When performing a genital assessment on a middle-aged man, the nurse notices
multiple soft, moist, painless papules in the shape of cauliflower-like patches scattered
across the shaft of the penis. These lesions are characteristic of:
a. Carcinoma.
b. Syphilitic chancres.
c. Genital herpes.
d. Genital warts.
A patient, an 85-year-old woman, is complaining about the fact that the bones in her
face have become more noticeable. What explanation should the nurse give her?
a. Diets low in protein and high in carbohydrates may cause enhanced facial bones.
b. Bones can become more noticeable if the person does not use a dermatologically
approved moisturizer.
c. More noticeable facial bones are probably due to a combination of factors related to
aging, such as decreased elasticity, subcutaneous fat, and moisture in her skin.
d. Facial skin becomes more elastic with age. This increased elasticity causes the skin to
be more taught, drawing attention to the facial bones.
When palpating the abdomen of a 20-year-old patient, the nurse notices the presence of
tenderness in the left upper quadrant with deep palpation. Which of these structures is
most likely to be involved?
a. Spleen
b. Sigmoid colon
c. Appendix
d. Gallbladder
The nurse is reviewing the blood supply to the arm. The major artery supplying the arm
is the _____ artery.
a. Ulnar
b. Radial
c. Brachial
d. Deep palmar
If a 29-year-old woman weighs 156 pounds, and the nurse determines her ideal body
weight to be 120 pounds, then how would the nurse classify the woman’s weight?
a. Obese
b. Mildly overweight
c. Suffering from malnutrition
d. Within appropriate range of ideal weight
If the nurse records the results to the Hirschberg test, the nurse has:
a. Tested the patellar reflex.
b. Assessed for appendicitis.
c. Tested the corneal light reflex.
d. Assessed for thrombophlebitis.
Which of the following statements is trueregarding the internal structures of the breast?
The breast is made up of:
a. Primarily muscle with very little fibrous tissue.
b. Fibrous, glandular, and adipose tissues.
c. Primarily milk ducts, known as lactiferous ducts.
d. Glandular tissue, which supports the breast by attaching to the chest wall.
A mother of a 1-month-old infant asks the nurse why it takes so long for infants to learn
to roll over. The nurse knows that the reason for this is:
a. A demyelinating process must be occurring with her infant.
b. Myelin is needed to conduct the impulses, and the neurons of a newborn are not yet
myelinated.
c. The cerebral cortex is not fully developed; therefore, control over motor function
gradually occurs.
d. The spinal cord is controlling the movement because the cerebellum is not yet fully
developed.
A mother brings her 28-month-old daughter into the clinic for a well-child visit. At the
beginning of the visit, the nurse focuses attention away from the toddler, but as the
interview progresses, the toddler begins to “warm up” and is smiling shyly at the nurse.
The nurse will be most successful in interacting with the toddler if which is done next?
a. Tickle the toddler, and get her to laugh.
b. Stoop down to her level, and ask her about the toy she is holding.
c. Continue to ignore her until it is time for the physical examination.
d. Ask the mother to leave during the examination of the toddler, because toddlers often
fuss less if their parent is not in view.
The nurse knows that developing appropriate nursing interventions for a patient relies
on the appropriateness of the __________ diagnosis.
a. Nursing
b. Medical
c. Admission
d. Collaborative
A patient in her first trimester of pregnancy is diagnosed with rubella. Which of these
statements is correct regarding the significance of this in relation to the infant’s
hearing?
a. Rubella may affect the mother’s hearing but not the infant’s.
b. Rubella can damage the infant’s organ of Corti, which will impair hearing.
c. Rubella is only dangerous to the infant in the second trimester of pregnancy.
d. Rubella can impair the development of CN VIII and thus affect hearing.
The nurse knows that which statement is true regarding the pain experienced by
infants?
a. Pain in infants can only be assessed by physiologic changes, such as an increased
heart rate.
b. The FPS-R can be used to assess pain in infants.
c. A procedure that induces pain in adults will also induce pain in the infant.
d. Infants feel pain less than do adults.
During an assessment of a 22-year-old woman who sustained a head injury from an
automobile accident 4 hours earlier, the nurse notices the following changes: pupils
were equal, but now the right pupil is fully dilated and nonreactive, and the left pupil is
4 mm and reacts to light. What do these findings suggest?
a. Injury to the right eye
b. Increased intracranial pressure
c. Test inaccurately performed
d. Normal response after a head injury
When checking for proper blood pressure cuff size, which guideline is correct?
a. The standard cuff size is appropriate for all sizes.
b. The length of the rubber bladder should equal 80% of the arm circumference.
c. The width of the rubber bladder should equal 80% of the arm circumference.
d. The width of the rubber bladder should equal 40% of the arm circumference.
A 40-year-old man has come into the clinic with complaints of extreme pain in his toes.
The nurse notices that his toes are slightly swollen, reddened, and warm to the touch.
