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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 to repeat them.
c. Ask the patient to place his finger in his ear to occlude outside noise.
d. Stand approximately 4 feet away to ensure that the patient can really hear at this
distance.
During an examination, the nurse notices that a patient's legs turn white when they are
raised above the patient's head. The nurse should suspect:
a. Lymphedema.
b. Raynaud disease.
c. Chronic arterial insufficiency.
d. Chronic venous insufficiency.
If a patient reports a recent breast infection, then the nurse should expect to find
________ node enlargement.
a. Nonspecific
b. Ipsilateral axillary
c. Contralateral axillary
d. Inguinal and cervical
A 14-year-old boy who has been diagnosed with Osgood-Schlatter disease reports
painful swelling just below the knee for the past 5 months. Which response by the nurse
is appropriate?
a. "If these symptoms persist, you may need arthroscopic surgery."
b. "You are experiencing degeneration of your knee, which may not resolve."
c. "Your disease is due to repeated stress on the patellar tendon. It is usually
self-limited, and your symptoms should resolve with rest."
d. "Increasing your activity and performing knee-strengthening exercises will help
decrease the inflammation and maintain mobility in the knee."
During an examination, the nurse notes a supernumerary nipple just under the patient's
left breast. The patient tells the nurse that she always thought it was a mole. Which
statement about this finding is correct?
a. This variation is normal and not a significant finding.
b. This finding is significant and needs further investigation.
c. A supernumerary nipple also contains glandular tissue and may leak milk during
pregnancy and lactation.
d. The patient is correcta supernumerary nipple is actually a mole that happens to be
located under the breast.
The nurse is preparing to assess the dorsalis pedis artery. Where is the correct location
for palpation?
a. Behind the knee
b. Over the lateral malleolus
c. In the groove behind the medial malleolus
d. Lateral to the extensor tendon of the great toe
During a health history of a patient who complains of chronic constipation, the patient
asks the nurse about high-fiber foods. The nurse relates that an example of a high-fiber
food would be:
a. Broccoli.
b. Hamburger.
c. Iceberg lettuce.
d. Yogurt.
A patient has been admitted for severe psoriasis. The nurse expects to see what finding
in the patient's fingernails?
a. Splinter hemorrhages
b. Paronychia
c. Pitting
d. Beau lines
When assessing the quality of a patient's pain, the nurse should ask which question?
a. "When did the pain start?"
b. "Is the pain a stabbing pain?"
c. "Is it a sharp pain or dull pain?"
d. "What does your pain feel like?"
Which finding is considered normal and expected when the nurse is performing a
physical examination on a pregnant woman?
a. Palpable, full thyroid
b. Edema in one lower leg
c. Significant diffuse enlargement of the thyroid
d. Pale mucous membranes of the mouth
A patient states that the pain medication is "not working" and rates his postoperative
pain at a 10 on a 1-to-10 scale. Which of these assessment findings indicates an acute
pain response to poorly controlled pain?
a. Confusion
b. Hyperventilation
c. Increased blood pressure and pulse
d. Depression
A 70-year-old patient is scheduled for open-heart surgery. The surgeon plans to use the
great saphenous vein for the coronary bypass grafts. The patient asks, "What happens to
my circulation when this vein is removed?" The nurse should reply:
a. "Venous insufficiency is a common problem after this type of surgery."
b. "Oh, you have lots of veinsyou won"t even notice that it has been removed."
c. "You will probably experience decreased circulation after the vein is removed."
d. "This vein can be removed without harming your circulation because the deeper
veins in your leg are in good condition."
The nurse is palpating an ovarian mass during an internal examination of a 63-year-old
woman. Which findings of the mass's characteristics would suggest the presence of an
ovarian cyst? Select all that apply.
a. Heavy and solid
b. Mobile and fluctuant
c. Mobile and solid
d. Fixed
e. Smooth and round
f. Poorly defined
During an assessment, the nurse notes that the patient's apical impulse is laterally
displaced and is palpable over a wide area. This finding indicates:
a. Systemic hypertension.
b. Pulmonic hypertension.
c. Pressure overload, as in aortic stenosis.
d. Volume overload, as in heart failure.
A 13-year-old girl is interested in obtaining information about the cause of her acne.
The nurse should share with her that acne:
a. Is contagious.
b. Has no known cause.
c. Is caused by increased sebum production.
d. Has been found to be related to poor hygiene.
During an examination of a woman, the nurse notices that her left breast is slightly
larger than her right breast. Which of these statements is trueabout this finding?
a. Breasts should always be symmetric.
b. Asymmetry of breast size and shape is probably due to breastfeeding and is nothing
to worry about.
c. Asymmetry is not unusual, but the nurse should verify that this change is not new.
d. Asymmetry of breast size and shape is very unusual and means she may have an
inflammation or growth.
The nurse is reviewing the changes that occur with menopause. Which changes are
associated with menopause?
a. Uterine and ovarian atrophy, along with a thinning of the vaginal epithelium
b. Ovarian atrophy, increased vaginal secretions, and increasing clitoral size
c. Cervical hypertrophy, ovarian atrophy, and increased acidity of vaginal secretions
d. Vaginal mucosa fragility, increased acidity of vaginal secretions, and uterine
hypertrophy
In using verbal responses to assist the patient's narrative, some responses focus on the
patient's frame of reference and some focus on the health care provider's perspective.
