Nurs 225 Midterm Practice Qs

When using the opthalmoscope, the interruption of the red reflex occurs when: a) There is opacity in the cornea or lens b) The patient has a pathologic process of the optic tract c) The blood vessels are tortuous d) The pupils are constricted

a) There is opacity in the cornea or lens

What assessment techniques do you use when assessing the skin, hair, and nails?

Inspection and palpation

A patient asks the nurse what her Snellen eye test results mean. Her visual acuity is 20/30. Which of the following responses is appropriate? a) "Your eyes see at 20 feet what visually unimpaired eyes see at 30 feet." b) "Your right eye can see the chart clearly at 20 feet and your left eye can see the chart clearly at 30 feet." c) "Your eyes see aat 30 feet what visually unimpaired eyes see at 20 feet." d) "Your left eye can see the chart clearly at 20 feet and your right eye can see the chart clearly at 30 feet."

a) "Your eyes see at 20 feet what visually unimpaired eyes see at 30 feet."

Which of the following is a normal assessment finding for the shape of the nails? a) About 160 degrees b) Concave c) Greater than 180 degrees d) Spoon shaped

a) About 160 degrees

A 18 year old patient presented to the emergency room with a pneumothorax of the right lower lobe. The physician recommended the placement of a chest tube. The nurse would expect to auscultate which type of lung sounds in the right lower lobe? a) Absent breath sounds b) Clear breath sounds c) Crackle breath sounds d) Rhonchi breath sounds

a) Absent breath sounds

When assessing a client with chest trauma, the nurse notes that the client is taking small breaths at first, then bigger breaths, and then a couple of small breaths, then 10 to 20 seconds of no breaths. How should the nurse record the breathing pattern? a) Cheyne-Stokes respiration b) Hyperventilation c) Obstructive sleep apnea d) Biots respiration

a) Cheyne-Stokes respiration

Which of the following may indicate internal hemorrhage? Select all that apply. a) Distension or swelling of affected body part b) An elevated white blood cell count c) A decreased blood pressure and increased pulse d) A change in the type and amount of drainage from a surgical drain

a) Distension or swelling of affected body part c) A decreased blood pressure and increased pulse d) A change in the type and amount of drainage from a surgical drain

A patient has a barrel-shaped chest, characterized by: a) Equal anteroposterior transverse diameter and ribs being horizontal b) Anteroposterior transverse diameter of 1:2 and an elliptic shape c) Anteroposterior transverse diameter of 2:1 and ribs being elevated d) Anteroposterior transverse diameter of 3:7 and ribs sloping back

a) Equal anteroposterior transverse diameter and ribs being horizontal

When teaching a patient about wound healing, the nurse should tell the patient which of the following? a) Inadequate nutrition delays wound healing and increases the risk of infection b) Chronic wounds heal more efficiently in a dry, open environment, so leave them open to air whenever possible c) Long-term steroid therapy diminishes the inflammatory response and speeds wound healing d) Fat tissue heals more readily because there is less vascularization

a) Inadequate nutrition delays wound healing and increases the risk of infection

Identify contributing factors to pressure ulcer formation. Select all that apply. a) Malnutrition b) Middle age c) Decreased sensory perception/mobility d) Stress e) Excessive sweating f) Ethnic background

a) Malnutrition c) Decreased sensory perception/mobility d) Stress e) Excessive sweating

The techniques used to assess vital signs include: Select all that apply. a) Observation b) Inspection c) Auscultation d) Light palpation e) Deep palpation

a) Observation b) Inspection c) Auscultation d) Light palpation

A nurse is assessing a client's thyroid gland as a part of a comprehensive physical examination. Which of the following findings should the nurse expect? Select all that apply. a) Palpating the thyroid in the lower half of the neck b) Visualizing the thyroid on inspection of the neck c) Hearing a bruit when auscultating the thyroid d) Feeling the thyroid ascend as the client swallows e) Finding the symmetric extension of the trachea on both sides of the midline

a) Palpating the thyroid in the lower half of the neck d) Feeling the thyroid ascend as the client swallows e) Finding the symmetric extension of the trachea on both sides of the midline

