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 vaginal bleeding.
b. Once a woman reaches menopause, the nurse does not need to ask any history
questions.
c. The nurse should screen for monthly breast tenderness.
d. Postmenopausal women are not at risk for contracting STIs; therefore, these
questions can be omitted.
A 52-year-old patient describes the presence of occasional floaters or spots moving in
front of his eyes. The nurse should:
a. Examine the retina to determine the number of floaters.
b. Presume the patient has glaucoma and refer him for further testing.
c. Consider these to be abnormal findings, and refer him to an ophthalmologist.
d. Know that floaters are usually insignificant and are caused by condensed vitreous
fibers.
A patient visits the clinic to ask about smoking cessation. He has smoked heavily for 30
years and wants to stop “cold turkey.” He asks the nurse, “What symptoms can I expect
if I do this?” Which of these symptoms should the nurse share with the patient as
possible symptoms of nicotine withdrawal? Select all that apply.
a. Headaches
b. Hunger
c. Sleepiness
d. Restlessness
e. Nervousness
f. Sweating
In obtaining a health history on a 74-year-old patient, the nurse notes that he drinks
alcohol daily and that he has noticed a tremor in his hands that affects his ability to hold
things. With this information, what response should the nurse make?
a. “Does your family know you are drinking every day?”
b. “Does the tremor change when you drink alcohol?”
c. “We”ll do some tests to see what is causing the tremor.”
d. “You really shouldn”t drink so much alcohol; it may be causing your tremor.”
An 85-year-old man has come in for a physical examination, and the nurse notices that
he uses a cane. When documenting general appearance, the nurse should document this
information under the section that covers:
a. Posture.
b. Mobility.
c. Mood and affect.
d. Physical deformity.
During ocular examinations, the nurse keeps in mind that movement of the extraocular
muscles is:
a. Decreased in the older adult.
b. Impaired in a patient with cataracts.
c. Stimulated by cranial nerves (CNs) I and II.
d. Stimulated by CNs III, IV, and VI.
A female nurse is interviewing a male patient who is near the same age as the nurse.
During the interview, the patient makes an overtly sexual comment. The nurse’s best
reaction would be:
a. “Stop that immediately!”
b. “Oh, you are too funny. Let’s keep going with the interview.”
c. “Do you really think I would be interested?”
d. “It makes me uncomfortable when you talk that way. Please stop.”
The nurse is evaluating patients for obesity-related diseases by calculating the
waist-to-hip ratios. Which one of these patients would be at increased risk?
a. 29-year-old woman whose waist measures 33 inches and hips measure 36 inches
b. 32-year-old man whose waist measures 34 inches and hips measure 36 inches
c. 38-year-old man whose waist measures 35 inches and hips measure 38 inches
d. 46-year-old woman whose waist measures 30 inches and hips measure 38 inches
The nurse is preparing to use an otoscope for an examination. Which statement is true
regarding the otoscope? The otoscope:
a. Is often used to direct light onto the sinuses.
b. Uses a short, broad speculum to help visualize the ear.
c. Is used to examine the structures of the internal ear.
d. Directs light into the ear canal and onto the tympanic membrane.
A physician has diagnosed a patient with purpura. After leaving the room, a nursing
student asks the nurse what the physician saw that led to that diagnosis. The nurse
should say, “The physician is referring to the:
a. “Blue dilation of blood vessels in a star-shaped linear pattern on the legs.”
b. “Fiery red, star-shaped marking on the cheek that has a solid circular center.”
c. “Confluent and extensive patch of petechiae and ecchymoses on the feet.”
d. “Tiny areas of hemorrhage that are less than 2 mm, round, discrete, and dark red in
color.”
The nurse is performing the diagnostic positions test. Normal findings would be which
of these results?
a. Convergence of the eyes
b. Parallel movement of both eyes
c. Nystagmus in extreme superior gaze
d. Slight amount of lid lag when moving the eyes from a superior to an inferior position
A 21-year-old patient has a head injury resulting from trauma and is unconscious. There
are no other injuries. During the assessment what would the nurse expect to find when
testing the patient’s deep tendon reflexes?
a. Reflexes will be normal.
b. Reflexes cannot be elicited.
c. All reflexes will be diminished but present.
d. Some reflexes will be present, depending on the area of injury.
