The nurse is conducting an interview in an outpatient clinic and is using a computer to
record data. Which are the best uses of the computer in this situation? Select all that
apply.
a. Collect the patient’s data in a direct, face-to-face manner.
b. Enter all the data as the patient states them.
c. Ask the patient to wait as the nurse enters the data.
d. Type the data into the computer after the narrative is fully explored.
e. Allow the patient to see the monitor during typing.
During assessment of a patient’s pain, the nurse is aware that certain nonverbal
behaviors are associated with chronic pain. Which of these behaviors are associated
with chronic pain? Select all that apply.
a. Sleeping
b. Moaning
c. Diaphoresis
d. Bracing
e. Restlessness
f. Rubbing
A 65-year-old patient remarks that she just cannot believe that her breasts ‘sag so
much.” She states it must be from a lack of exercise. What explanation should the nurse
offer her? After menopause:
a. Only women with large breasts experience sagging.
b. Sagging is usually due to decreased muscle mass within the breast.
c. A diet that is high in protein will help maintain muscle mass, which keeps the breasts
from sagging.
d. The glandular and fat tissue atrophies, causing breast size and elasticity to diminish,
resulting in breasts that sag.
During a health history interview, a 38-year-old woman shares that she is thinking about
having another baby. The nurse knows which statement to be true regarding pregnancy
after 35 years of age?
a. Fertility does not start to decline until age 40 years.
b. Occurrence of Down syndrome is significantly more frequent after the age of 35
years.
c. Genetic counseling and prenatal screening are not routine until after age 40 years.
d. Women older than 35 years who are pregnant have the same rate of
pregnancy-related complications as those who are younger than 35 years.
Generally, the changes normally associated with menopause occur because the cells in
the reproductive tract are:
a. Aging.
b. Becoming fibrous.
c. Estrogen dependent.
d. Able to respond to estrogen.
The nurse is unable to identify any changes in sound when percussing over the
abdomen of an obese patient. What should the nurse do next?
a. Ask the patient to take deep breaths to relax the abdominal musculature.
b. Consider this finding as normal, and proceed with the abdominal assessment.
c. Increase the amount of strength used when attempting to percuss over the abdomen.
d. Decrease the amount of strength used when attempting to percuss over the abdomen.
A 70-year-old patient tells the nurse that he has noticed that he is having trouble
hearing, especially in large groups. He says that he “can”t always tell where the sound
is coming from” and the words often sound “mixed up.” What might the nurse suspect
as the cause for this change?
a. Atrophy of the apocrine glands
b. Cilia becoming coarse and stiff
c. Nerve degeneration in the inner ear
d. Scarring of the tympanic membrane
The nurse is presenting a class on risk factors for cardiovascular disease. Which of
these are considered modifiable risk factors for MI? Select all that apply.
a. Ethnicity
b. Abnormal lipids
c. Smoking
d. Gender
e. Hypertension
f. Diabetes
g. Family history
A 9-year-old girl is in the clinic for a sport physical examination. After some initial
shyness she finally asks, “Am I normal? I don”t seem to need a bra yet, but I have some
friends who do. What if I never get breasts?” The nurse’s best response would be:
a. “Don”t worry, you still have plenty of time to develop.”
b. “I know just how you feel, I was a late bloomer myself. Just be patient, and they will
grow.”
c. “You will probably get your periods before you notice any significant growth in your
breasts.”
d. “I understand that it is hard to feel different from your friends. Breasts usually
develop between 8 and 10 years of age.”
When assessing tactile fremitus, the nurse recalls that it is normal to feel tactile fremitus
most intensely over which location?
a. Between the scapulae
b. Third intercostal space, MCL
c. Fifth intercostal space, midaxillary line (MAL)
d. Over the lower lobes, posterior side
During an examination of an aging man, the nurse recognizes that normal changes to
expect would be:
a. Change in scrotal color.
b. Decrease in the size of the penis.
c. Enlargement of the testes and scrotum.
d. Increase in the number of rugae over the scrotal sac.