After the review of systems is documented, the nurse's next assessment step is to: a) Perform a physical assessment b) Look at the laboratory data c) Medicate d) Make a nursing diagnosis

a) Perform a physical assessment

Which of the following assessments best confirms symmetric chest expansion? a) Placing hands on the posterolateral chest wall with thumbs at the level of T9 or T10 aand then sliding the hands up to pinch a small fold of skin between the thumbs b) Inspection of the shape and configuration of the chest wall c) Placing the palmar surface of one hand against the chest and having the person repeat the words "ninety-nine" d) Percussion of the posterior chest

a) Placing hands on the posterolateral chest wall with thumbs at the level of T9 or T10 aand then sliding the hands up to pinch a small fold of skin between the thumbs

A nurse in a provider's office is documenting his findings following an assessment he performed for a client new to the practice. Which of the following parameters should he include as part of the general survey? Select all that apply. a) Posture b) Skin lesions c) Speech d) Allergies e) Immunization

a) Posture b) Skin lesions c) Speech

A nurse is assessing a client who has an acute respiratory infection that places her at risk for hypoxemia. Which of the following findings are early indicators that should alert the nurse that the patient is developing hypoxemia? Select all that apply. a) Restlessness b) Tachypnea c) Bradycardia d) Confusion e) Pallor

a) Restlessness b) Tachypnea d) Confusion e) Pallor

The nurse is eliciting objective data when asking the patient to: a) State her name, the time, and where she is b) State if her pain is a 6 on a scale of 0 to 10 c) State when the pain started d) State if she could be pregnant

a) State her name, the time, and where she is

Visual acuity is assessed with: a) The Snellen eye chart b) An opthalmoscope c) The Hirschberg test d) The Confrontation test

a) The Snellen eye chart

The nurse is caring for a patient after major abdominal surgery. Which of the following demonstrates the correct understanding in regard to wound dehiscence? a) The nurse should be alert for an increase in serosanguineous drainage from the wound b) Wound dehiscence is most likely to occur during the first 24-48 hours after surgery c) The nurse should administer a cough suppressant to prevent wound dehiscence d) The condition is an emergency that requires surgical repair

a) The nurse should be alert for an increase in serosanguineous drainage from the wound

Identify prevention strategies for pressure ulcers. Select all that apply. a) Use a moisture barrier ointment; apply after incontinent episodes b) Reposition at least every 4 hours; use a written schedule c) When the patient is in the side-lying position in bed use the 30-degree lateral position d) Place the patient on a pressure-reducing support surface e) Maintain the head of the bed at 45 degrees f) Massage the reddened bony prominences g) Oral supplements should be instituted if the patient is found to be undernourished

a) Use a moisture barrier ointment; apply after incontinent episodes c) When the patient is in the side-lying position in bed use the 30-degree lateral position d) Place the patient on a pressure-reducing support surface g) Oral supplements should be instituted if the patient is found to be undernourished Rationale: - Increased moisture contributes to formation of pressure ulcers, to moisture-barrier ointment is an effective preventative strategy - Patients should be reposition at least every 2 hours, not 4 - The 30 degree tilt is the standard hospital bed position for comfort & safety - Bony prominences should not be massaged to prevent irritation or damage to skin. Bony prominences are at higher risk of developing pressure ulcers than other areas of the body - Malnutrition impairs wound healing, so proper nutrition will aid in the prevention of ulcer formation

The function of the nasal turbinates' is to: a) Warm the inhaled air b) Detect odors c) Stimulate tear formation d) Lighten the weight of the skull bones

a) Warm the inhaled air

Which of the following would be considered an abnormal assessment finding? a) A patient's skin is warm to the touch b) A patient's tongue is covered in a white-yellowish coating c) A patient's hair is thick in texture and light brown in color d) A patient's nails display a 160 degree shape/curvature

b) A patient's tongue is covered in a white-yellowish coating Rationale: this can indicate a fungal infection, e.g. thrush

