NUR 306 PrepU Questions
Pressure ulcers are staged as I through IV. Put the following in order from stage I through stage IV. 1. ulceration involving the dermis 2. necrosis with damage to underlying muscle 3. intact, firm skin with redness 4. full-thickness skin loss
3. intact, firm skin with redness 1. ulceration involving the dermis 4. full-thickness skin loss 2. necrosis with damage to underlying muscle
A new nurse asks the charge nurse what the Mini-Mental Status Examination tests. What is the appropriate response by the charge nurse? A. "A quick tool that is useful to examine the orientation, memory, speech, and cognitive functions" B. "This examination tests the mood, feelings, thought processes, and perceptions of the client" C. "This scale allows for tracking of the client's response to stimulation and early detection of changes" D. "Testing of remote and recent memory makes this test useful to track the progression of dementia in a client"
A. "A quick tool that is useful to examine the orientation, memory, speech, and cognitive functions"
The student nurse reports that the breath sounds of an infant are loud and harsh. How should the nurse best respond? A. "Breath sounds in infants will be louder and harsher due to a thinner chest wall." B. "This is a sign of infection. The physician needs to be notified." C. "This infant needs oxygen to ease his breathing." D. "This is an indication of respiratory distress in infants."
A. "Breath sounds in infants will be louder and harsher due to a thinner chest wall."
A patient in the clinic where you work is considered legally blind. The nurse knows that this means the vision in his better eye, corrected by glasses, is what? A. 20/200 or less B. 20/100 or less C. 20/300 or less D. 20/400 or less
A. 20/200 or less
As a part of the ear examination for hearing loss, a nurse conducts a Weber test on a client. To accurately perform this test, the nurse should place the base of the tuning fork in which of the following locations? A. At the center of the client's forehead B. On the client's mastoid process C. Behind the external auditory canal D. In front of the external auditory canal
A. At the center of the client's forehead
Which nutrient deficiency should a nurse recognize as placing a client at risk for osteoporosis? A. Calcium B. Protein C. Vitamin D D. Vitamin C
A. Calcium
When examining the eyes of an elderly client, the nurse observes a brownish discoloration of the lens. The nurse interprets this finding as being suggestive of what health problem? A. Cataracts B. Conjunctivitis C. Presbyopia D. Glaucoma
A. Cataracts
The nurse is performing a breast examination. Which of the following findings are considered a common or concerning symptom? (Select all that apply.) A. Change in shape B. Unusual nipple discharge C. Edema D. Rash E. Breast discomfort
A. Change in shape B. Unusual nipple discharge C. Edema D. Rash E. Breast discomfort
A patient describes painless loss of peripheral vision. He describes increasing tunnel vision. What condition does he likely have? A. Chronic angle glaucoma B. Presbyopia C. Acute glaucoma D. Retinal detachment
A. Chronic angle glaucoma
When inspecting the hair, what would the nurse note? Select all that apply. A. Condition of hair shaft B. Hair breakage of more than 6 hairs C. Length of hair D. Color E. Hair shafts that are shiny
A. Condition of hair shaft D. Color E. Hair shafts that are shiny
A nurse is inspecting the bulbar conjunctiva and sclera of a 67-year-old client, and notices yellowish nodules on the medial side of the iris. Which of the following is the most appropriate nursing action at this time? A. Document the finding and proceed with the examination B. Examine the client's eye for presence of a foreign body C. Notify the physician of the finding D. Ask the client whether he has recently had trouble focusing when reading up close
A. Document the finding and proceed with the examination
The nurse's assessment of an adult female client reveals the presence of excessive hair on her face and chest. The nurse should plan further evaluation of which body system? A. Endocrine B. Cardiovascular C. Genitourinary D. Neurologic
A. Endocrine
The nurse notes a large keloid on the pierced ear of an adolescent. The client asks what caused this finding. Which of the following would the nurse incorporate into the response as the most likely cause? A. Excessive collagen formation B. Inadequate circulation C. Decreased subcutaneous tissue D. Continuous trauma
A. Excessive collagen formation
The nurse is preparing to test a client's eyes for accommodation. The nurse would have the client focus on an object in which sequence for this test? A. Far, then near B. Lateral, then far C. Lateral, then near D. Near, then far
A. Far, then near
Which finding should a nurse recognize as normal when assessing the ears of an elderly client? A. High tone frequency loss B. Bulging tympanic membrane C. Decrease in cerumen production D. Increased elasticity of the pinna
A. High tone frequency loss
