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 apply.
a. Ask the patient, “Do you have pain?”
b. Assess the patient’s breathing independent of vocalization.
c. Note whether the patient is calling out, groaning, or crying.
d. Have the patient rate pain on a 1-to-10 scale.
e. Observe the patient’s body language for pacing and agitation.
During a nutritional assessment, why is it important for the nurse to ask a patient what
medications he or she is taking?
a. Certain drugs can affect the metabolism of nutrients.
b. The nurse needs to assess the patient for allergic reactions.
c. Medications need to be documented in the record for the physician’s review.
d. Medications can affect one’s memory and ability to identify food eaten in the last 24
hours.
During an interview, a woman says, “I have decided that I can no longer allow my
children to live with their father’s violence, but I just can”t seem to leave him.” Using
interpretation, the nurse’s best response would be:
a. “You are going to leave him?”
b. “If you are afraid for your children, then why can”t you leave?”
c. “It sounds as if you might be afraid of how your husband will respond.”
d. “It sounds as though you have made your decision. I think it is a good one.”
The nurse is discussing BSEs with a postmenopausal woman. The best time for
postmenopausal women to perform BSEs is:
a. On the same day every month.
b. Daily, during the shower or bath.
c. One week after her menstrual period.
d. Every year with her annual gynecologic examination.
Illness is considered part of life’s rhythmic course and is an outward sign of disharmony
within. This statement most accurately reflects the views about illness from which
theory?
a. Naturalistic
b. Biomedical
c. Reductionist
d. Magicoreligious
A semiconscious woman is brought to the emergency department after she was found
on the floor in her kitchen. Her face, nail beds, lips, and oral mucosa are a bright
cherry-red color. The nurse suspects that this coloring is due to:
a. Polycythemia.
b. Carbon monoxide poisoning.
c. Carotenemia.
d. Uremia.
The nurse is performing an examination of the anus and rectum. Which of these
statements is correct and important to remember during this examination?
a. The rectum is approximately 8 cm long.
b. The anorectal junction cannot be palpated.
c. Above the anal canal, the rectum turns anteriorly.
d. No sensory nerves are in the anal canal or rectum.
Which of these statements describes the closure of the valves in a normal cardiac cycle?
a. The aortic valve closes slightly before the tricuspid valve.
b. The pulmonic valve closes slightly before the aortic valve.
c. The tricuspid valve closes slightly later than the mitral valve.
d. Both the tricuspid and pulmonic valves close at the same time.
The nurse has administered a pain medication to a patient by an IV infusion. The nurse
should reassess the patient’s response to the pain medication within _____ minutes.
a. 5
b. 15
c. 30
d. 60
During a class on cultural practices, the nurse hears the term cultural taboo. Which
statement illustrates the concept of a cultural taboo?
a. Believing that illness is a punishment of sin
b. Trying prayer before seeking medical help
c. Refusing to accept blood products as part of treatment
d. Stating that a child’s birth defect is the result of the parents’ sins
The nurse is assessing the joints of a woman who has stated, “I have a long family
history of arthritis, and my joints hurt.” The nurse suspects that she has osteoarthritis.
Which of these are symptoms of osteoarthritis? Select all that apply.
a. Symmetric joint involvement
b. Asymmetric joint involvement
c. Pain with motion of affected joints
d. Affected joints are swollen with hard, bony protuberances
e. Affected joints may have heat, redness, and swelling
The nurse is documenting the assessment of an infant. During the abdominal
assessment, the nurse noticed a very loud splash auscultated over the upper abdomen
when the nurse rocked her from side to side. This finding would indicate:
a. Epigastric hernia.
b. Pyloric obstruction.
c. Hypoactive bowel sounds.
d. Hyperactive bowel sounds.
A female patient does not speak English well, and the nurse needs to choose an
interpreter. Which of the following would be the most appropriate choice?
a. Trained interpreter
b. Male family member
c. Female family member
d. Volunteer college student from the foreign language studies department
During an annual physical examination, a 43-year-old patient states that she does not
perform monthly breast self-examinations (BSEs). She tells the nurse that she believes
that mammograms “do a much better job than I ever could to find a lump.” The nurse
should explain to her that:
a. BSEs may detect lumps that appear between mammograms.
b. BSEs are unnecessary until the age of 50 years.
c. She is correctmammography is a good replacement for BSE.
d. She does not need to perform BSEs as long as a physician checks her breasts
annually.
The nurse is providing nutrition information to the mother of a 1-year-old child. Which
of these statements represents accurate information for this age group?
a. Maintaining adequate fat and caloric intake is important for a child in this age group.
b. The recommended dietary allowances for an infant are the same as for an adolescent.
c. The baby’s growth is minimal at this age; therefore, caloric requirements are
decreased.
d. The baby should be placed on skim milk to decrease the risk of coronary artery
disease when he or she grows older.