A patient comes to the ER reporting nasal drainage at home that is green or yellow in color. The nurse suspects this patient may have a) A cold b) A sinus infection c) Nasal cancer d) Pneumonia

b) A sinus infection

A patient comes to the ER reporting nasal drainage at home that is green or yellow in color. The nurse suspects this patient may have: a) A cold b) A sinus infection c) Nasal cancer d) Pneumonia

b) A sinus infection

Your 32 year old female patient was admitted due to pain and swelling in her neck. Her submandibular lymph nodes are tender, immobile, and warm to touch. You suspect that these assessment findings are due to: a) A blood clot b) An infection c) A motor vehicle accident d) Old age

b) An infection

A 42 year old female patient has a chest tube in the left lower lobe of her lung. In caring for a patient with a chest tube, the nurse understands the importance of checking for an air leak and the presence of subcutaneous air. The nurse would assess the patient for a) Broncophony b) Crepitus c) Decreased breath sounds d) Tactile fremitus

b) Crepitus

A nurse is instructing a group of nursing students in the priorities of care in performing an integumentary assessments for their clients. Which of the following findings should the students recognize as requiring immediate intervention? a) Pallor b) Cyanosis c) Jaundice d) Erythema

b) Cyanosis

During an inspection of a patient's nares, a deviated septum is noted. What should the nurse do next? a) Request a consultation with an ear, nose, and throat doctor b) Document the deviation in the medical record in case the person needs to be suctioned c) Teach the person what to do if a nosebleed should occur d) Explore further because polyps frequently accompany a deviated septum

b) Document the deviation in the medical record in case the person needs to be suctioned

A nurse is assessing an adult client's internal ear canals with an otoscope as a part of a head an neck examination. Which of the following actions are appropriate? Select all that apply. a) Pull the auricle down and back b) Insert the speculum lightly down and forward c) Insert the speculum 2 - 2.5 cm (0.8 - 1 inch) d) Make sure the speculum does not touch the ear canal e) Use light to visualize the tympanic membrane in a cone shape

b) Insert the speculum lightly down and forward d) Make sure the speculum does not touch the ear canal e) Use light to visualize the tympanic membrane in a cone shape Rationale: the aurical should be pulled up and back. The speculum should be inserted halfway into the ear canal, less than 2 cm.

Select the best description of bronchovesicular breath sounds. a) High-pitched, of longer duration on inspiration than expiration b) Moderate-pitched, inspiration equal to expiration c) Low-pitched, inspiration greater than expiration d) Rustling sounds, like wind in the trees

b) Moderate-pitched, inspiration equal to expiration

You are assessing your patient's pupils for pupillary reaction and accommodation. You notice that the patient's eyes are very slow to constrict. Which of the following actions would you take? a) Document this as a normal assessment finding b) Notify the patient's physician c) Reassess the patient's pupils in 5 minutes d) Recheck your penlight (maybe it was not bright enough)

b) Notify the patient's physician

You are assessing your patient's pupils for pupillary reaction and accommodation. You notice that the patient's eyes are very slow to constrict. Which of the following actions would you take? a) Document this as a normal assessment finding. b) Notify the patient's physician c) Reassess the patient's pupils in 5 minutes d) Recheck your penlight maybe it was not bright enough

b) Notify the patient's physician

Vital signs, level of consciousness, and skin color that you observe are considered which type of data? a) Focused data b) Objective data c) Secondary data d) Subjective data

b) Objective data

The nurse is assessing a confused patient. In trying to determine the client's level of pain, the nurse should a) Be aware that confused patients do not feel as much pain due to their confusion b) Observe the client carefully for changes in behavior or vital signs c) Ask the client's family how much pain the client normally has d) Use only pain scales that feature numbers or faces the client can point to

b) Observe the client carefully for changes in behavior or vital signs Rationale: Nurse should observe the confused client for non verbal cues to pain when they cannot express it verbally.