A nurse is preparing a program on osteoporosis for a local women's group. What would the nurse cite as a risk factor? A. History of smoking B. Multiparity (multiple pregnancies) C. African-American ethnicity D. Obesity
A. History of smoking
The nurse is preparing to palpate the submandibular salivary glands. The nurse would place the hands at which location? A. Inferior to the mandible beneath the tongue B. Bilaterally, parallel to and anterior to the sternomastoid muscle C. On each side between the top of the ear and the eye D. On each side of the client's face, anterior and inferior to the ears
A. Inferior to the mandible beneath the tongue
A client reports right-sided temporal headache accompanied by nausea and vomiting. A nurse recognizes that which condition is likely to produce these symptoms? A. Migraine headache B. Bell's palsy C. Tension headache D. Temporal arteritis
A. Migraine headache
A 12-year-old patient has difficulty seeing the chalkboard but is able to read without trouble. What condition do they likely have? A. Myopia B. Hyperopia C. Presbyopia D. Scotoma
A. Myopia
When assessing the skin, hair, and nails of the older adult, the nurse needs to know the normal effects of aging on these structures. Which of the following are normal effects of aging on the integumentary system? Select all that apply. A. Nails become thick and brittle with slow growth B. The number of sweat and sebaceous glands increases C. Wound healing slows as a result of decreased mitotic activity D. Nails become thin and brittle with increased growth E. The epidermis thickens F. The epidermis thins
A. Nails become thick and brittle with slow growth C. Wound healing slows as a result of decreased mitotic activity F. The epidermis thins
On a health history, a client reports no visual disturbances, last eye exam two years ago, and does not wear glasses. The nurse notices that the client squints when signing the consent for treatment form and holds the paper close to the face. What should the nurse do next? A. Perform both the distant and near visual acuity tests B. Test the pupils for direct and consensual reaction to light C. Obtain a referral to the ophthalmologist for a complete eye exam D. Document the findings in the client's record
A. Perform both the distant and near visual acuity tests
A 66-year-old client states that he has increasing difficulty hearing high-pitched sounds. The patient's statement most likely suggests that he has what diagnosis? A. Presbycusis B. Otalgia C. Tinnitus D. Vertigo
A. Presbycusis
During a health history, a 48-year-old client states, "I've noticed that I need to hold my newspaper farther away so that I can read it." Which of the following would the nurse suspect? A. Presbyopia B. Cataracts C. Tropia D. Myopia
A. Presbyopia
The nurse observes a middle-aged colleague fully extending her arm to read the label on a vial of medication. Which of the following age-related changes is the nurse likely to have observed? A. Presbyopia B. Macular degeneration C. Loss of convergence D. Cataract formation
A. Presbyopia
Trauma that results in stretching or tearing of ligaments is referred to as: A. Sprain B. Strain C. Bursitis D. Tendinitis
A. Sprain
After examining the breast development of a 13-year-old girl, the nurse records breast and nipples appear as small mounds with areolar development evident. The appropriate stage of maturity would be: A. Stage 2 B. Stage 3 C. Stage 1 D. Stage 4
A. Stage 2
An adult client is having his skin assessed. The client tells the nurse he has been a heavy smoker for the last 40 years. The client has clubbing of the fingernails. What does this finding tell the nurse? A. The client has chronic hypoxia B. The client has melanoma C. The client has asthma D. The client has COPD
A. The client has chronic hypoxia
The nurse is completing a client's ear assessment. What assessment finding would indicate the need to perform Weber's test? A. The client has unilateral hearing loss. B. The client has a history of stroke. C. The client has suspected otitis externa. D. The client is older than age 65.
A. The client has unilateral hearing loss.
A nurse is testing the range of motion of a client's wrist for supination. Which movement will this involve? A. Turning the palm of the hand upward B. Moving the tips of the fingers away from the forearm C. Turning the palm of the hand downward D. Moving the tips of the fingers toward the forearm
A. Turning the palm of the hand upward
What is the most important focus area for the integumentary system? A. UV radiation exposure. B. Chemical exposure. C. Moles with defined borders smaller than 6 mm. D. Washing the face and hands.
A. UV radiation exposure.
The American Cancer Society currently recommends that palpation of the breast be done in what pattern? A. Vertical B. Circular C. Radial D. Horizontal
A. Vertical
The size and shape of the breasts in females are related to the amount of: A. fatty tissue. B. lactiferous ducts. C. glandular tissue. D. fibrous tissue.