When the nurse is performing a testicular examination on a 25-year-old man, which
finding is considered normal?
a. Nontender subcutaneous plaques
b. Scrotal area that is dry, scaly, and nodular
c. Testes that feel oval and movable and are slightly sensitive to compression
d. Single, hard, circumscribed, movable mass, less than 1 cm under the surface of the
testes
During auscultation of a patient’s heart sounds, the nurse hears an unfamiliar sound. The
nurse should:
a. Document the findings in the patient’s record.
b. Wait 10 minutes, and auscultate the sound again.
c. Ask the patient how he or she is feeling.
d. Ask another nurse to double check the finding.
A patient who has had rheumatoid arthritis for years comes to the clinic to ask about
changes in her fingers. The nurse will assess for signs of what problems?
a. Heberden nodes
b. Bouchard nodules
c. Swan-neck deformities
d. Dupuytren contractures
The articulation of the mandible and the temporal bone is known as the:
a. Intervertebral foramen.
b. Condyle of the mandible.
c. Temporomandibular joint.
d. Zygomatic arch of the temporal bone.
During auscultation of the lungs, the nurse expects decreased breath sounds to be heard
in which situation?
a. When the bronchial tree is obstructed
b. When adventitious sounds are present
c. In conjunction with whispered pectoriloquy
d. In conditions of consolidation, such as pneumonia
The nurse is aware that one change that may occur in the gastrointestinal system of an
aging adult is:
a. Increased salivation.
b. Increased liver size.
c. Increased esophageal emptying.
d. Decreased gastric acid secretion.
If an American Indian woman has come to the clinic to seek help with regulating her
diabetes, then the nurse can expect that she:
a. Will comply with the treatment prescribed.
b. Has obviously given up her belief in naturalistic causes of disease.
c. May also be seeking the assistance of a shaman or medicine man.
d. Will need extra help in dealing with her illness and may be experiencing a crisis of
faith.
The nurse is providing care for a 68-year-old woman who is complaining of
constipation. What concern exists regarding her nutritional status?
a. Absorption of nutrients may be impaired.
b. Constipation may represent a food allergy.
c. The patient may need emergency surgery to correct the problem.
d. Gastrointestinal problems will increase her caloric demand.
During a morning assessment, the nurse notices that an older patient is less attentive
and is unable to recall yesterday’s events. Which test is appropriate for assessing the
patient’s mental status?
a. Geriatric Depression Scale, short form
b. Rapid Disability Rating Scale-2
c. Mini-Cog
d. Get Up and Go Test
A female patient tells the nurse that she has four children and has had three pregnancies.
How should the nurse document this?
a. Gravida 3, para 4
b. Gravida 4, para 3
c. This information cannot be documented using the terms gravida and para.
d. “The patient seems to be confused about how many times she has been pregnant.”
Which of these percussion findings would the nurse expect to find in a patient with a
large amount of ascites?
a. Dullness across the abdomen
b. Flatness in the right upper quadrant
c. Hyperresonance in the left upper quadrant
d. Tympany in the right and left lower quadrants
A patient is brought by ambulance to the emergency department with multiple traumas
received in an automobile accident. He is alert and cooperative, but his injuries are
quite severe. How would the nurse proceed with data collection?
a. Collect history information first, then perform the physical examination and institute
life-saving measures.
b. Simultaneously ask history questions while performing the examination and initiating
life-saving measures.
c. Collect all information on the history form, including social support patterns,
strengths, and coping patterns.
d. Perform life-saving measures and delay asking any history questions until the patient
is transferred to the intensive care unit.
A patient with a lack of oxygen to his heart will have pain in his chest and possibly in
the shoulder, arms, or jaw. The nurse knows that the best explanation why this occurs is
which one of these statements?
a. A problem exists with the sensory cortex and its ability to discriminate the location.
b. The lack of oxygen in his heart has resulted in decreased amount of oxygen to the
areas experiencing the pain.
c. The sensory cortex does not have the ability to localize pain in the heart;
consequently, the pain is felt elsewhere.
d. A lesion has developed in the dorsal root, which is preventing the sensation from
being transmitted normally.
