Unlock document.
This document is partially blurred.
Unlock all pages and 1 million more documents.
Get Access
During examination, the nurse finds that a patient is unable to distinguish objects placed
in his hand. The nurse would document:
a. Stereognosis.
b. Astereognosis.
c. Graphesthesia.
d. Agraphesthesia.
A 70-year-old patient with a history of hypertension has a blood pressure of 180/100
mm Hg and a heart rate of 90 beats per minute. The nurse hears an extra heart sound at
the apex immediately before the S1. The sound is heard only with the bell of the
stethoscope while the patient is in the left lateral position. With these findings and the
patient's history, the nurse knows that this extra heart sound is most likely a(n):
a. Split S1.
b. Atrial gallop.
c. Diastolic murmur.
d. Summation sound.
A patient who is 24 weeks' pregnant asks about wearing a seat belt while driving.
Which response by the nurse is correct?
a. "Seat belts should not be worn during pregnancy."
b. "Place the lap belt below the uterus and use the shoulder strap at the same time."
c. "Place the lap belt below the uterus but omit the shoulder strap during pregnancy."
d. "Place the lap belt at your waist above the uterus and use the shoulder strap at the
same time."
During an examination of the eye, the nurse would expect what normal finding when
assessing the lacrimal apparatus?
a. Presence of tears along the inner canthus
b. Blocked nasolacrimal duct in a newborn infant
c. Slight swelling over the upper lid and along the bony orbit if the individual has a cold
d. Absence of drainage from the puncta when pressing against the inner orbital rim
A 10 year old is at the clinic for "a sore throat that has lasted 6 days." Which of these
findings would be consistent with an acute infection?
a. Tonsils 1+/1-4+ and pink; the same color as the oral mucosa
b. Tonsils 2+/1-4+ with small plugs of white debris
c. Tonsils 3+/1-4+ with large white spots
d. Tonsils 3+/1-4+ with pale coloring
Which statement is true regarding the complete physical assessment?
a. The male genitalia should be examined in the supine position.
b. The patient should be in the sitting position for examination of the head and neck.
c. The vital signs, height, and weight should be obtained at the end of the examination.
d. To promote consistency between patients, the examiner should not vary the order of
the assessment.
A female patient has nausea, breast tenderness, fatigue, and amenorrhea. Her last
menstrual period was 6 weeks ago. The nurse interprets that this patient is experiencing
__________ signs of pregnancy.
a. Positive
b. Possible
c. Probable
d. Presumptive
During an examination, the nurse notices that a patient is unable to stick out his tongue.
Which cranial nerve is involved with the successful performance of this action?
a. I
b. V
c. XI
d. XII
Which structure is located in the left lower quadrant of the abdomen?
a. Liver
b. Duodenum
c. Gallbladder
d. Sigmoid colon
An 11-year-old girl is in the clinic for a sports physical examination. The nurse notices
that she has begun to develop breasts, and during the conversation the girl reveals that
she is worried about her development. The nurse should use which of these techniques
to best assist the young girl in understanding the expected sequence for development?
The nurse should:
a. Use the Tanner scale on the five stages of sexual development.
b. Describe her development and compare it with that of other girls her age.
c. Use the Jacobsen table on expected development on the basis of height and weight
data.
d. Reassure her that her development is within normal limits and tell her not to worry
about the next step.
A 54-year-old man comes to the clinic with a "horrible problem." He tells the nurse that
he has just discovered a lump on his breast and is fearful of cancer. The nurse knows
which statement about breast cancer in men is true?
a. Breast masses in men are difficult to detect because of minimal breast tissue.
b. Breast cancer in men rarely spreads to the lymph nodes.
c. One percent of all breast cancers occurs in men.
d. Most breast masses in men are diagnosed as gynecomastia.
While performing an assessment of the perianal area of a patient, the nurse notices that
the pigmentation of anus is darker than the surrounding skin, the anal opening is closed,
and a skin sac that is shiny and blue is noted. The patient mentioned that he has had
pain with bowel movements and has occasionally noted some spots of blood. What
would this assessment and history most likely indicate?
a. Anal fistula
b. Pilonidal cyst
c. Rectal prolapse
d. Thrombosed hemorrhoid
During auscultation of fetal heart tones (FHTs), the nurse determines that the heart rate
is 136 beats per minute. The nurse's next action should be to:
a. Document the results, which are within normal range.
b. Take the maternal pulse to verify these findings as the uterine souffle.
c. Have the patient change positions and count the FHTs again.
d. Immediately notify the physician for possible fetal distress.
Symptoms, such as pain, are often influenced by a person's cultural heritage. Which of
the following is a true statement regarding pain?
a. Nurses' attitudes toward their patients' pain are unrelated to their own experiences
with pain.
b. Nurses need to recognize that many cultures practice silent suffering as a response to
pain.
c. A nurse's area of clinical practice will most likely determine his or her assessment of
a patient's pain.
d. A nurse's years of clinical experience and current position are strong indicators of his
or her response to patient pain.
A teenage patient comes to the emergency department with complaints of an inability to
breathe and a sharp pain in the left side of his chest. The assessment findings include
cyanosis, tachypnea, tracheal deviation to the right, decreased tactile fremitus on the
left, hyperresonance on the left, and decreased breath sounds on the left. The nurse
interprets that these assessment findings are consistent with:
a. Bronchitis.
b. Pneumothorax.
c. Acute pneumonia.
d. Asthmatic attack.