During a breast examination on a female patient, the nurse notices that the nipple is flat,
broad, and fixed. The patient states it ‘started doing that a few months ago.” This
finding suggests:
a. Dimpling.
b. Retracted nipple.
c. Nipple inversion.
d. Deviation in nipple pointing.
During a visit to the clinic, a patient states, “The doctor just told me he thought I ought
to stop smoking. He doesn”t understand how hard I”ve tried. I just don”t know the best
way to do it. What should I do?” The nurse’s most appropriate response in this case
would be:
a. “I”d quit if I were you. The doctor really knows what he is talking about.”
b. “Would you like some information about the different ways a person can quit
smoking?”
c. “Stopping your dependence on cigarettes can be very difficult. I understand how you
feel.”
d. “Why are you confused? Didn”t the doctor give you the information about the
smoking cessation program we offer?”
The nurse is reviewing the characteristics of breath sounds. Which statement about
bronchovesicular breath sounds is true? Bronchovesicular breath sounds are:
a. Musical in quality.
b. Usually caused by a pathologic disease.
c. Expected near the major airways.
d. Similar to bronchial sounds except shorter in duration.
The nurse notices that a patient’s palpebral fissures are not symmetric. On examination,
the nurse may find that damage has occurred to which cranial nerve (CN)?
a. III
b. V
c. VII
d. VIII
The nurse is aware of which statement to be true regarding the incidence of testicular
cancer?
a. Testicular cancer is the most common cancer in men aged 30 to 50 years.
b. The early symptoms of testicular cancer are pain and induration.
c. Men with a history of cryptorchidism are at the greatest risk for the development of
testicular cancer.
d. The cure rate for testicular cancer is low.
A patient comes to the clinic complaining of neck and shoulder pain and is unable to
turn her head. The nurse suspects damage to CN ______ and proceeds with the
examination by _____________.
a. XI; palpating the anterior and posterior triangles
b. XI; asking the patient to shrug her shoulders against resistance
c. XII; percussing the sternomastoid and submandibular neck muscles
d. XII; assessing for a positive Romberg sign
The nurse is assessing a patient with a history of intravenous drug abuse. In assessing
his mouth, the nurse notices a dark red confluent macule on the hard palate. This could
be an early sign of:
a. Acquired immunodeficiency syndrome (AIDS).
b. Measles.
c. Leukemia.
d. Carcinoma.
The nurse is assessing color vision of a male child. Which statement is correct? The
nurse should:
a. Check color vision annually until the age of 18 years.
b. Ask the child to identify the color of his or her clothing.
c. Test for color vision once between the ages of 4 and 8 years.
d. Begin color vision screening at the child’s 2-year checkup.
During an interview, the nurse states, “You mentioned having shortness of breath. Tell
me more about that.” Which verbal skill is used with this statement?
a. Reflection
b. Facilitation
c. Direct question
d. Open-ended question
A 22-year-old woman comes to the clinic because of severe sunburn and states, “I was
out in the sun for just a couple of minutes.” The nurse begins a medication review with
her, paying special attention to which medication class?
a. Nonsteroidal antiinflammatory drugs for pain
b. Tetracyclines for acne
c. Proton pump inhibitors for heartburn
d. Thyroid replacement hormone for hypothyroidism
A patient tells the nurse that he is allergic to penicillin. What would be the nurse’s best
response to this information?
a. “Are you allergic to any other drugs?”
b. “How often have you received penicillin?”
c. “I”ll write your allergy on your chart so you won”t receive any penicillin.”
d. “Describe what happens to you when you take penicillin.”
