Which statement is true regarding the arterial system?
a. Arteries are large-diameter vessels.
b. The arterial system is a high-pressure system.
c. The walls of arteries are thinner than those of the veins.
d. Arteries can greatly expand to accommodate a large blood volume increase.
An older patient has been admitted to the intensive care unit (ICU) after falling at
home. Within 8 hours, his condition has stabilized and he is transferred to a medical
unit. The family is wondering whether he will be able to go back home. Which
assessment instrument is most appropriate for the nurse to choose at this time?
a. Lawton IADL instrument
b. Hospital Admission Risk Profile (HARP)
c. Mini-Cog
d. NEECHAM Confusion Scale
During an assessment, the nurse notices that a patient’s left arm is swollen from the
shoulder down to the fingers, with nonpitting brawny edema. The right arm is normal.
The patient had a left-sided mastectomy 1 year ago. The nurse suspects which problem?
a. Venous stasis
b. Lymphedema
c. Arteriosclerosis
d. Deep-vein thrombosis
The nurse is assessing a patient for possible peptic ulcer disease. Which condition or
history often causes this problem?
a. Hypertension
b. Streptococcal infections
c. Recurrent constipation with frequent laxative use
d. Frequent use of nonsteroidal antiinflammatory drugs
The nurse is preparing to examine a patient who has been complaining of right lower
quadrant pain. Which technique is correct during the assessment?
The nurse should:
a. Examine the tender area first.
b. Examine the tender area last.
c. Avoid palpating the tender area.
d. Palpate the tender area first, and then auscultate for bowel sounds.
Before auscultating the abdomen for the presence of bowel sounds on a patient, the
nurse should:
a. Warm the endpiece of the stethoscope by placing it in warm water.
b. Leave the gown on the patient to ensure that he or she does not get chilled during the
examination.
c. Ensure that the bell side of the stethoscope is turned to the “on” position.
d. Check the temperature of the room, and offer blankets to the patient if he or she feels
cold.
A 46-year-old man requires an assessment of his sigmoid colon. Which instrument or
technique is most appropriate for this examination?
a. Proctoscope
b. Ultrasound
c. Colonoscope
d. Rectal examination with an examining finger
Immediately after birth, the nurse is unable to suction the nares of a newborn. An
attempt is made to pass a catheter through both nasal cavities with no success. What
should the nurse do next?
a. Attempt to suction again with a bulb syringe.
b. Wait a few minutes, and try again once the infant stops crying.
c. Recognize that this situation requires immediate intervention.
d. Contact the physician to schedule an appointment for the infant at his or her next
hospital visit.
During a cardiac assessment on a 38-year-old patient in the hospital for “chest pain,” the
nurse finds the following: jugular vein pulsations 4 cm above the sternal angle when the
patient is elevated at 45 degrees, blood pressure 98/60 mm Hg, heart rate 130 beats per
minute, ankle edema, difficulty breathing when supine, and an S3 on auscultation.
Which of these conditions best explains the cause of these findings?
a. Fluid overload
b. Atrial septal defect
c. MI
d. Heart failure
Which of these actions illustrates the correct technique the nurse should use when
assessing oral temperature with a mercury thermometer?
a. Wait 30 minutes if the patient has ingested hot or iced liquids.
b. Leave the thermometer in place 3 to 4 minutes if the patient is afebrile.
c. Place the thermometer in front of the tongue, and ask the patient to close his or her
lips.
d. Shake the mercury-in-glass thermometer down to below 36.6 C before taking the
temperature.
When the nurse is testing the triceps reflex, what is the expected response?
a. Flexion of the hand
b. Pronation of the hand
c. Extension of the forearm
d. Flexion of the forearm
During a cardiovascular assessment, the nurse knows that a thrill is:
a. Vibration that is palpable.
b. Palpated in the right epigastric area.
c. Associated with ventricular hypertrophy.
d. Murmur auscultated at the third intercostal space.