The nurse is assessing the skin of a patient who has acquired immunodeficiency
syndrome (AIDS) and notices multiple patchlike lesions on the temple and beard area
that are faint pink in color. The nurse recognizes these lesions as:
a. Measles (rubeola).
b. Kaposi's sarcoma.
c. Angiomas.
d. Herpes zoster.
A patient tells the nurse that his food simply does not have any taste anymore. The
nurse's best response would be:
a. "That must be really frustrating."
b. "When did you first notice this change?"
c. "My food doesn"t always have a lot of taste either."
d. "Sometimes that happens, but your taste will come back."
During an assessment, the nurse notices that a patient is handling a small charm that is
tied to a leather strip around his neck. Which action by the nurse is appropriate?
a. Ask the patient about the item and its significance.
b. Ask the patient to lock the item with other valuables in the hospital's safe.
c. Tell the patient that a family member should take valuables home.
d. No action is necessary.
During an examination, the nurse knows that the best way to palpate the lymph nodes in
the neck is described by which statement?
a. Using gentle pressure, palpate with both hands to compare the two sides.
b. Using strong pressure, palpate with both hands to compare the two sides.
c. Gently pinch each node between one's thumb and forefinger, and then move down the
neck muscle.
d. Using the index and middle fingers, gently palpate by applying pressure in a rotating
pattern.
The nurse is reviewing data collected after an assessment. Of the data listed below,
which would be considered related cues that would be clustered together during data
analysis? Select all that apply.
a. Inspiratory wheezes noted in left lower lobes
b. Hypoactive bowel sounds
c. Nonproductive cough
d. Edema, +2, noted on left hand
e. Patient reports dyspnea upon exertion
f. Rate of respirations 16 breaths per minute
The nurse is assessing a patient's skin during an office visit. What part of the hand and
technique should be used to best assess the patient's skin temperature?
a. Fingertips; they are more sensitive to small changes in temperature.
b. Dorsal surface of the hand; the skin is thinner on this surface than on the palms.
c. Ulnar portion of the hand; increased blood supply in this area enhances temperature
sensitivity.
d. Palmar surface of the hand; this surface is the most sensitive to temperature
variations because of its increased nerve supply in this area.
A patient has been admitted to the hospital with vertebral fractures related to
osteoporosis. She is in extreme pain. This type of pain would be classified as:
a. Referred.
b. Cutaneous.
c. Visceral.
d. Deep somatic.
During the assessment of an 80-year-old patient, the nurse notices that his hands show
tremors when he reaches for something and his head is always nodding. No associated
rigidity is observed with movement. Which of these statements is most accurate?
a. These findings are normal, resulting from aging.
b. These findings could be related to hyperthyroidism.
c. These findings are the result of Parkinson disease.
d. This patient should be evaluated for a cerebellar lesion.
The nurse is examining the glans and knows which finding is normal for this area?
a. The meatus may have a slight discharge when the glans is compressed.
b. Hair is without pest inhabitants.
c. The skin is wrinkled and without lesions.
d. Smegma may be present under the foreskin of an uncircumcised male.
A mother brings her 3-month-old infant to the clinic for evaluation of a cold. She tells
the nurse that he has had "a runny nose for a week." When performing the physical
assessment, the nurse notes that the child has nasal flaring and sternal and intercostal
retractions. The nurse's next action should be to:
a. Assure the mother that these signs are normal symptoms of a cold.
b. Recognize that these are serious signs, and contact the physician.
c. Ask the mother if the infant has had trouble with feedings.
d. Perform a complete cardiac assessment because these signs are probably indicative of
early heart failure.
During a staff meeting, nurses discuss the problems with accessing research studies to
incorporate evidence-based clinical decision making into their practice. Which
suggestion by the nurse manager would best help these problems?
a. Form a committee to conduct research studies.
b. Post published research studies on the unit's bulletin boards.
c. Encourage the nurses to visit the library to review studies.
d. Teach the nurses how to conduct electronic searches for research studies.
During an examination of a patient's abdomen, the nurse notes that the abdomen is
rounded and firm to the touch. During percussion, the nurse notes a drumlike quality of
the sounds across the quadrants. This type of sound indicates:
a. Constipation.
b. Air-filled areas.
c. Presence of a tumor.
d. Presence of dense organs.
The nurse is assessing a patient with possible cardiomyopathy and assesses the
hepatojugular reflux. If heart failure is present, then the nurse should recognize which
finding while pushing on the right upper quadrant of the patient's abdomen, just below
the rib cage?
a. The jugular veins will rise for a few seconds and then recede back to the previous
level if the heart is properly working.
b. The jugular veins will remain elevated as long as pressure on the abdomen is
maintained.
c. An impulse will be visible at the fourth or fifth intercostal space at or inside the
midclavicular line.
d. The jugular veins will not be detected during this maneuver.
A 30-year-old woman is visiting the clinic because of "pain in my bottom when I have a
bowel movement." The nurse should assess for which problem?
a. Pinworms
b. Hemorrhoids
c. Colon cancer
d. Fecal incontinence
The nurse is testing a patient's visual accommodation, which refers to which action?
a. Pupillary constriction when looking at a near object
b. Pupillary dilation when looking at a far object
c. Changes in peripheral vision in response to light
d. Involuntary blinking in the presence of bright light
While performing an assessment of the mouth, the nurse notices that the patient has a
1-cm ulceration that is crusted with an elevated border and located on the outer third of
the lower lip. What other information would be most important for the nurse to assess?
a. Nutritional status
b. When the patient first noticed the lesion
c. Whether the patient has had a recent cold
d. Whether the patient has had any recent exposure to sick animals