A. fatty tissue.
A patient voices a concern about a milky discharge coming from her nipples. She is not pregnant and her youngest child is 7 years old. The nurse should ask questions with the understanding that causes of this milky discharge can be related to: (Select all that apply) A. hypothyroidism B. pituitary prolactinoma C. Paget disease D. intraductal papilloma E. dopamine agonist drugs
A. hypothyroidism B. pituitary prolactinoma E. dopamine agonist drugs
An adult client visits the clinic and tells the nurse that he has been experiencing double vision for the past few days. The nurse refers the client to a physician for evaluation of possible: A. increased intracranial pressure. B. hypertension. C. glaucoma. D. ophthalmic migraine.
A. increased intracranial pressure.
An adult male client visits the outpatient center and tells the nurse that he has been experiencing patchy hair loss. The nurse should further assess the client for: A. symptoms of stress. B. recent radiation therapy. C. pigmentation irregularities. D. allergies to certain foods.
A. symptoms of stress.
A nurse examines a client with complaints of a sore throat and finds that the tonsils are enlarged and touching one another. Using a grading scale of 1+ to 4+, how should the nurse appropriately document the tonsils? A. 1+ B. 4+ C. 3+ D. 2+
B. 4+
A nurse is assessing a small child who has lead poisoning. Which characteristic of the gums should the nurse expect this client? A. Enlarged, reddened B. A grey-white line C. Pink, moist, firm D. Red, bleeding
B. A grey-white line
Which of the following would the nurse suspect if assessment reveals a skull and facial bones that are larger and thicker than normal? A. Brain tumor B. Acromegaly C. Paget disease D. Parkinson disease
B. Acromegaly
A patient describes a painful, red eye with tunnel vision. What condition do they likely have? A. Chronic angle glaucoma B. Acute glaucoma C. Retinal detachment D. Scotoma
B. Acute glaucoma
When palpating the neck, performing which of the following techniques will help differentiate lymph nodes from a band of muscles? A. Observing for hypertrophy when the client turns the head against resistance B. Attempting to roll the structure up and down and side to side C. Applying pressure and assessing for induration D. Palpating for lateral movement when the client swallows a sip of water
B. Attempting to roll the structure up and down and side to side
Which clients are most at risk for depressive symptoms? Select all that apply. A. Males B. Chronically ill patients C. Females D. Married patients E. Divorced patients
B. Chronically ill patients C. Females E. Divorced patients
A client is being discharged home from the hospital. This client has a history of falling at home. A caregiver is not able to stay with the client all the time. What can be done to decrease the risk for falling at the client's home? Select all that apply. A. Have the client go to a physical therapy three times a week B. Correct environmental hazards in the home C. Install grab bars in the bathroom D. Place colorful throw rugs near the exits E. Make sure house hallways are well lit
B. Correct environmental hazards in the home C. Install grab bars in the bathroom E. Make sure house hallways are well lit
A patient presents to the clinic with "sores around the mouth." The nurse notes vesicular lesions on the upper lip and right corner of the lips. The patient describes these as painful. The nurse suspects what condition? A. Syphilis B. Herpes simplex C. Actinic cheilitis D. Angioedema
B. Herpes simplex
The nurse notes the client has weak pulses bilaterally. The nurse understands that this could indicate the client is experiencing what? A. Occlusion B. Hypovolemia C. Hypervolemia D. Constriction
B. Hypovolemia
A patient describes painless loss of central vision. She often peers off to the side to look straight ahead or to read. What condition does she likely have? A. Chronic angle glaucoma B. Macular degeneration C. Acute glaucoma D. Myopia
B. Macular degeneration
This condition is a common cause of poor central vision among the elderly. It is: A. Glaucoma B. Macular degeneration C. Presbyopia D. Retinal detachment
B. Macular degeneration
Which risk factor for traumatic brain injury should a nurse include in a discussion about prevention for a group of adolescents? A. Most firearm incidents are accidental B. Modes of transportation are the leading cause C. Falls occur more frequently in the younger population D. Females have twice the risk that males do
B. Modes of transportation are the leading cause
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 had a total hip replacement 2 years ago. C. The client suffered a fractured humerus 1 year earlier. D. The client has a diagnosis of type 1 diabetes.
B. The client had a total hip replacement 2 years ago.
As part of a mental status assessment, the nurse asks a client to draw the face of a clock. The nurse is assessing which of the following? A. Concentration and orientation B. Visual perceptual and constructional ability C. Expressions and feelings D. Perceptions and thought processes
B. Visual perceptual and constructional ability
An older client asks why vision is not as sharp as it used to be when the eyes are focused forward. What should the nurse realize this client is describing? A. detached retina B. macular degeneration C. cataracts D. glaucoma
B. macular degeneration
The nurse is assessing a middle-aged female client who is new to the clinic. The nurse observes the presence of significant facial hair that is uncharacteristic of the client's ethnicity. What assessment question should the nurse ask? A. "What dietary supplements do you usually take?" B. "Have you ever been assessed for diabetes?" C. "Do you take steroid medications on a regular basis?" D. "Has anyone in your family ever been diagnosed with skin cancer?"