During an examination, the nurse notes that a patient is exhibiting flight of ideas. Which
statement by the patient is an example of flight of ideas?
a. “My stomach hurts. Hurts, spurts, burts.”
b. “Kiss, wood, reading, ducks, onto, maybe.”
c. “Take this pill? The pill is red. I see red. Red velvet is soft, soft as a baby’s bottom.”
d. “I wash my hands, wash them, wash them. I usually go to the sink and wash my
hands.”
A patient states, “Whenever I open my mouth real wide, I feel this popping sensation in
front of my ears.” To further examine this, the nurse would:
a. Place the stethoscope over the temporomandibular joint, and listen for bruits.
b. Place the hands over his ears, and ask him to open his mouth “really wide.”
c. Place one hand on his forehead and the other on his jaw, and ask him to try to open
his mouth.
d. Place a finger on his temporomandibular joint, and ask him to open and close his
mouth.
A professional tennis player comes into the clinic complaining of a sore elbow. The
nurse will assess for tenderness at the:
a. Olecranon bursa.
b. Annular ligament.
c. Base of the radius.
d. Medial and lateral epicondyle.
A mother brings her child into the clinic for an examination of the scalp and hair. She
states that the child has developed irregularly shaped patches with broken-off, stublike
hair in some places; she is worried that this condition could be some form of premature
baldness. The nurse tells her that it is:
a. Folliculitis that can be treated with an antibiotic.
b. Traumatic alopecia that can be treated with antifungal medications.
c. Tinea capitis that is highly contagious and needs immediate attention.
d. Trichotillomania; her child probably has a habit of absentmindedly twirling her hair.
The nurse is reviewing causes of increased intraocular pressure. Which of these factors
determines intraocular pressure?
a. Thickness or bulging of the lens
b. Posterior chamber as it accommodates increased fluid
c. Contraction of the ciliary body in response to the aqueous within the eye
d. Amount of aqueous produced and resistance to its outflow at the angle of the anterior
chamber
A 59-year-old patient has been diagnosed with prostatitis and is being seen at the clinic
for complaints of burning and pain during urination. He is experiencing:
a. Dysuria.
b. Nocturia.
c. Polyuria.
d. Hematuria.
During an abdominal assessment, the nurse elicits tenderness on light palpation in the
right lower quadrant. The nurse interprets that this finding could indicate a disorder of
which of these structures?
a. Spleen
b. Sigmoid
c. Appendix
d. Gallbladder
During the examination, offering some brief teaching about the patient’s body or the
examiner’s findings is often appropriate. Which one of these statements by the nurse is
most appropriate?
a. “Your atrial dysrhythmias are under control.”
b. “You have pitting edema and mild varicosities.”
c. “Your pulse is 80 beats per minute, which is within the normal range.”
d. “I”m using my stethoscope to listen for any crackles, wheezes, or rubs.”
A patient calls the clinic for instructions before having a Papanicolaou (Pap) smear. The
most appropriate instructions from the nurse are:
a. “If you are menstruating, please use pads to avoid placing anything into the vagina.”
b. “Avoid intercourse, inserting anything into the vagina, or douching within 24 hours
of your appointment.”
c. “If you suspect that you have a vaginal infection, please gather a sample of the
discharge to bring with you.”
d. “We would like you to use a mild saline douche before your examination. You may
pick this up in our office.”
A 45-year-old man is in the clinic for a physical examination. During the abdominal
assessment, the nurse percusses the abdomen and notices an area of dullness above the
right costal margin of approximately 11 cm. The nurse should:
a. Document the presence of hepatomegaly.
b. Ask additional health history questions regarding his alcohol intake.
c. Describe this dullness as indicative of an enlarged liver, and refer him to a physician.
d. Consider this finding as normal, and proceed with the examination.