A patient tells the nurse that she is having a hard time bringing her hand to her mouth
when she eats or tries to brush her teeth. The nurse knows that for her to move her hand
to her mouth, she must perform which movement?
a. Flexion
b. Abduction
c. Adduction
d. Extension
A woman comes to the clinic and states, “I”ve been sick for so long! My eyes have
gotten so puffy, and my eyebrows and hair have become coarse and dry.” The nurse will
assess for other signs and symptoms of:
a. Cachexia.
b. Parkinson syndrome.
c. Myxedema.
d. Scleroderma.
The nurse hears bilateral loud, long, and low tones when percussing over the lungs of a
4-year-old child. The nurse should:
a. Palpate over the area for increased pain and tenderness.
b. Ask the child to take shallow breaths, and percuss over the area again.
c. Immediately refer the child because of an increased amount of air in the lungs.
d. Consider this finding as normal for a child this age, and proceed with the
examination.
During the aging process, the hair can look gray or white and begin to feel thin and fine.
The nurse knows that this occurs because of a decrease in the number of functioning:
a. Metrocytes.
b. Fungacytes.
c. Phagocytes.
d. Melanocytes.
In an interview, the nurse may find it necessary to take notes to aid his or her memory
later. Which statement is true regarding note-taking?
a. Note-taking may impede the nurse’s observation of the patient’s nonverbal behaviors.
b. Note-taking allows the patient to continue at his or her own pace as the nurse records
what is said.
c. Note-taking allows the nurse to shift attention away from the patient, resulting in an
increased comfort level.
d. Note-taking allows the nurse to break eye contact with the patient, which may
increase his or her level of comfort.
A woman states that 2 weeks ago she had a urinary tract infection that was treated with
an antibiotic. As a part of the interview, the nurse should ask, “Have you noticed any:
a. “Changes in your urination patterns?”
b. “Excessive vaginal bleeding?”
c. “Unusual vaginal discharge or itching?”
d. “Changes in your desire for intercourse?”
The nurse is using an otoscope to assess the nasal cavity. Which of these techniques is
correct?
a. Inserting the speculum at least 3 cm into the vestibule
b. Avoiding touching the nasal septum with the speculum
c. Gently displacing the nose to the side that is being examined
d. Keeping the speculum tip medial to avoid touching the floor of the nares
A few days after a summer hiking trip, a 25-year-old man comes to the clinic with a
rash. On examination, the nurse notes that the rash is red, macular, with a bull’s eye
pattern across his midriff and behind his knees. The nurse suspects:
a. Rubeola.
b. Lyme disease.
c. Allergy to mosquito bites.
d. Rocky Mountain spotted fever.
During a morning assessment, the nurse notices that the patient’s sputum is frothy and
pink. Which condition could this finding indicate?
a. Croup
b. Tuberculosis
c. Viral infection
d. Pulmonary edema
To assess a rectal temperature accurately in an adult, the nurse would:
a. Use a lubricated blunt tip thermometer.
b. Insert the thermometer 2 to 3 inches into the rectum.
c. Leave the thermometer in place up to 8 minutes if the patient is febrile.
d. Wait 2 to 3 minutes if the patient has recently smoked a cigarette.
During an inspection of the precordium of an adult patient, the nurse notices the chest
moving in a forceful manner along the sternal border. This finding most likely suggests
a(n):
a. Normal heart.
b. Systolic murmur.
c. Enlargement of the left ventricle.
d. Enlargement of the right ventricle.
Just before going home, a new mother asks the nurse about the infant’s umbilical cord.
Which of these statements is correct?
a. “It should fall off in 10 to 14 days.”
b. “It will soften before it falls off.”
c. “It contains two veins and one artery.”
d. “Skin will cover the area within 1 week.”
The nurse is planning health teaching for a 65-year-old woman who has had a
cerebrovascular accident (stroke) and has aphasia. Which of these questions is most
important to use when assessing mental status in this patient?
a. “Please count backward from 100 by seven.”
b. “I will name three items and ask you to repeat them in a few minutes.”
c. “Please point to articles in the room and parts of the body as I name them.”
d. “What would you do if you found a stamped, addressed envelope on the sidewalk?”
A woman is in the family planning clinic seeking birth control information. She states
that her breasts “change all month long” and that she is worried that this is unusual.
What is the nurse’s best response? The nurse should tell her that:
a. Continual changes in her breasts are unusual. The breasts of nonpregnant women
usually stay pretty much the same all month long.
b. Breast changes in response to stress are very common and that she should assess her
life for stressful events.
c. Because of the changing hormones during the monthly menstrual cycle, cyclic breast
changes are common.
d. Breast changes normally occur only during pregnancy and that a pregnancy test is
needed at this time.
A patient says that she has recently noticed a lump in the front of her neck below her
“Adam’s apple” that seems to be getting bigger. During the assessment, the finding that
leads the nurse to suspect that this may not be a cancerous thyroid nodule is that the
lump (nodule):
a. Is tender.
b. Is mobile and not hard.
c. Disappears when the patient smiles.
d. Is hard and fixed to the surrounding structures.
The nurse is assessing a patient’s pain. The nurse knows that the most reliable indicator
of pain would be the:
a. Patient’s vital signs.
b. Physical examination.
c. Results of a computerized axial tomographic scan.
d. Subjective report.