C. "Do you take steroid medications on a regular basis?"
A nurse palpates an enlarged and tender left sided supraclavicular lymph node in a client. Where should the nurse focus the physical assessment to obtain more data about this finding? A. Upper extremities for changes in sensation, movement, and range of motion B. Head and neck area for signs of infection or inflammation C. Abdomen and thoracic area for changes associated with malignancy D. Spinal cord area for signs of degeneration and decreased mobility
C. Abdomen and thoracic area for changes associated with malignancy
While conducting an assessment, the nurse suspects that a client is making up things in response to specific questions. What behavior is this client demonstrating? A. Derailment B. Perseveration C. Confabulation D. Flight of ideas
C. Confabulation
When depression goes undiagnosed, what consequences occur eight times more frequently than in the general population? A. Bankruptcy B. Polyhedonia C. Death D. Comorbidity
C. Death
The nurse uses the Mini-Mental State Examination to assess a client. For which reason is this assessment tool most likely used? A. Depression B. Bipolar disorder C. Dementia D. Schizophrenia
C. Dementia
The nurse notes that a client's capillary refill is 5 seconds. What should this finding indicate to the nurse? A. A normal finding B. Vitamin C deficiency C. Hypoxia D. Infection
C. Hypoxia
A mother brings her child to the health care clinic and reports that her son has a four-day history of intense itching to his legs. On inspection of the child's legs, the nurse notes a honey-colored exudate coming from a vesicular rash bilaterally. The nurse recognizes this finding as what skin condition? A. Herpes zoster B. Psoriasis C. Impetigo D. Viral Exanthum
C. Impetigo
A client tells the nurse about a raised lesion on the client's leg. What is the nurse's first nursing action? A. Document the statement B. Ask further questions C. Inspect the area D. Move on to next body system
C. Inspect the area
Scoliosis is a ___________ curvature of the spine. A. Kyphotic B. Lordotic C. Lateral D. Lumbar
C. Lateral
During an oral assessment, the nurse identifies that client has white patches in his mouth. How would this be documented in the medical record? A. Gingivitis B. Fordyce granules C. Leukoplakia D. Petechiae
C. Leukoplakia
During your physical examination of the patient you note an enlarged tender tonsillar lymph node. What would you do? A. Look for involvement of other regions of the body B. Assess for dietary changes C. Look for a source such as infection in the area that it drains D. Assess for meningitis
C. Look for a source such as infection in the area that it drains
Which of the following symptoms is not characteristic of hypothyroidism? A. Hoarseness B. Intolerance to cold C. Palpitations D. Constipation
C. Palpitations
A nurse is teaching a group of children about how to grow healthy bones and to prevent osteoporosis later in life. Which of the following should the nurse mention? Select all that apply. A. Drinking 8 cups of water per day B. Eating a low-fat diet C. Playing outside in the sun for at least 20 minutes a day D. Wearing sunscreen when outdoors E. Drinking plenty of vitamin D-fortified milk
C. Playing outside in the sun for at least 20 minutes a day E. Drinking plenty of vitamin D-fortified milk
A patient describes increasing difficulty reading print but fine vision otherwise. What condition do they likely have? A. Myopia B. Hyperopia C. Presbyopia D. Scotoma
C. Presbyopia
A nurse assesses a client for past history of nail problems. The nurse should ask questions about which of these conditions? A. Alopecia, dermatitis, chemotherapy B. Eczema, melanoma, herpes zoster C. Psoriasis, fungal infections, trauma D. Vitiligo, hirsutism, vitamin deficiency
C. Psoriasis, fungal infections, trauma
The nurse documents "Romberg test positive" on a client's medical record. What did the nurse most likely assess in this client? A. Unsteady gait B. Weak hand grasps C. Swaying D. Poor brachial reflex
C. Swaying
The nurse is performing a breast exam. Which area would be most important for the nurse to assess? A. Lower inner quadrant B. Lower outer quadrant C. Upper outer quadrant D. Upper inner quadrant
C. Upper outer quadrant
The nurse assesses a client and palpates a temporal artery that is hard, thick, and tender with absent pulsations. The nurse would gather additional information related to which aspect of health? A. Hearing B. Neurologic status C. Vision D. Mental status
C. Vision
A client's tongue and oral mucosa are blue-tinged in color. What health problem should the nurse suspect this client is experiencing? A. anemia B. liver disease C. advanced lung disease D. congestive heart failure
C. advanced lung disease
While assessing the skin of an older adult client, the nurse observes that the client has small yellowish brown patches on her hands. The nurse should instruct the client that these spots are A. signs of dermatitis. B. precancerous lesions. C. caused by aging of the skin in older adults. D. signs of an infectious process.
