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In performing a voice test to assess hearing, which of these actions would the nurse perform? a. Shield the lips so that the sound is muffled. b. Whisper a set of random numbers and letters, and then ask the patient […]

During a well-baby checkup, a mother is concerned because her 2-month-old infant cannot hold her head up when she is pulled to a sitting position. Which response by the nurse is appropriate? a. “Head control is usually achieved by 4 […]

The nurse is preparing to use a stethoscope for auscultation. Which statement is true regarding the diaphragm of the stethoscope? The diaphragm: a. Is used to listen for high-pitched sounds. b. Is used to listen for low-pitched sounds. c. Should […]

During an admission assessment of a patient with dementia, the nurse assesses for pain because the patient has recently had several falls. Which of these are appropriate for the nurse to assess in a patient with dementia? Select all that […]

The nurse is describing how to perform a testicular self-examination to a patient. Which statement is most appropriate? a. “A good time to examine your testicles is just before you take a shower.” b. “If you notice an enlarged testicle […]

A patient reports excruciating headache pain on one side of his head, especially around his eye, forehead, and cheek that has lasted approximately to 2 hours, occurring once or twice each day. The nurse should suspect: a. Hypertension. b. Cluster […]

The nurse is preparing to interview a postmenopausal woman. Which of these statements is true as it applies to obtaining the health history of a postmenopausal woman? a. The nurse should ask a postmenopausal woman if she has ever had […]

The nurse is conducting an interview in an outpatient clinic and is using a computer to record data. Which are the best uses of the computer in this situation? Select all that apply. a. Collect the patient’s data in a […]

Which statement is true regarding the arterial system? a. Arteries are large-diameter vessels. b. The arterial system is a high-pressure system. c. The walls of arteries are thinner than those of the veins. d. Arteries can greatly expand to accommodate […]

When performing a genital assessment on a middle-aged man, the nurse notices multiple soft, moist, painless papules in the shape of cauliflower-like patches scattered across the shaft of the penis. These lesions are characteristic of: a. Carcinoma. b. Syphilitic chancres. […]

During examination, the nurse finds that a patient is unable to distinguish objects placed in his hand. The nurse would document: a. Stereognosis. b. Astereognosis. c. Graphesthesia. d. Agraphesthesia. A 70-year-old patient with a history of hypertension has a blood […]

An individual who takes the magicoreligious perspective of illness and disease is likely to believe that his or her illness was caused by: a. Germs and viruses. b. Supernatural forces. c. Eating imbalanced foods. d. An imbalance within his or […]

Which of the following reflects the traditional health and illness beliefs and practices of those of African heritage? Health is: a. Being rewarded for good behavior. b. The balance of the body and spirit. c. Maintained by wearing jade amulets. […]

The nurse is preparing to do a functional assessment. Which statement best describes the purpose of a functional assessment? a. The functional assessment assesses how the individual is coping with life at home. b. It determines how children are meeting […]

A man has come in to the clinic for a skin assessment because he is worried he might have skin cancer. During the skin assessment the nurse notices several areas of pigmentation that look greasy, dark, and ‘stuck on” his […]

A 75-year-old woman is at the office for a preoperative interview. The nurse is aware that the interview may take longer than interviews with younger persons. What is the reason for this? a. An aged person has a longer story […]

The nurse is reviewing the technique of palpating for tactile fremitus with a new graduate. Which statement by the graduate nurse reflects a correct understanding of tactile fremitus? “Tactile fremitus: a. “Is caused by moisture in the alveoli.” b. “Indicates […]

During a discussion about BSEs with a 30-year-old woman, which of these statements by the nurse is most appropriate? a. “The best time to examine your breasts is during ovulation.” b. “Examine your breasts every month on the same day […]

The nurse is preparing to examine a 4-year-old child. Which action is appropriate for this age group? a. Explain the procedures in detail to alleviate the child’s anxiety. b. Give the child feedback and reassurance during the examination. c. Do […]

After the examination of an infant, the nurse documents opisthotonos. The nurse recognizes that this finding often occurs with: a. Cerebral palsy. b. Meningeal irritation. c. Lower motor neuron lesion. d. Upper motor neuron lesion. A patient has a normal […]

A patient has been admitted to a hospital after the staff in the nursing home noticed a pressure ulcer in his sacral area. The nurse examines the pressure ulcer and determines that it is a stage II ulcer. Which of […]

A patient has been shown to have a sensorineural hearing loss. During the assessment, it would be important for the nurse to: a. Speak loudly so the patient can hear the questions. b. Assess for middle ear infection as a […]

A 70-year-old patient is being seen in the clinic for severe exacerbation of his heart failure. Which of these findings is the nurse most likely to observe in this patient? a. Shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, and ankle […]

A 17-year-old student is a swimmer on her high school’s swim team. She has had three bouts of otitis externa this season and wants to know what to do to prevent it. The nurse instructs her to: a. Use a […]

A patient with pleuritis has been admitted to the hospital and complains of pain with breathing. What other key assessment finding would the nurse expect to find upon auscultation? a. Stridor b. Friction rub c. Crackles d. Wheezing When considering […]

The nurse will use which technique of assessment to determine the presence of crepitus, swelling, and pulsations? a. Palpation b. Inspection c. Percussion d. Auscultation Which of these would be formulated by a nurse using diagnostic reasoning? a. Nursing diagnosis […]

The nurse is reviewing statistics regarding breast cancer. Which woman, aged 40 years in the United States, has the highest risk for developing breast cancer? a. Black b. White c. Asian d. American Indian The nurse is aware that intimate […]

The nurse is performing an assessment on an adult. The adult’s vital signs are normal, and capillary refill time is 5 seconds. What should the nurse do next? a. Ask the patient about a history of frostbite. b. Suspect that […]

The nurse is giving report to the next shift and is using the situation, background, assessment, recommendation (SBAR) framework for communication. Which of these statements reflects the Background portion of the report? a. “I”m worried that his gastrointestinal bleeding is […]

The nurse is preparing to assess an older adult and discovers that the older adult is in severe pain. Which statement about pain and the older adult is true? a. Pain is inevitable with aging. b. Older adults with cognitive […]

A mother brings her newborn in for an assessment and asks, “Is there something wrong with my baby? His head seems so big.” Which statement is true regarding the relative proportions of the head and trunk of the newborn? a. […]

An older man is concerned about his sexual performance. The nurse knows that in the absence of disease, a withdrawal from sexual activity later in life may be attributable to: a. Side effects of medications. b. Decreased libido with aging. […]

A 22-year-old woman has been considering using oral contraceptives. As a part of her health history, the nurse should ask: a. “Do you have a history of heart murmurs?” b. “Will you be in a monogamous relationship?” c. “Have you […]

In assessing a patient’s major risk factors for heart disease, which would the nurse want to include when taking a history? a. Family history, hypertension, stress, and age b. Personality type, high cholesterol, diabetes, and smoking c. Smoking, hypertension, obesity, […]