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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 be lightly held against the person's skin to block out low-pitched sounds.
d. Should be lightly held against the person's skin to listen for extra heart sounds and
murmurs.
During an abdominal assessment, the nurse tests for a fluid wave. A positive fluid wave
test occurs with:
a. Splenomegaly.
b. Distended bladder.
c. Constipation.
d. Ascites.
A 55-year-old man is in the clinic for a yearly checkup. He is worried because his father
died of prostate cancer. The nurse knows which tests should be performed at this time?
Select all that apply.
a. Blood test for prostate-specific antigen (PSA)
b. Urinalysis
c. Transrectal ultrasound
d. Digital rectal examination (DRE)
e. Prostate biopsy
Which statement would be most appropriate when the nurse is introducing the topic of
sexual relationships during an interview?
a. "Now, it is time to talk about your sexual history. When did you first have
intercourse?"
b. "Women often feel dissatisfied with their sexual relationships. Would it be okay to
discuss this now?"
c. "Women often have questions about their sexual relationship and how it affects their
health. Do you have any questions?"
d. "Most women your age have had more than one sexual partner. How many would
you say you have had?"
The nurse is preparing to assess a patient's abdomen by palpation. How should the nurse
proceed?
a. Palpation of reportedly "tender" areas are avoided because palpation in these areas
may cause pain.
b. Palpating a tender area is quickly performed to avoid any discomfort that the patient
may experience.
c. The assessment begins with deep palpation, while encouraging the patient to relax
and to take deep breaths.
d. The assessment begins with light palpation to detect surface characteristics and to
accustom the patient to being touched.
A 72-year-old patient has a history of hypertension and chronic lung disease. An
important question for the nurse to include in the health history would be:
a. "Do you use a fluoride supplement?"
b. "Have you had tonsillitis in the last year?"
c. "At what age did you get your first tooth?"
d. "Have you noticed any dryness in your mouth?"
While performing the otoscopic examination of a 3-year-old boy who has been pulling
on his left ear, the nurse finds that his left tympanic membrane is bright red and that the
light reflex is not visible. The nurse interprets these findings to indicate a(n):
a. Fungal infection.
b. Acute otitis media.
c. Perforation of the eardrum.
d. Cholesteatoma.
The nurse is bathing an 80-year-old man and notices that his skin is wrinkled, thin, lax,
and dry. This finding would be related to which factor in the older adult?
a. Increased vascularity of the skin
b. Increased numbers of sweat and sebaceous glands
c. An increase in elastin and a decrease in subcutaneous fat
d. An increased loss of elastin and a decrease in subcutaneous fat
The nurse is providing patient education for a man who has been diagnosed with a
rotator cuff injury. The nurse knows that a rotator cuff injury involves the:
a. Nucleus pulposus.
b. Articular processes.
c. Medial epicondyle.
d. Glenohumeral joint.
During a physical examination, a 45-year-old woman states that she has had a crusty,
itchy rash on her breast for approximately 2 weeks. In trying to find the cause of the
rash, which question would be important for the nurse to ask?
a. "Is the rash raised and red?"
b. "Does it appear to be cyclic?"
c. "Where did the rash first appearon the nipple, the areola, or the surrounding skin?"
d. "What was she doing when she first noticed the rash, and do her actions make it
worse?"
A 65-year-old patient with a history of heart failure comes to the clinic with complaints
of "being awakened from sleep with shortness of breath." Which action by the nurse is
most appropriate?
a. Obtaining a detailed health history of the patient's allergies and a history of asthma
b. Telling the patient to sleep on his or her right side to facilitate ease of respirations
c. Assessing for other signs and symptoms of paroxysmal nocturnal dyspnea
d. Assuring the patient that paroxysmal nocturnal dyspnea is normal and will probably
resolve within the next week
When assessing a newborn infant who is 5 minutes old, the nurse knows which of these
statements to be true?
a. The left ventricle is larger and weighs more than the right ventricle.
b. The circulation of a newborn is identical to that of an adult.
c. Blood can flow into the left side of the heart through an opening in the atrial septum.
d. The foramen ovale closes just minutes before birth, and the ductus arteriosus closes
immediately after.
A patient's thyroid gland is enlarged, and the nurse is preparing to auscultate the thyroid
gland for the presence of a bruit. A bruit is a __________ sound that is heard best with
the __________ of the stethoscope.
a. Low gurgling; diaphragm
b. Loud, whooshing, blowing; bell
c. Soft, whooshing, pulsatile; bell
d. High-pitched tinkling; diaphragm
Which statement bestdescribes a proficient nurse? A proficient nurse is one who:
a. Has little experience with a specified population and uses rules to guide performance.
b. Has an intuitive grasp of a clinical situation and quickly identifies the accurate
solution.
c. Sees actions in the context of daily plans for patients.
d. Understands a patient situation as a whole rather than a list of tasks and recognizes
the long-term goals for the patient.