C. caused by aging of the skin in older adults.
A sign of infection in the elder that is more common than fever is: A. diarrhea. B. cough. C. confusion. D. pain.
C. confusion.
An adult client tells the nurse that her peripheral vision is not what it used to be and she has a blind spot in her left eye. The nurse should refer the client for evaluation of possible: A. bacterial infection. B. migraine headaches. C. glaucoma. D. increased intracranial pressure.
C. glaucoma.
While assessing an adult client, the nurse observes freckles on the client's face. The nurse should document the presence of A. plaques. B. papules. C. macules. D. bulla.
C. macules.
A client is diagnosed with a scotoma. What question is appropriate for the nurse to ask to obtain more data about this condition? A. "How often do you have redness or tearing?" B. "Is night blindness a problem for you?" C. "Do you see floaters in front of your eyes?" D. "Are the blind spots constant or intermittent?"
D. "Are the blind spots constant or intermittent?"
A 72-year-old teacher comes to a skilled nursing facility for rehabilitation after being in the hospital for 6 weeks. She was treated for sepsis and respiratory failure and had to be on a ventilator for 3 weeks. The nurse is completing an initial assessment and evaluating the client's skin condition. On her sacrum there is full-thickness skin loss that is 5 cm in diameter with damage to the subcutaneous tissue. The underlying muscle is not affected. What is the stage of this pressure ulcer? A. 4 B. 1 C. 2 D. 3
D. 3
The nurse is assessing a client's tonsils and note that they touch the uvula. The nurse would document this finding as which of the following? A. 4+ B. 1+ C. 2+ D. 3+
D. 3+
The nurse notes a tophus of the ear of an older adult. Which assessment data is consistent with a tophus? A. A sac with a membranous lining filled with fluid B. Redness and bulging of the eardrum C. Scarring of the tympanic membrane D. A hard nodule composed of uric acid crystals
D. A hard nodule composed of uric acid crystals
Which technique by the nurse demonstrates proper use of the ophthalmoscope? A. Approaches the client directly in front of the pupil B. Uses right eye to examine the client's left eye C. Moves the scope around so the entire optic disk may be seen D. Asks the client to fix the gaze upon an object and look straight ahead
D. Asks the client to fix the gaze upon an object and look straight ahead
The nurse is assessing cranial nerves and should look for which sign of cranial nerve VII damage? A. Tongue deviation B. Puffy "moon" face C. Hearing loss D. Asymmetrical smile
D. Asymmetrical smile
When recording the findings of the lymph glands, a nurse should note all except: A. Size B. Shape C. Consistency D. Color
D. Color
The ICU nurse is caring for a trauma victim whose status is critical. On assessment, the nurse notes uremic frost along the client's hairline. What would this indicate to the nurse? A. Respiratory failure B. Cardiovascular failure C. Hepatic failure D. Renal failure
D. Renal failure
A patient describes increasing floaters and flashing lights in their vision. What condition do they likely have? A. Scotoma B. Chronic angle glaucoma C. Acute glaucoma D. Retinal detachment
D. Retinal detachment
An older adult female client is concerned because her skin is very dry. She asks the nurse why she has dry skin now when she never had dry skin before. The nurse responds to the client based on the understanding that dry skin is normal with aging due to a decrease of what? A. Squamous cells B. Sweat glands C. Subcutaneous tissue D. Sebum production
D. Sebum production
A nurse is assessing an older adult client's risk for pressure ulcers using the Braden Scale for Predicting Pressure Sore Risk. Which aspect of the client's current health status would be reflected in her score on this scale? A. The client adheres to a vegetarian diet. B. The client has a surgical diagnosis. C. The client has a full-time caregiver. D. The client is consistently incontinent of urine.
D. The client is consistently incontinent of urine.
The nurse is planning to assess a client for graphesthesia. How will the nurse perform this phase of assessment? A. The nurse will simultaneously touch the client in the same area on both sides of the body, and the client will identify where the touch occurred. B. The client is asked to identify the number of points felt when the nurse touches the client with the ends of two applicators at the same time. C. Have the client close the eyes. The nurse will then gently touch the client, and the client will identify where the touch occurred. D. The client will close the eyes and identify what number the nurse writes in the palm of the client's hand with a blunt-ended object.