The nurse notices that a patient has a solid, elevated, circumscribed lesion that is less
than 1 cm in diameter. When documenting this finding, the nurse reports this as a:
a. Bulla.
b. Wheal.
c. Nodule.
d. Papule.
Which of these statements represents subjective data the nurse obtained from the patient
regarding the patient’s skin?
a. Skin appears dry.
b. No lesions are obvious.
c. Patient denies any color change.
d. Lesion is noted on the lateral aspect of the right arm.
A 2-year-old child has been brought to the clinic for a well-child checkup. The best way
for the nurse to begin the assessment is to:
a. Ask the parent to place the child on the examining table.
b. Have the parent remove all of the child’s clothing before the examination.
c. Allow the child to keep a security object such as a toy or blanket during the
examination.
d. Initially focus the interactions on the child, essentially ignoring the parent until the
child’s trust has been obtained.
When examining the eye, the nurse notices that the patient’s eyelid margins
approximate completely. The nurse recognizes that this assessment finding:
a. Is expected.
b. May indicate a problem with extraocular muscles.
c. May result in problems with tearing.
d. Indicates increased intraocular pressure.
While assessing a patient who is hospitalized and bedridden, the nurse notices that the
patient has been incontinent of stool. The stool is loose and gray-tan in color. The nurse
recognizes that this finding indicates which of the following?
a. Occult blood
b. Inflammation
c. Absent bile pigment
d. Ingestion of iron preparations
A patient states during the interview that she noticed a new lump in the shower a few
days ago. It was on her left breast near her axilla. The nurse should plan to:
a. Palpate the lump first.
b. Palpate the unaffected breast first.
c. Avoid palpating the lump because it could be a cyst, which might rupture.
d. Palpate the breast with the lump first but plan to palpate the axilla last.
During a complete health assessment, how would the nurse test the patient’s hearing?
a. Observing how the patient participates in normal conversation
b. Using the whispered voice test
c. Using the Weber and Rinne tests
d. Testing with an audiometer
The nurse is conducting a class on alcohol and the effects of alcohol on the body. How
many standard drinks (each containing 14 grams of alcohol) per day in men are
associated with increased deaths from cirrhosis, cancers of the mouth, esophagus, and
injuries?
a. 2
b. 4
c. 6
d. 8
The nurse is preparing to assess the ankle-brachial index (ABI) of a patient. Which
statement about the ABI is true?
a. Normal ABI indices are from 0.5 to 1.0.
b. Normal ankle pressure is slightly lower than the brachial pressure.
c. The ABI is a reliable measurement of peripheral vascular disease in individuals with
diabetes.
d. An ABI of 0.9 to 0.7 indicates the presence of peripheral vascular disease and mild
claudication.
During an examination, the nurse notices that a female patient has a round “moon” face,
central trunk obesity, and a cervical hump. Her skin is fragile with bruises. The nurse
determines that the patient has which condition?
a. Marfan syndrome
b. Gigantism
c. Cushing syndrome
d. Acromegaly
A patient has a long history of chronic obstructive pulmonary disease (COPD). During
the assessment, the nurse will most likely observe which of these?
a. Unequal chest expansion
b. Increased tactile fremitus
c. Atrophied neck and trapezius muscles
d. Anteroposterior-to-transverse diameter ratio of 1:1
The nurse is interviewing a male patient who has a hearing impairment. What
techniques would be most beneficial in communicating with this patient?
a. Determine the communication method he prefers.
b. Avoid using facial and hand gestures because most hearing-impaired people find this
degrading.
c. Request a sign language interpreter before meeting with him to help facilitate the
communication.
d. Speak loudly and with exaggerated facial movement when talking with him because
doing so will help him lip read.
While obtaining a health history of a 3-month-old infant from the mother, the nurse asks
about the infant’s ability to suck and grasp the mother’s finger. What is the nurse
assessing?
a. Reflexes
b. Intelligence
c. CNs
d. Cerebral cortex function