During an examination, the nurse asks a patient to bend forward from the waist and
notices that the patient has lateral tilting. When his leg is raised straight up, the patient
complains of a pain going down his buttock into his leg. The nurse suspects:
a. Scoliosis.
b. Meniscus tear.
c. Herniated nucleus pulposus.
d. Spasm of paravertebral muscles.
The tissue that connects the tongue to the floor of the mouth is the:
a. Uvula.
b. Palate.
c. Papillae.
d. Frenulum.
The nurse needs to assess a patient's ability to perform activities of daily living (ADLs)
and should choose which tool for this assessment?
a. Direct Assessment of Functional Abilities (DAFA)
b. Lawton Instrumental Activities of Daily Living (IADL) scale
c. Barthel Index
d. Older Americans Resources and Services Multidimensional Functional Assessment
Questionnaire"IADL (OMFAQ-IADL)
A 35-year-old pregnant woman comes to the clinic for a monthly appointment. During
the assessment, the nurse notices that she has a brown patch of hyperpigmentation on
her face. The nurse continues the skin assessment aware that another finding may be:
a. Keratoses.
b. Xerosis.
c. Chloasma.
d. Acrochordons.
The area of the nervous system that is responsible for mediating reflexes is the:
a. Medulla.
b. Cerebellum.
c. Spinal cord.
d. Cerebral cortex.
The nurse is assessing a patient's eyes for the accommodation response and would
expect to see which normal finding?
a. Dilation of the pupils
b. Consensual light reflex
c. Conjugate movement of the eyes
d. Convergence of the axes of the eyes
The nurse is teaching a class on preventing osteoporosis to a group of perimenopausal
women. Which of these actions is the best way to prevent or delay bone loss in this
group?
a. Taking calcium and vitamin D supplements
b. Taking medications to prevent osteoporosis
c. Performing physical activity, such as fast walking
d. Assessing bone density annually
When auscultating the lungs of an adult patient, the nurse notes that low-pitched, soft
breath sounds are heard over the posterior lower lobes, with inspiration being longer
than expiration. The nurse interprets that these sounds are:
a. Normally auscultated over the trachea.
b. Bronchial breath sounds and normal in that location.
c. Vesicular breath sounds and normal in that location.
d. Bronchovesicular breath sounds and normal in that location.
During a neonatal examination, the nurse notices that the newborn infant has six toes.
This finding is documented as:
a. Unidactyly.
b. Syndactyly.
c. Polydactyly.
d. Multidactyly.
The nurse is preparing to conduct a health history. Which of these statements best
describes the purpose of a health history?
a. To provide an opportunity for interaction between the patient and the nurse
b. To provide a form for obtaining the patient's biographic information
c. To document the normal and abnormal findings of a physical assessment
d. To provide a database of subjective information about the patient's past and current
health
A 26-year-old woman was robbed and beaten a month ago. She is returning to the clinic
today for a follow-up assessment. The nurse will want to ask her which one of these
questions?
a. "How are things going with the trial?"
b. "How are things going with your job?"
c. "Tell me about your recent engagement!"
d. "Are you having any disturbing dreams?"
During an assessment, the nurse has elevated a patient's legs 12 inches off the table and
has had him wag his feet to drain off venous blood. After helping him sit up and dangle
his legs over the side of the table, the nurse should expect that a normal finding at this
point would be:
a. Significant elevational pallor.
b. Venous filling within 15 seconds.
c. No change in the coloration of the skin.
d. Color returning to the feet within 20 seconds of assuming a sitting position.
While examining a patient, the nurse observes abdominal pulsations between the
xiphoid process and umbilicus. The nurse would suspect that these are:
a. Pulsations of the renal arteries.
b. Pulsations of the inferior vena cava.
c. Normal abdominal aortic pulsations.
d. Increased peristalsis from a bowel obstruction.
The nurse educator is preparing an education module for the nursing staff on the dermis
layer of skin. Which of these statements would be included in the module? The dermis:
a. Contains mostly fat cells.
b. Consists mostly of keratin.
c. Is replaced every 4 weeks.
d. Contains sensory receptors.
A patient with a known history of heavy alcohol use has been admitted to the ICU after
he was found unconscious outside a bar. The nurse closely monitors him for symptoms
of withdrawal. Which of these symptoms may occur during this time? Select all that
apply.
a. Bradycardia
b. Coarse tremor of the hands
c. Transient hallucinations
d. Somnolence
e. Sweating
The nurse manager is explaining culturally competent care during a staff meeting.
Which statement accurately describes the concept of culturally competent care? "The
caregiver:
a. Is able to speak the patient's native language."
b. Possesses some basic knowledge of the patient's cultural background."
c. Applies the proper background knowledge of a patient's cultural background to
provide the best possible health care."
d. Understands and attends to the total context of the patient's situation."