D. The client will close the eyes and identify what number the nurse writes in the palm of the client's hand with a blunt-ended object.
A nurse wants to assess a client's orientation. The nurse recognizes that which orientation is usually lost first when the client is confused? A. Person B. Location C. Place D. Time
D. Time
A patient is found to have a smooth, glossy tongue. What vitamin deficiency might this indicate? A. Vitamin B1 deficiency B. Vitamin D deficiency C. Vitamin C deficiency D. Vitamin B12 deficiency
D. Vitamin B12 deficiency
What light should the nurse use to inspect a lesion on the thigh of a client for the presence of fungus? A. Artificial light B. Flashlight C. Sunlight D. Wood's light
D. Wood's light
The nurse notes that a client's nails are greater than a 160-degree angle. What should the nurse assess as a priority for this client? A. bowel sounds B. body temperature C. heart sounds D. pulse oximetry
D. pulse oximetry
A client complains of a headache over both temporal areas. What type of headache should the nurse suspect the client is experiencing? A. hypertensive B. migraine C. cluster D. tension
D. tension
True or false: After testing deep tendon reflexes, the nurse documents 2+. The nurse should evaluate further.
False
True or false: Local redness of the skin warns of impending necrosis.
True
True or false: The thyroid gland is usually larger in women than in men.
True
A 52-year-old patient with myopia calls the ophthalmology clinic very upset. She tells the nurse, "I keep seeing semi-clear spots floating across my vision. What is wrong with me?" What would be the most appropriate response by the nurse? A. "It is not an uncommon finding in people older than 40 years for this to happen. They are called 'floaters'." B. "I have an opening tomorrow at 2 in the afternoon. Can you come in then?" C. "Please come into the clinic right away so we can see what is wrong." D. "Because it is almost 5 o'clock, please go to the emergency department right away. This sounds very serious."
A. "It is not an uncommon finding in people older than 40 years for this to happen. They are called 'floaters'."
Where is the temporal artery palpated? A. Above the cheek bone near the scalp line B. Just left of midline at the base of the neck C. Between the mandibular joint and the base of the ear D. Just left or right of the spine at the base of the skull
A. Above the cheek bone near the scalp line
Upon examination of the head and neck of a client, a nurse notes that the submandibular nodes are tender and enlarged. The nurse should assess the client for further findings related to what condition? A. Acute infection B. Metastatic disease C. Chronic infection D. Cushing's disease
A. Acute infection
A golden yellow pigment that is heavily keratinized and is found in subcutaneous fat is called what? A. Carotene B. Melanin C. Deoxyhemoglobin D. Oxyhemoglobin
A. Carotene
A nurse is working with a client who has a history of headaches. When preparing to assess the client's temporomandibular joint (TMJ), the nurse should provide what instruction? A. "When I place my hands on your cheeks, clench your teeth and then relax them." B. "I'm going to put my fingers in front of your ears and ask you to open your mouth wide." C. "Turn so I can see the side of your face and then open your mouth wide like you're yawning." D. "I'm going to press on several different places below and in front of your ear."
B. "I'm going to put my fingers in front of your ears and ask you to open your mouth wide."
The nurse measures a client's pupils and documents the size. Which size would the nurse document as normal? A. 8 mm B. 4 mm C. 6 mm D. 2 mm
B. 4 mm
A client diagnosed with goiter has undergone a thyroidectomy. Which statement from the client indicates understanding of post-operative care teaching? A. I will complete the entire course of thyroid hormone replacement over six weeks. B. I must take thyroid hormone replacement medication for the rest of my life. C. I must keep my follow up appointments to receive my thyroid hormone injections. D. I will take my thyroid hormone replacement medication once every week.
B. I must take thyroid hormone replacement medication for the rest of my life.
Mrs. Hill is a 28-year-old woman of African ancestry with a history of systemic lupus erythematosis (SLE). She has noticed a raised dark red rash on her legs. When the nurse presses on the rash, it doesn't blanch. What would the nurse tell the client regarding her rash? A. It is likely to be related to an allergic reaction. B. It is likely to be related to her lupus. C. It should not cause any problems. D. It is likely to be related to an exposure to a chemical.
