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 months of age.”
b. “You shouldn”t be trying to pull your baby up like that until she is older.”
c. “Head control should be achieved by this time.”
d. “This inability indicates possible nerve damage to the neck muscles.”
The nurse is reviewing in age-related changes in the eye for a class. Which of these
physiologic changes is responsible for presbyopia?
a. Degeneration of the cornea
b. Loss of lens elasticity
c. Decreased adaptation to darkness
d. Decreased distance vision abilities
A female nurse is interviewing a man who has recently immigrated. During the course
of the interview, he leans forward and then finally moves his chair close enough that his
knees are nearly touching the nurse’s knees. The nurse begins to feel uncomfortable
with his proximity. Which statement most closely reflects what the nurse should do
next?
a. The nurse should try to relax; these behaviors are culturally appropriate for this
person.
b. The nurse should discreetly move his or her chair back until the distance is more
comfortable, and then continue with the interview.
c. These behaviors are indicative of sexual aggression, and the nurse should confront
this person about his behaviors.
d. The nurse should laugh but tell him that he or she is uncomfortable with his
proximity and ask him to move away.
A black patient is in the intensive care unit because of impending shock after an
accident. The nurse expects to find what characteristics in this patient’s skin?
a. Ruddy blue.
b. Generalized pallor.
c. Ashen, gray, or dull.
d. Patchy areas of pallor.
When assessing muscle strength, the nurse observes that a patient has complete range of
motion against gravity with full resistance. What grade of muscle strength should the
nurse record using a 0- to 5-point scale?
a. 2
b. 3
c. 4
d. 5
When auscultating the blood pressure of a 25-year-old patient, the nurse notices the
phase I Korotkoff sounds begin at 200 mm Hg. At 100 mm Hg, the Korotkoff sounds
muffle. At 92 mm Hg, the Korotkoff sounds disappear. How should the nurse record
this patient’s blood pressure?
a. 200/92
b. 200/100
c. 100/200/92
d. 200/100/92
A patient is asked to indicate on a form how many times he eats a specific food. This
method describes which of these tools for obtaining dietary information?
a. Food diary
b. Calorie count
c. 24-hour recall
d. Food-frequency questionnaire
The nurse is performing a neurologic assessment on a 41-year-old woman with a
history of diabetes. When testing her ability to feel the vibrations of a tuning fork, the
nurse notices that the patient is unable to feel vibrations on the great toe or ankle
bilaterally, but she is able to feel vibrations on both patellae. Given this information,
what would the nurse suspect?
a. Hyperalgesia
b. Hyperesthesia
c. Peripheral neuropathy
d. Lesion of sensory cortex
The nurse recognizes that an example of a person who is heritage consistent would be
a:
a. Woman who has adapted her clothing to the clothing style of her new country.
b. Woman who follows the traditions that her mother followed regarding meals.
c. Man who is not sure of his ancestor’s country of origin.
d. Child who is not able to speak his parents’ native language.
To test for gross motor skill and coordination of a 6-year-old child, which of these
techniques would be appropriate? Ask the child to:
a. Hop on one foot.
b. Stand on his head.
c. Touch his finger to his nose.
d. Make “funny” faces at the nurse.
The external male genital structures include the:
a. Testis.
b. Scrotum.
c. Epididymis.
d. Vas deferens.
When the nurse is discussing sexuality and sexual issues with an adolescent, a
permission statement helps convey that it is normal to think or feel a certain way.
Which statement is the best example of a permission statement?
a. “It is okay that you have become sexually active.”
b. “Girls your age often have questions about sexual activity. Do you have any
questions?”
c. “If it is okay with you, I”d like to ask you some questions about your sexual history.”
d. “Girls your age often engage in sexual activities. It is okay to tell me if you have had
intercourse.”
A 35-year-old man is seen in the clinic for an infection in his left foot. Which of these
findings should the nurse expect to see during an assessment of this patient?
a. Hard and fixed cervical nodes
b. Enlarged and tender inguinal nodes
c. Bilateral enlargement of the popliteal nodes
d. Pelletlike nodes in the supraclavicular region
During a vaginal examination of a 38-year-old woman, the nurse notices that the vulva
and vagina are erythematous and edematous with thick, white, curdlike discharge
adhering to the vaginal walls. The woman reports intense pruritus and thick white
discharge from her vagina. The nurse knows that these history and physical
examination findings are most consistent with which condition?
a. Candidiasis
b. Trichomoniasis
c. Atrophic vaginitis
d. Bacterial vaginosis
The review of systems provides the nurse with:
a. Physical findings related to each system.
b. Information regarding health promotion practices.
c. An opportunity to teach the patient medical terms.
d. Information necessary for the nurse to diagnose the patient’s medical problem.
When examining children affected with Down syndrome (trisomy 21), the nurse looks
for the possible presence of:
a. Ear dysplasia.
b. Long, thin neck.
c. Protruding thin tongue.
d. Narrow and raised nasal bridge.
The nurse is assessing the vital signs of a 3-year-old patient who appears to have an
irregular respiratory pattern. How should the nurse assess this child’s respirations?
a. Respirations should be counted for 1 full minute, noticing rate and rhythm.
b. Child’s pulse and respirations should be simultaneously checked for 30 seconds.
c. Child’s respirations should be checked for a minimum of 5 minutes to identify any
variations in his or her respiratory pattern.
d. Patient’s respirations should be counted for 15 seconds and then multiplied by 4 to
obtain the number of respirations per minute.