His complaints would suggest:
a. Osteoporosis.
b. Acute gout.
c. Ankylosing spondylitis.
d. Degenerative joint disease.
A patient has been in the intensive care unit for 10 days. He has just been moved to the
medical-surgical unit, and the admitting nurse is planning to perform a mental status
examination. During the tests of cognitive function, the nurse would expect that he:
a. May display some disruption in thought content.
b. Will state, “I am so relieved to be out of intensive care.”
c. Will be oriented to place and person, but the patient may not be certain of the date.
d. May show evidence of some clouding of his level of consciousness.
The nurse has palpated a lump in a female patient’s right breast. The nurse documents
this as a small, round, firm, distinct, lump located at 2 o”clock, 2 cm from the nipple. It
is nontender and fixed. No associated retraction of the skin or nipple, no erythema, and
no axillary lymphadenopathy are observed. What information is missing from the
documentation?
a. Shape of the lump
b. Consistency of the lump
c. Size of the lump
d. Whether the lump is solitary or multiple
The nurse is assessing the abdomen of a pregnant woman who is complaining of having
“acid indigestion” all the time. The nurse knows that esophageal reflux during
pregnancy can cause:
a. Diarrhea.
b. Pyrosis.
c. Dysphagia.
d. Constipation.
The nurse is taking a family history. Important diseases or problems about which the
patient should be specifically asked include:
a. Emphysema.
b. Head trauma.
c. Mental illness.
d. Fractured bones.
When examining the face of a woman who is 28 weeks’ pregnant, the nurse notices the
presence of a butterfly-shaped increase in pigmentation on the face. The proper term for
this finding in the documentation is:
a. Striae.
b. Chloasma.
c. Linea nigra.
d. Mask of pregnancy.
When reviewing the musculoskeletal system, the nurse recalls that hematopoiesis takes
place in the:
a. Liver.
b. Spleen.
c. Kidneys.
d. Bone marrow.
The nurse is checking the range of motion in a patient’s knee and knows that the knee is
capable of which movement(s)?
a. Flexion and extension
b. Supination and pronation
c. Circumduction
d. Inversion and eversion
After assessing a female patient, the nurse notices flesh-colored, soft, pointed, moist,
papules in a cauliflower-like patch around her introitus. This finding is most likely:
a. Urethral caruncle.
b. Syphilitic chancre.
c. Herpes simplex virus.
d. Human papillomavirus.
When inspecting the anterior chest of an adult, the nurse should include which
assessment?
a. Diaphragmatic excursion
b. Symmetric chest expansion
c. Presence of breath sounds
d. Shape and configuration of the chest wall
A new mother calls the clinic to report that part of her left breast is red, swollen, tender,
very hot, and hard. She has a fever of 38.3oC. She also has had symptoms of influenza,
such as chills, sweating, and feeling tired. The nurse notices that she has been
breastfeeding for 1 month. From her description, what condition does the nurse
suspect?
a. Mastitis
b. Paget disease
c. Plugged milk duct
d. Mammary duct ectasia
The nurse is assessing a patient who has been admitted for cirrhosis of the liver,
secondary to chronic alcohol use. During the physical assessment, the nurse looks for
cardiac problems that are associated with chronic use of alcohol, such as:
a. Hypertension.
b. Ventricular fibrillation.
c. Bradycardia.
d. Mitral valve prolapse.
The nurse is administering a Mini-Cog test to an older adult woman. When asked to
draw a clock showing the time of 10:45, the patient drew a clock with the numbers out
of order and with an incorrect time. This result indicates which finding?
a. Cognitive impairment
b. Amnesia
c. Delirium
d. Attention-deficit disorder
Which situation is most appropriate during which the nurse performs a focused or
problem-centered history?
a. Patient is admitted to a long-term care facility.
b. Patient has a sudden and severe shortness of breath.
c. Patient is admitted to the hospital for surgery the following day.
d. Patient in an outpatient clinic has cold and influenza-like symptoms.
When performing an assessment of a patient, the nurse notices the presence of an
enlarged right epitrochlear lymph node. What should the nurse do next?
a. Assess the patient’s abdomen, and notice any tenderness.
b. Carefully assess the cervical lymph nodes, and check for any enlargement.
c. Ask additional health history questions regarding any recent ear infections or sore
throats.
d. Examine the patient’s lower arm and hand, and check for the presence of infection or
lesions.
A patient is especially worried about an area of skin on her feet that has turned white.
The health care provider has told her that her condition is vitiligo. The nurse explains to
her that vitiligo is:
a. Caused by an excess of melanin pigment
b. Caused by an excess of apocrine glands in her feet
c. Caused by the complete absence of melanin pigment
d. Related to impetigo and can be treated with an ointment
The sac that surrounds and protects the heart is called the:
a. Pericardium.
b. Myocardium.
c. Endocardium.
d. Pleural space.