B. It is likely to be related to her lupus.
While performing a nursing assessment, the nurse finds the client's nail beds, fingers, and lips to be cyanotic. What is the best response of the nurse? A. Administer oxygen B. Notify the health care provider C. Administer IV fluids D. Reassess in 30 minutes
B. Notify the health care provider
A nurse palpates a client's ear and finds that the tragus is tender. The nurse suspects which of the following? A. Otitis media B. Otitis externa C. Ruptured tympanic membrane D. Mastoiditis
B. Otitis externa
When assessing the elbow, a nurse asks the client to hold the arm out and turn the palm down. The nurse is testing which of the following? A. Supination B. Pronation C. Flexion D. Rotation
B. Pronation
Which characteristic feature of the tympanic membrane should a nurse anticipate finding in a client with otitis media? A. Pearly, translucent with no bulging B. Red, bulging with an absent light reflex C. Yellowish, bulging with fluid bubbles D. Gray, translucent with retraction
B. Red, bulging with an absent light reflex
The nurse is assessing a client complaining of swelling in the neck. While palpating the neck, the nurse finds a 2-cm lump that is fixed and hard. Why does this finding require emergency investigation? A. This could be a sign of an embolus B. This could be a sign of cancer C. This could be a sign of a parotid stone D. This could be a sign of pneumothorax
B. This could be a sign of cancer
The nurse is preparing to examine an adult client's eyes using a Snellen chart. The nurse should: A. ask the client to remove his glasses. B. position the client 609.6 cm (20 ft) away from the chart. 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.
B. position the client 609.6 cm (20 ft) away from the chart.
The nurse assesses an older adult bedridden client in her home. While assessing the client's buttocks, the nurse observes that a small area of the skin is broken and resembles an erosion. The nurse should document the client's pressure ulcer as: A. stage I. B. stage II. C. stage III. D. stage IV.
B. stage II.
A client visits the clinic and tells the nurse that he is depressed because of a recent job loss. He complains of dull, aching, tight, and diffuse headaches that have lasted for several days. The nurse should recognize that these are symptoms of: A. tumor-related headaches. B. tension headaches. C. migraine headaches. D. cluster headaches.
B. tension headaches.
Prevention is the best policy for treating traumatic brain injuries (TBI). The age group with the highest incidents of TBI related to falls are: A. Children, age 0 to 4 B. Adolescents, age 15 to 19 C. Adults, age 65 and older D. Older adults, age 75 and older
C. Adults, age 65 and older
An 81-year-old client complains of neck pain and demonstrates decreased range of motion on examination. Which of the following causes should the nurse most suspect in this client? A. Meningeal inflammation B. Stress C. Arthritis D. Injury to the sternomastoid
C. Arthritis
A client presents to the health care clinic with reports of onset of neck pain 3 days ago. The nurse recognizes that the most common cause of neck pain is what condition? A. Compression fractures B. Cervical spinal cord compression C. Cervical strain D. Cervical disc degenerative disease
C. Cervical strain
A nurse is instructing a client on how to assess himself for herpes simplex lesions by their configuration. Which configuration should the nurse tell the client to look for? A. Linear B. Annular C. Clustered D. Discrete
C. Clustered
A nurse shines a light into one of the client's eyes during an ocular exam and the pupil of the other eye constricts. The nurse interprets this as which of the following? A. Accommodation B. Direct reflex C. Consensual response D. Optic chiasm
C. Consensual response
The nurse is preparing to examine a client's skin. What would the nurse do next? A. Have the client remove clothing from the upper body. B. Wear gloves when preparing to inspect the skin and nails. C. Expose only the body part that is being examined. D. Ensure that the room is hot to prevent chilling.
C. Expose only the body part that is being examined.
The nurse detects enlarged, tender preauricular nodes in a client. Which of the following would the nurse need to examine for possible infection? A. Teeth B. Lips C. Eyes D. Sinuses
C. Eyes
The nurse is planning to assess a client's near vision. Which technique should be used? A. Ask the client to move the eyes in the direction of a moving finger B. Shine a light on the bridge of the nose C. Have the client read newspaper print held 14 inches from the eyes D. Have the client stand 20 feet from a wall chart and read the letters after covering one eye
C. Have the client read newspaper print held 14 inches from the eyes
A nurse is providing care at an inner-city shelter, and a man who frequents the shelter presents with a significant frontal growth that is located midline at the base of his neck. The nurse should recognize the need for what referral? A. Referral for further assessment of swallowing ability B. Referral for assessment of cranial nerve function C. Referral for further assessment of thyroid function D. Referral for assessment of lymphatic system function
C. Referral for further assessment of thyroid function
An adult client tells the nurse that his father had cataracts. He asks the nurse about risk factors for cataracts. The nurse should instruct the client that a potential risk factor is: A. use of antibiotics. B. obesity. C. ultraviolet light exposure. D. lack of vitamin C in the diet.