The nurse is reviewing the assessment of an aortic aneurysm. Which of these statements
is true regarding an aortic aneurysm?
a. A bruit is absent.
b. Femoral pulses are increased.
c. A pulsating mass is usually present.
d. Most are located below the umbilicus.
A patient’s blood pressure is 118/82 mm Hg. He asks the nurse, “What do the numbers
mean?” The nurse’s best reply is:
a. “The numbers are within the normal range and are nothing to worry about.”
b. “The bottom number is the diastolic pressure and reflects the stroke volume of the
heart.”
c. “The top number is the systolic blood pressure and reflects the pressure of the blood
against the arteries when the heart contracts.”
d. “The concept of blood pressure is difficult to understand. The primary thing to be
concerned about is the top number, or the systolic blood pressure.”
A 50-year-old woman calls the clinic because she has noticed some changes in her body
and breasts and wonders if these changes could be attributable to the hormone
replacement therapy (HRT) she started 3 months earlier. The nurse should tell her:
a. “HRT is at such a low dose that side effects are very unusual.”
b. “HRT has several side effects, including fluid retention, breast tenderness, and
vaginal bleeding.”
c. “Vaginal bleeding with HRT is very unusual; I suggest you come into the clinic
immediately to have this evaluated.”
d. “It sounds as if your dose of estrogen is too high; I think you may need to decrease
the amount you are taking and then call back in a week.”
A 75-year-old woman who has a history of diabetes and peripheral vascular disease has
been trying to remove a corn on the bottom of her foot with a pair of scissors. The nurse
will encourage her to stop trying to remove the corn with scissors because:
a. The woman could be at increased risk for infection and lesions because of her chronic
disease.
b. With her diabetes, she has increased circulation to her foot, and it could cause severe
bleeding.
c. She is 75 years old and is unable to see; consequently, she places herself at greater
risk for self-injury with the scissors.
d. With her peripheral vascular disease, her range of motion is limited and she may not
be able to reach the corn safely.
A 22-year-old woman is being seen at the clinic for problems with vulvar pain, dysuria,
and fever. On physical examination, the nurse notices clusters of small, shallow vesicles
with surrounding erythema on the labia. Inguinal lymphadenopathy present is also
present. The most likely cause of these lesions is:
a. Pediculosis pubis.
b. Contact dermatitis.
c. HPV.
d. Herpes simplex virus type 2.
The uterus is usually positioned tilting forward and superior to the bladder. This
position is known as:
a. Anteverted and anteflexed.
b. Retroverted and anteflexed.
c. Retroverted and retroflexed.
d. Superiorverted and anteflexed.
During a prenatal check, a patient begins to cry as the nurse asks her about previous
pregnancies. She states that she is remembering her last pregnancy, which ended in
miscarriage. The nurse’s best response to her crying would be:
a. “I”m so sorry for making you cry!”
b. “I can see that you are sad remembering this. It is all right to cry.”
c. “Why don”t I step out for a few minutes until you”re feeling better?”
d. “I can see that you feel sad about this; why don”t we talk about something else?”
The findings from an assessment of a 70-year-old patient with swelling in his ankles
include jugular venous pulsations 5 cm above the sternal angle when the head of his bed
is elevated 45 degrees. The nurse knows that this finding indicates:
a. Decreased fluid volume.
b. Increased cardiac output.
c. Narrowing of jugular veins.
d. Elevated pressure related to heart failure.
An assessment of a 23-year-old patient reveals the following: an auricle that is tender
and reddish-blue in color with small vesicles. The nurse would need to know additional
information that includes which of these?
a. Any change in the ability to hear
b. Any recent drainage from the ear
c. Recent history of trauma to the ear
d. Any prolonged exposure to extreme cold
During an assessment, the nurse asks a female patient, “How many alcoholic drinks do
you have a week?” Which answer by the patient would indicate at-risk drinking?
a. “I may have one or two drinks a week.”
b. “I usually have three or four drinks a week.”
c. “I”ll have a glass or two of wine every now and then.”
d. “I have seven or eight drinks a week, but I never get drunk.”
In obtaining a review of systems on a “healthy” 7-year-old girl, the health care provider
knows that it would be important to include the:
a. Last glaucoma examination.
b. Frequency of breast self-examinations.
c. Date of her last electrocardiogram.
d. Limitations related to her involvement in sports activities.
When examining the face of a patient, the nurse is aware that the two pairs of salivary
glands that are accessible to examination are the ___________ and ___________
glands.
a. Occipital; submental
b. Parotid; jugulodigastric
c. Parotid; submandibular
d. Submandibular; occipital
During a woman’s 34th week of pregnancy, she is told that she has preeclampsia. The
nurse knows which statement concerning preeclampsia is true?
a. Preeclampsia has little effect on the fetus.
b. Edema is one of the main indications of preeclampsia.
c. Eclampsia only occurs before delivery of the baby.
d. Untreated preeclampsia may contribute to restriction of fetal growth.