During a speculum inspection of the vagina, the nurse would expect to see what at the
end of the vaginal canal?
a. Cervix
b. Uterus
c. Ovaries
d. Fallopian tubes
A 30-year-old woman has recently moved to the United States with her husband. They
are living with the woman’s sister until they can get a home of their own. When
company arrives to visit with the woman’s sister, the woman feels suddenly shy and
retreats to the back bedroom to hide until the company leaves. She explains that her
reaction to guests is simply because she does not know how to speak “perfect English.”
This woman could be experiencing:
a. Culture shock.
b. Cultural taboos.
c. Cultural unfamiliarity.
d. Culture disorientation.
The nurse is asking an adolescent about illicit substance abuse. The adolescent answers,
“Yes, I”ve used marijuana at parties with my friends.” What is the next question the
nurse should ask?
a. “Who are these friends?”
b. “Do your parents know about this?”
c. “When was the last time you used marijuana?”
d. “Is this a regular habit?”
Which technique is correct when the nurse is assessing the radial pulse of a patient?
The pulse is counted for:
a. 1 minute, if the rhythm is irregular.
b. 15 seconds and then multiplied by 4, if the rhythm is regular.
c. 2 full minutes to detect any variation in amplitude.
d. 10 seconds and then multiplied by 6, if the patient has no history of cardiac
abnormalities.
An older adult woman is brought to the emergency department after being found lying
on the kitchen floor for 2 days; she is extremely dehydrated. What would the nurse
expect to see during the examination?
a. Smooth mucous membranes and lips
b. Dry mucous membranes and cracked lips
c. Pale mucous membranes
d. White patches on the mucous membranes
During an internal examination, the nurse notices that the cervix bulges outside the
introitus when the patient is asked to strain. The nurse will document this as:
a. Uterine prolapse, graded first degree.
b. Uterine prolapse, graded second degree.
c. Uterine prolapse, graded third degree.
d. A normal finding.
A patient has suddenly developed shortness of breath and appears to be in significant
respiratory distress. After calling the physician and placing the patient on oxygen,
which of these actions is the best for the nurse to take when further assessing the
patient?
a. Count the patient’s respirations.
b. Bilaterally percuss the thorax, noting any differences in percussion tones.
c. Call for a chest x-ray study, and wait for the results before beginning an assessment.
d. Inspect the thorax for any new masses and bleeding associated with respirations.
A patient is at the clinic to have her blood pressure checked. She has been coming to the
clinic weekly since she changed medications 2 months ago. The nurse should:
a. Collect a follow-up data base and then check her blood pressure.
b. Ask her to read her health record and indicate any changes since her last visit.
c. Check only her blood pressure because her complete health history was documented
2 months ago.
d. Obtain a complete health history before checking her blood pressure because much
of her history information may have changed.
During an examination, the nurse finds that a patient’s left temporal artery is tortuous
and feels hardened and tender, compared with the right temporal artery. The nurse
suspects which condition?
a. Crepitation
b. Mastoiditis
c. Temporal arteritis
d. Bell palsy
Which statement about the apices of the lungs is true? The apices of the lungs:
a. Are at the level of the second rib anteriorly.
b. Extend 3 to 4 cm above the inner third of the clavicles.
c. Are located at the sixth rib anteriorly and the eighth rib laterally.
d. Rest on the diaphragm at the fifth intercostal space in the midclavicular line (MCL).
While obtaining a health history, a patient tells the nurse that he has frequent nosebleeds
and asks the best way to get them to stop. What would be the nurse’s best response?
a. “While sitting up, place a cold compress over your nose.”
b. “Sit up with your head tilted forward and pinch your nose.”
c. “Just allow the bleeding to stop on its own, but don”t blow your nose.”
d. “Lie on your back with your head tilted back and pinch your nose.”
During an assessment, the nurse uses the CAGE test. The patient answers “yes” to two
of the questions. What could this be indicating?
a. The patient is an alcoholic.
b. The patient is annoyed at the questions.
c. The patient should be thoroughly examined for possible alcohol withdrawal
symptoms.
d. The nurse should suspect alcohol abuse and continue with a more thorough substance
abuse assessment.