C. ultraviolet light exposure.
The nurse is preparing to examine the skin of an adult client with a diagnosis of herpes simplex. The nurse plans to measure the client's symptomatic lesions and measure the size of the client's: A. wheals. B. bullae. C. vesicles. D. nodules.
C. vesicles.
The nurse notes multiple elevated masses with irregular transient borders that are superficial, raised, and erythematous in a client who complains of an "itching rash." Which question would be most important for the nurse to ask? A. "Does anyone else in your family have a rash like this?" B. "What have you been doing to control the itching?" C. "Have you ever had a rash like this before?" D. "Are you allergic to foods, medications, or other substances?"
D. "Are you allergic to foods, medications, or other substances?"
The nurse notes a cyst on the ear of an older adult. Which assessment data is consistent with a cyst? A. A hard nodule composed of uric acid crystals B. Redness and bulging of the eardrum C. Swelling of the external ear canal D. A sac with a membranous lining filled with fluid
D. A sac with a membranous lining filled with fluid
A nurse notes that a client looks much older than his chronologic age. Which of the following conditions would most likely contribute to this appearance? A. Marfans syndrome B. Parkinsons disease C. Cushings syndrome D. Alcoholism
D. Alcoholism
An 8-year-old girl comes with her mother for evaluation of hair loss. The girls denies pulling or twisting her hair, and her mother has not noted this behavior at all. She does not put her daughter's hair in braids. Physical examination reveals a clearly demarcated, round patch of hair loss without visible scaling or inflammation. No hair shafts are visible. Based on this description, what is the most likely diagnosis? A. Traction alopecia B. Tinea capitis C. Trichotillomania D. Alopecia areata
D. Alopecia areata
A nurse observes the presence of hirsutism on a female client. The nurse should perform further assessment on this client for findings associated with which disease process? A. Lupus erythematosus B. Basal cell carcinoma C. Iron deficiency anemia D. Cushing's disease
D. Cushing's disease
Which layer of the skin contains blood vessels, nerves, sebaceous glands, lymphatic vessels, hair follicles, and sweat glands? A. Subcutaneous layer B. Connective layer C. Epidermis D. Dermis
D. Dermis
The terms "generalized," "exposed surfaces," "upper arm," and "skin folds" are used to describe which major characteristic of skin lesions? A. Arrangement B. Color C. Type D. Distribution
D. Distribution
A nurse performs palpation of a client's lymph nodes. Which finding should be reported to the health care provider? A. Mobile from side to side B. Soft in consistency C. Round and 8 mm in size D. Fixed to underlying tissue
D. Fixed to underlying tissue
After describing how to assess the sinuses to a group of students, the students demonstrate understanding of the teaching when they identify which sinuses as being located in the upper jaw? A. Frontal B. Sphenoidal C. Ethmoidal D. Maxillary
D. Maxillary
Upon inspection of a client with reports of a fever, the nurse notices that the client's earlobes are asymmetrical in appearance. The nurse recognizes that the most common cause for the asymmetry of the earlobes is what condition? A. Thyroid enlargement B. Bell's palsy C. Acute pharyngitis D. Parotid enlargement
D. Parotid enlargement
A young man comes to the clinic with an extremely pruritic rash over his knees and elbows, which has come and gone for several years. It seems to be worse in the winter and improves with some sun exposure. Examination reveals scabbing and crusting with some silvery scales. The nurse also notices small "pits" in the nails. What would account for these findings? A. Tinea infection B. Pityriasis rosea C. Eczema D. Psoriasis
D. Psoriasis
On examination of a client, the nurse detects a fecal odor to the breath. The nurse recognizes this finding as characteristic of what disease process? A. End-stage liver disease B. Diabetic ketoacidosis C. Respiratory infection D. Small bowel obstruction
D. Small bowel obstruction
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 pigmentation of the client's skin C. The client's history of integumentary disorders D. The client's ability to change position
D. The client's ability to change position
Palpation of a 15-year-old boy's submandibular lymph nodes reveals them to be enlarged and tender. What is the nurse's most reasonable interpretation of this assessment finding? A. The boy requires assessment of his thyroid gland. B. There is an inflammatory response in the musculature of the boy's neck. C. The tissue underlying the nodes is infected. D. There is an infection in the area that these nodes drain.
D. There is an infection in the area that these nodes drain.
While assessing an adult client, the nurse observes an elevated, palpable, solid mass with a circumscribed border that measures 0.75 cm. The nurse documents this as a: A. patch. B. macule. C. plaque. D. papule.
D. papule.
The nurse is planning to assess a client's lymph nodes. Which set of nodes should the nurse assess first? A. submental B. superficial cervical C. supraclavicular D. preauricular
D. preauricular
