nurse expectantly. What would be the nurse's best response to this behavior?
Be silent and allow him to continue when he is ready
27. The patient with presbyopia may complain of:
Inability to read the newspaper print up close.
46. The nurse is preparing to use a stethoscope for auscultation. Which statement is true regarding the bell of the stethoscope? The bell:
Is used to listen for low-pitched sounds
39. When evaluating the temperature of older adults, the nurse remembers which aspect about an older adult's body temperature?
It is lower than that of younger adults
29. The general survey includes:
Observing the patient's stature and nutritional status
37. A physical examination can be considered to be complete, focused or a recheck (a re-evaluation). Which situation would warrant a focused physical examination?
Patient admitted with chest pain
1. The nurse caring for geriatric patients knows that a normal physiologic change associated with the aging process is:
Peripheral blood vessels growing more rigid with age producing a rise in systolic blood pressure.
33. The nurse begins to care for a patient who is unable to speak or understand English. The best approach for overcoming the language barrier would be to:
Use a medically trained and culturally sensitive interpreter.
28. When listening to a patient's breath sounds, the nurse is unsure of a sound that is heard. The nurse's next action should be to:
Validate the data by asking a coworker to listen to the breath sounds.
40. Which technique is correct when the nurse is assessing the radial pulse of a patient? Count the:
pulse for 1 minute if the rhythm is irregular