A patient is experiencing moderate respiratory distress. In addition to lung sounds and use of accessory muscles, the nurse performs this assessment to assess the patient's arterial oxygenation. a) Obtains the respiratory rate b) Obtains a pulse oximetry reading c) Obtains a reading from the end-tidal CO2 meter d) Obtain a reading from the peak flow meter

b) Obtains a pulse oximetry reading

A patient comes to the clinic and reports pain when he touches his ear. This finding is most consistent with: a) Acoustic neuroma b) Otitis externa c) Otitis media d) Meniere disease

b) Otitis externa

You assess a patient who reports a cough. The characteristic timing of the cough of chronic bronchitis is described as: a) Continuous throughout the day b) Productive cough for at least 3 months of the year for 2 consecutive years c) Occurring in the afternoon or evening because of exposure to irritants at work d) Occurring in the early morning

b) Productive cough for at least 3 months of the year for 2 consecutive years

During the otoscopic examination of a child younger than 3 years, the nurse: a) Pulls the pinna up and back b) Pulls the pinna down c) Holds the pinna gently but firmly in its normal position d) Tilts the head slightly toward the examiner

b) Pulls the pinna down

Conjunctivitis is associated with: a) Absent red reflex b) Reddened conjunctiva c) Impairment of vision d) Fever

b) Reddened conjunctiva

A 70 year old woman reports dry mouth. The most frequent cause is: a) The aging process b) Related to the medications she may be taking c) The use of dentures d) Related to a diminished sense of smell

b) Related to the medications she may be taking

The nurse records "positive consensual light reflex." This indicates: a) Convergence of the axes of the eyeballs b) Simultaneous constriction of the other pupil when one eye is exposed to bright light c) Reflex direction of the eye toward an object attracting a person's attention d) Adaptation of the eye for near vision

b) Simultaneous constriction of the other pupil when one eye is exposed to bright light

A nurse is completing an integumentary assessment of a client who has anemia. Which of the following is an expected finding? a) Absent turgor b) Spoon-shaped nails c) Shiny, hairless legs d) Yellow mucous membranes

b) Spoon-shaped nails

The nurse is admitting an older patient from a nursing home. During the assessment, the nurse notes a shallow open ulcer without slough on the right heel of the patient. The pressure ulcer would be staged as: a) Stage 1 b) Stage 2 c) Stage 3 d) Stage 4

b) Stage 2

The nurse understands that the next assessment step for a patient who is having dyspnea would be: a) Ambulate to expand the lungs b) Send for a chest x-ray c) Check oxygen saturation d) Place the patient on 100% oxygen

c) Check oxygen saturation

On examining a patient's nails, the nurse notes that the angle of the nail base is > 160 degrees and the nail base feels spongy on palpation. These findings are consistent with: a) Acute respiratory distress syndrome b) Normal findings for the nails c) Congenital heart disease and chronic obstructive pulmonary disease (COPD) d) Atelectasis

c) Congenital heart disease and chronic obstructive pulmonary disease (COPD)

The nurse is caring for a patient with a pressure ulcer on the left hip. The ulcer is black. The nurse recognizes that the next step in caring for this patient includes: a) Monitoring of the wound b) Irrigation of the wound c) Debridement of the wound d) Management of drainage

c) Debridement of the wound

You are auscultating breath sounds on a patient. Which of the following best describes how to proceed? a) Hold the bell of the stethoscope against the chest wall; listen to the entire right field and the entire left field. b) Listen from the apices to the bases of each lung field using the bell of the stethoscope. c) Hold the diaphragm of the stethoscope against the chest wall; listen to one full respiration in each location, being sure to do side to side comparisons d) Select the bell or diaphragm depending on the quality of sounds heard; listen for one respiration in each location, moving from side to side.

c) Hold the diaphragm of the stethoscope against the chest wall; listen to one full respiration in each location, being sure to do side to side comparisons

The 6 eye muscles that control eye movement are innervated by cranial nerves: a) II, III, V b) IV, VI, VII c) III, IV, VI d) II, III, VI

c) III, IV, VI

The cover test is used to assess for: a) Nystagmus b) Peripheral vision c) Muscle weakness d) Visual acuity

c) Muscle weakness The cover test detects deviated alignment of the eyes. The examiner covers one of the patient's eyes with an opaque card, then moves the card. If the eye jumps back into a straight gaze, the test is positive and eye muscle weakness is detected.