An example of a verbal response that focuses on the health care provider's perspective
would be:
a. Empathy.
b. Reflection.
c. Facilitation.
d. Confrontation.
Which statement is best for the nurse to use when preparing to administer the Abuse
Assessment Screen?
a. "We are required by law to ask these questions."
b. "We need to talk about whether you believe you have been abused."
c. "We are asking these questions because we suspect that you are being abused."
d. "We need to ask the following questions because domestic violence is so common in
our society."
A female patient has denied any abuse when answering the Abuse Assessment Screen,
but the nurse has noticed some other conditions that are associated with IPV. Examples
of such conditions include:
a. Asthma.
b. Confusion.
c. Depression.
d. Frequent colds.
When performing a genitourinary assessment, the nurse notices that the urethral meatus
is ventrally positioned. This finding is:
a. Called hypospadias.
b. A result of phimosis.
c. Probably due to a stricture.
d. Often associated with aging.
During auscultation of the lungs of an adult patient, the nurse notices the presence of
bronchophony. The nurse should assess for signs of which condition?
a. Airway obstruction
b. Emphysema
c. Pulmonary consolidation
d. Asthma
A young swimmer comes to the sports clinic complaining of a very sore shoulder. He
was running at the pool, slipped on some wet concrete, and tried to catch himself with
his outstretched hand. He landed on his outstretched hand and has not been able to
move his shoulder since. The nurse suspects:
a. Joint effusion.
b. Tear of rotator cuff.
c. Adhesive capsulitis.
d. Dislocated shoulder.
A patient who is visiting the clinic complains of having 'stomach pains for 2 weeks" and
describes his stools as being 'soft and black" for approximately the last 10 days. He
denies taking any medications. The nurse is aware that these symptoms are mostly
indicative of:
a. Excessive fat caused by malabsorption.
b. Increased iron intake, resulting from a change in diet.
c. Occult blood, resulting from gastrointestinal bleeding.
d. Absent bile pigment from liver problems.
A patient's weekly blood pressure readings for 2 months have ranged between 124/84
mm Hg 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. Prehypertension
c. Stage 1 hypertension
d. Stage 2 hypertension
The nurse is reviewing venous blood flow patterns. Which of these statements best
describes the mechanism(s) by which venous blood returns to the heart?
a. Intraluminal valves ensure unidirectional flow toward the heart.
b. Contracting skeletal muscles milk blood distally toward the veins.
c. High-pressure system of the heart helps facilitate venous return.
d. Increased thoracic pressure and decreased abdominal pressure facilitate venous return
to the heart.
The nurse is examining a 62-year-old man and notes that he has bilateral gynecomastia.
The nurse should explore his health history for which related conditions? Select all that
apply.
a. Malnutrition
b. Hyperthyroidism
c. Type 2 diabetes mellitus
d. Liver disease
e. History of alcohol abuse
As the nurse enters a patient's room, the nurse finds her crying. The patient states that
she has just found out that the lump in her breast is cancer and says, "I"m so afraid of,
um, you know." The nurse's most therapeutic response would be to say in a gentle
manner:
a. "You"re afraid you might lose your breast?"
b. "No, I"m not sure what you are talking about."
c. "I"ll wait here until you get yourself under control, and then we can talk."
d. "I can see that you are very upset. Perhaps we should discuss this later."
During an assessment of an adult, the nurse has noted unequal chest expansion and
recognizes that this occurs in which situation?
a. In an obese patient
b. When part of the lung is obstructed or collapsed
c. When bulging of the intercostal spaces is present
d. When accessory muscles are used to augment respiratory effort
The nurse is conducting a class on BSE. Which of these statements indicates the proper
BSE technique?
a. The best time to perform BSE is in the middle of the menstrual cycle.
b. The woman needs to perform BSE only bimonthly unless she has fibrocystic breast
tissue.
c. The best time to perform a BSE is 4 to 7 days after the first day of the menstrual
period.
d. If she suspects that she is pregnant, then the woman should not perform a BSE until
her baby is born.
The nurse is reviewing the anatomy and physiologic functioning of the heart. Which
statement best describes what is meant by atrial kick?
a. The atria contract during systole and attempt to push against closed valves.
b. Contraction of the atria at the beginning of diastole can be felt as a palpitation.
c. Atrial kick is the pressure exerted against the atria as the ventricles contract during
systole.
d. The atria contract toward the end of diastole and push the remaining blood into the
ventricles.
When performing a peripheral vascular assessment on a patient, the nurse is unable to
palpate the ulnar pulses. The patient's skin is warm and capillary refill time is normal.
Next, the nurse should:
a. Check for the presence of claudication.
b. Refer the individual for further evaluation.
c. Consider this finding as normal, and proceed with the peripheral vascular evaluation.
d. Ask the patient if he or she has experienced any unusual cramping or tingling in the
arm.
