Which of the following reflects the traditional health and illness beliefs and practices of
those of African heritage? Health is:
a. Being rewarded for good behavior.
b. The balance of the body and spirit.
c. Maintained by wearing jade amulets.
d. Being in harmony with nature.
When performing a genital examination on a 25-year-old man, the nurse notices deeply
pigmented, wrinkled scrotal skin with large sebaceous follicles. On the basis of this
information, the nurse would:
a. Squeeze the glans to check for the presence of discharge.
b. Consider this finding as normal, and proceed with the examination.
c. Assess the testicles for the presence of masses or painless lumps.
d. Obtain a more detailed history, focusing on any scrotal abnormalities the patient has
noticed.
Which statement concerning the testes is true?
a. The lymphatic vessels of the testes drain into the abdominal lymph nodes.
b. The vas deferens is located along the inferior portion of each testis.
c. The right testis is lower than the left because the right spermatic cord is longer.
d. The cremaster muscle contracts in response to cold and draws the testicles closer to
the body.
When assessing the intensity of a patient’s pain, which question by the nurse is
appropriate?
a. “What makes your pain better or worse?”
b. “How much pain do you have now?”
c. “How does pain limit your activities?”
d. “What does your pain feel like?”
In response to a question regarding the use of alcohol, a patient asks the nurse why the
nurse needs to know. What is the reason for needing this information?
a. This information is necessary to determine the patient’s reliability.
b. Alcohol can interact with all medications and can make some diseases worse.
c. The nurse needs to be able to teach the patient about the dangers of alcohol use.
d. This information is not necessary unless a drinking problem is obvious.
The nurse assesses an older woman and suspects physical abuse. Which questions are
appropriate for screening for abuse? Select all that apply.
a. “Has anyone made you afraid, touched you in ways that you did not want, or hurt you
physically?”
b. “Are you being abused?”
c. “Have you relied on people for any of the following: bathing, dressing, shopping,
banking, or meals?”
d. “Have you been upset because someone talked to you in a way that made you feel
shamed or threatened?”
e. “Have you relied on people for any of the following: bathing, dressing, shopping,
banking, or meals?”
In performing a breast examination, the nurse knows that examining the upper outer
quadrant of the breast is especially important. The reason for this is that the upper outer
quadrant is:
a. The largest quadrant of the breast.
b. The location of most breast tumors.
c. Where most of the suspensory ligaments attach.
d. More prone to injury and calcifications than other locations in the breast.
When planning a cultural assessment, the nurse should include which component?
a. Family history
b. Chief complaint
c. Medical history
d. Health-related beliefs
A patient has been diagnosed with osteoporosis and asks the nurse, “What is
osteoporosis?” The nurse explains that osteoporosis is defined as:
a. Increased bone matrix.
b. Loss of bone density.
c. New, weaker bone growth.
d. Increased phagocytic activity.
During a health history interview, a female patient states that she has noticed a few
drops of clear discharge from her right nipple. What should the nurse do next?
a. Immediately contact the physician to report the discharge.
b. Ask her if she is possibly pregnant.
c. Ask the patient some additional questions about the medications she is taking.
d. Immediately obtain a sample for culture and sensitivity testing.
During the neurologic assessment of a “healthy” 35-year-old patient, the nurse asks him
to relax his muscles completely. The nurse then moves each extremity through full
range of motion. Which of these results would the nurse expect to find?
a. Firm, rigid resistance to movement
b. Mild, even resistance to movement
c. Hypotonic muscles as a result of total relaxation
d. Slight pain with some directions of movement
When assessing a 75-year-old patient who has asthma, the nurse notes that he assumes a
tripod position, leaning forward with arms braced on the chair. On the basis of this
observation, the nurse should:
a. Assume that the patient is eager and interested in participating in the interview.
b. Evaluate the patient for abdominal pain, which may be exacerbated in the sitting
position.
c. Assume that the patient is having difficulty breathing and assist him to a supine
position.
d. Recognize that a tripod position is often used when a patient is having respiratory
difficulties.
The physician reports that a patient with a neck tumor has a tracheal shift. The nurse is
aware that this means that the patient’s trachea is:
a. Pulled to the affected side.
b. Pushed to the unaffected side.
c. Pulled downward.
d. Pulled downward in a rhythmic pattern.
During a home visit, the nurse notices that an older adult woman is caring for her
bedridden husband. The woman states that this is her duty, she does the best she can,
and her children come to help when they are in town. Her husband is unable to care for
himself, and she appears thin, weak, and exhausted. The nurse notices that several of his
prescription medication bottles are empty. This situation is best described by the term:
a. Physical abuse.
b. Financial neglect.
c. Psychological abuse.
d. Unintentional physical neglect.
After the health history has been obtained and before beginning the physical
examination, the nurse should first ask the patient to:
a. Empty the bladder.
b. Completely disrobe.
c. Lie on the examination table.
d. Walk around the room.
When assessing a patient in the hospital setting, the nurse knows which statement to be
true?
a. The patient will need a brief assessment at least every 4 hours.
b. The patient will need a consistent, specialized examination every 8 hours that focuses
on certain parameters.
c. The patient will need a complete head-to-toe physical examination every 24 hours.
d. Most patients require a minimal examination each shift unless they are in critical
condition.
A 19-year-old woman comes to the clinic at the insistence of her brother. She is wearing
black combat boots and a black lace nightgown over the top of her other clothes. Her
hair is dyed pink with black streaks throughout. She has several pierced holes in her
nares and ears and is wearing an earring through her eyebrow and heavy black makeup.
The nurse concludes that:
a. She probably does not have any problems.
b. She is only trying to shock people and that her dress should be ignored.
c. She has a manic syndrome because of her abnormal dress and grooming.
d. More information should be gathered to decide whether her dress is appropriate.