A nurse in a provider's office is preparing to auscultate and percuss a client's thorax as a part of a comprehensive physical examination. Which of the following findings should the nurse expect? Select all that apply. a) Rhonchi b) Crackles c) Resonance d) Tactile fremitus e) Bronchovesicular sounds

c) Resonance d) Tactile fremitus e) Bronchovesicular sounds

A nurse should interpret which finding as an early sign of a tension pneumothorax in a patient with chest trauma? a) Diminished bilateral breath sounds b) Muffled heart sounds c) Respiratory distress d) Tracheal deviation

c) Respiratory distress

You are receiving report at the start of your shift about a 60 year old male with a history of eye trauma. You are told that this patient is experiencing difficulty with his peripheral vision. Which of the following assessment findings would you expect? Select all that apply. a) The patient's eyes are closed b) The patient reports no change to his vision c) The patient states "I cannot see you when you stand next to me" d) The patient states "I can only see you if stand in front of me"

c) The patient states "I cannot see you when you stand next to me" d) The patient states "I can only see you if stand in front of me"

You are receiving report at the start of your shift about a 60 year old male with a history of eye trauma. You are told that this patient is experiencing difficulty with his peripheral vision. Which of the following assessment findings would you expect? Select all that apply. a) The patient's eyes are closed b) The patient reports no change to his vision c) The patient states "I cannot see you when you stand next to me." d) The patient states "I can only see you if you stand in front of me."

c) The patient states "I cannot see you when you stand next to me." d) The patient states "I can only see you if you stand in front of me."

A patient is admitted with a Stage I pressure ulcer in their sacral area. To provide pressure relief at night, the nurse teaches the patient to sleep in which position? a) Supine with the head of the bed elevated b) Supine with a foam wedge between the knees c) Thirty-degree lateral inclined position d) Full side-lying position supported with pillows

c) Thirty-degree lateral inclined position

The patient's tonsils are graded as 3+. The tonsils would be: a) Visible b) Halfway between the tonsillar pillars and uvula c) Touching the uvula d) Touching each other

c) Touching the uvula

A nurse is performing an otoscopic examination of a client. Which of the following is an unexpected finding? a) Pearly, gray tympanic membrane (TM) b) Malleous visible behind the TM c) Flaky skin in the external canal near the TM d) Black cerumen partially occluding the TM

d) Black cerumen partially occluding the TM

Which sinuses can you assess through examination? a) Ethmoid and sphenoid b) Frontal and ethmoid c) Maxillary and sphenoid d) Frontal and maxillary

d) Frontal and maxillary

A nurse is instructing a group of nursing students in the priorities of care in performing an integumentary assessment for their clients. Which of the following findings should the nursing students report as vesicles? Select all that apply. a) Acne b) Warts c) Psoriasis d) Herpes simplex e) Varicella

d) Herpes simplex e) Varicella

Oral malignancies are most likely to develop: a) On the soft palate b) On the tongue c) In the buccal cheek mucosa d) In the mucosa under the tongue

d) In the mucosa under the tongue

A postoperative patient arrives at an ambulatory care center and states, "I am not feeling good." Upon assessment, you note an elevated temperature. An indication that the wound is infected would be: a) It has no odor b) A culture is negative c) The edges reveal the presence of fluid d) It shows purulent drainage coming from the incision site

d) It shows purulent drainage coming from the incision site

After examining a patient, the nurse notes: fever, increased respiratory rate, chest expansion decreased on left side, dull to percussion over left lower lobe, breath sounds louder with fine crackles over left lower lobe. These findings are consistent with: a) Bronchitis b) Asthma c) Pleural effusion d) Lobar pneumonia

d) Lobar pneumonia

A nurse in a clinical is caring for a client who has sinusitis. Which of the following techniques should the nurse use to identify clinical manifestations of this disorder? a) Percussion of the posterior lobes of lungs b) Auscultation of the trachea c) Inspection of the conjunctiva d) Palpation of the orbital areas

d) Palpation of the orbital areas

While auscultating a patient's lungs, the nurse notes a coarse, low-pitched sound during inspiration and expiration. This patient reports pain with breathing. These findings are consistent with: a) Fine crackles b) Wheezes c) Atelectatic crackles d) Pleural friction rub

d) Pleural friction rub

Which results show a chest tube insertion was done properly? a) Bronchial breath sounds heard at both bases. b) Brochovesicular breath sounds heard over the upper lung field. c) Crackles heard on the affected side. d) Vesicular breath sound heard over both lung fields.

d) Vesicular breath sound heard over both lung fields.