A 30-year-old woman with a history of mitral valve problems states that she has been
“very tired.” She has started waking up at night and feels like her “heart is pounding.”
During the assessment, the nurse palpates a thrill and lift at the fifth left intercostal
space midclavicular line. In the same area, the nurse also auscultates a blowing,
swishing sound right after the S1. These findings would be most consistent with:
a. Heart failure.
b. Aortic stenosis.
c. Pulmonary edema.
d. Mitral regurgitation.
A nurse is helping at a health fair at a local mall. When taking blood pressures on a
variety of people, the nurse keeps in mind that:
a. After menopause, blood pressure readings in women are usually lower than those
taken in men.
b. The blood pressure of a Black adult is usually higher than that of a White adult of the
same age.
c. Blood pressure measurements in people who are overweight should be the same as
those of people who are at a normal weight.
d. A teenager’s blood pressure reading will be lower than that of an adult.
When performing an external genitalia examination of a 10-year-old girl, the nurse
notices that no pubic hair has grown in and the mons and the labia are covered with fine
vellus hair. These findings are consistent with stage _____ of sexual maturity, according
to the Sexual Maturity Rating scale.
a. 1
b. 2
c. 3
d. 4
A physician tells the nurse that a patient’s vertebra prominens is tender and asks the
nurse to reevaluate the area in 1 hour. The area of the body the nurse will assess is:
a. Just above the diaphragm.
b. Just lateral to the knee cap.
c. At the level of the C7 vertebra.
d. At the level of the T11 vertebra.
The nurse suspects that a patient has hyperthyroidism, and the laboratory data indicate
that the patient’s T4 and T3 hormone levels are elevated. Which of these findings would
the nurse most likely find on examination?
a. Tachycardia
b. Constipation
c. Rapid dyspnea
d. Atrophied nodular thyroid gland
A 29-year-old woman tells the nurse that she has “excruciating pain” in her back. Which
would be the nurse’s appropriate response to the woman’s statement?
a. “How does your family react to your pain?”
b. “The pain must be terrible. You probably pinched a nerve.”
c. “I”ve had back pain myself, and it can be excruciating.”
d. “How would you say the pain affects your ability to do your daily activities?”
A 45-year-old woman is at the clinic for a mental status assessment. In giving her the
Four Unrelated Words Test, the nurse would be concerned if she could not ____ four
unrelated words ____.
a. Invent; within 5 minutes
b. Invent; within 30 seconds
c. Recall; after a 30-minute delay
d. Recall; after a 60-minute delay
During an admission assessment, the nurse notices that a male patient has an enlarged
and rather thick skull. The nurse suspects acromegaly and would further assess for:
a. Exophthalmos.
b. Bowed long bones.
c. Coarse facial features.
d. Acorn-shaped cranium.
When a breastfeeding mother is diagnosed with a breast abscess, which of these
instructions from the nurse is correct? The mother needs to:
a. Continue to nurse on both sides to encourage milk flow.
b. Immediately discontinue nursing to allow for healing.
c. Temporarily discontinue nursing on the affected breast, and manually express milk
and discard it.
d. Temporarily discontinue nursing on affected breast, but manually express milk and
give it to the baby.
Which of these statements best describes the action of the hormone progesterone during
pregnancy?
a. Progesterone produces the hormone human chorionic gonadotropin.
b. Duct formation in the breast is stimulated by progesterone.
c. Progesterone promotes sloughing of the endometrial wall.
d. Progesterone maintains the endometrium around the fetus.
In response to a question about stress, a 39-year-old woman tells the nurse that her
husband and mother both died in the past year. Which response by the nurse is most
appropriate?
a. “This has been a difficult year for you.”
b. “I don”t know how anyone could handle that much stress in 1 year!”
c. “What did you do to cope with the loss of both your husband and mother?”
d. “That is a lot of stress; now let’s go on to the next section of your history.”