During a health history, the patient tells the nurse, “I have pain all the time in my
stomach. It’s worse 2 hours after I eat, but it gets better if I eat again!” Based on these
symptoms, the nurse suspects that the patient has which condition?
a. Appendicitis
b. Gastric ulcer
c. Duodenal ulcer
d. Cholecystitis
A teenage girl has arrived complaining of pain in her left wrist. She was playing
basketball when she fell and landed on her left hand. The nurse examines her hand and
would expect a fracture if the girl complains of a:
a. Dull ache.
b. Deep pain in her wrist.
c. Sharp pain that increases with movement.
d. Dull throbbing pain that increases with rest.
A patient has hard, nonpitting edema of the left lower leg and ankle. The right leg has
no edema. Based on these findings, the nurse recalls that:
a. Nonpitting, hard edema occurs with lymphatic obstruction.
b. Alterations in arterial function will cause edema.
c. Phlebitis of a superficial vein will cause bilateral edema.
d. Long-standing arterial obstruction will cause pitting edema.
When reviewing the concepts of health, the nurse recalls that the components of holistic
health include which of these?
a. Disease originates from the external environment.
b. The individual human is a closed system.
c. Nurses are responsible for a patient’s health state.
d. Holistic health views the mind, body, and spirit as interdependent.
The most important step that the nurse can take to prevent the transmission of
microorganisms in the hospital setting is to:
a. Wear protective eye wear at all times.
b. Wear gloves during any and all contact with patients.
c. Wash hands before and after contact with each patient.
d. Clean the stethoscope with an alcohol swab between patients.
The nurse is reviewing the hot/cold theory of health and illness. Which statement best
describes the basic tenets of this theory?
a. The causation of illness is based on supernatural forces that influence the humors of
the body.
b. Herbs and medicines are classified on their physical characteristics of hot and cold
and the humors of the body.
c. The four humors of the body consist of blood, yellow bile, spiritual connectedness,
and social aspects of the individual.
d. The treatment of disease consists of adding or subtracting cold, heat, dryness, or
wetness to restore the balance of the humors of the body.
A patient has had arthritic pain in her hips for several years since a hip fracture. She is
able to move around in her room and has not offered any complaints so far this
morning. However, when asked, she states that her pain is “bad this morning” and rates
it at an 8 on a 1-to-10 scale. What does the nurse suspect? The patient:
a. Is addicted to her pain medications and cannot obtain pain relief.
b. Does not want to trouble the nursing staff with her complaints.
c. Is not in pain but rates it high to receive pain medication.
d. Has experienced chronic pain for years and has adapted to it.
When using the various instruments to assess an older person’s ADLs, the nurse needs
to remember that a disadvantage of these instruments includes:
a. Reliability of the tools.
b. Self or proxy reporting of functional activities.
c. Lack of confidentiality during the assessment.
d. Insufficient details concerning the deficiencies identified.
The nurse is performing a functional assessment on an 82-year-old patient who recently
had a stroke. Which of these questions would be most important to ask?
a. “Do you wear glasses?”
b. “Are you able to dress yourself?”
c. “Do you have any thyroid problems?”
d. “How many times a day do you have a bowel movement?”
During an examination of a 3-year-old child, the nurse notices a bruit over the left
temporal area. The nurse should:
a. Continue the examination because a bruit is a normal finding for this age.
b. Check for the bruit again in 1 hour.
c. Notify the parents that a bruit has been detected in their child.
d. Stop the examination, and notify the physician.
A 70-year-old woman tells the nurse that every time she gets up in the morning or after
she’s been sitting, she gets “really dizzy” and feels like she is going to fall over. The
nurse’s best response would be:
a. “Have you been extremely tired lately?”
b. “You probably just need to drink more liquids.”
c. “I”ll refer you for a complete neurologic examination.”
d. “You need to get up slowly when you”ve been lying down or sitting.”
When examining a 16-year-old male teenager, the nurse should:
a. Discuss health teaching with the parent because the teen is unlikely to be interested in
promoting wellness.
b. Ask his parent to stay in the room during the history and physical examination to
answer any questions and to alleviate his anxiety.
c. Talk to him the same manner as one would talk to a younger child because a teen’s
level of understanding may not match his or her speech.
d. Provide feedback that his body is developing normally, and discuss the wide
variation among teenagers on the rate of growth and development.
A man has been admitted to the observation unit for observation after being treated for a
large cut on his forehead. As the nurse works through the interview, one of the standard
questions has to do with alcohol, tobacco, and drug use. When the nurse asks him about
tobacco use, he states, “I quit smoking after my wife died 7 years ago.” However, the
nurse notices an open pack of cigarettes in his shirt pocket. Using confrontation, the
nurse could say:
a. “Mr. K., I know that you are lying.”
b. “Mr. K., come on, tell me how much you smoke.”
c. “Mr. K., I didn’t realize your wife had died. It must be difficult for you at this time.
Please tell me more about that.”
d. “Mr. K., you have said that you don”t smoke, but I see that you have an open pack of
cigarettes in your pocket.”
After a class on culture and ethnicity, the new graduate nurse reflects a correct
understanding of the concept of ethnicity with which statement?
a. “Ethnicity is dynamic and ever changing.”
b. “Ethnicity is the belief in a higher power.”
c. “Ethnicity pertains to a social group within the social system that claims shared
values and traditions.”
d. “Ethnicity is learned from birth through the processes of language acquisition and
socialization.”
In performing an assessment of a woman’s axillary lymph system, the nurse should
assess which of these nodes?
a. Central, axillary, lateral, and sternal
b. Pectoral, lateral, anterior, and sternal
c. Central, lateral, pectoral, and subscapular
d. Lateral, pectoral, axillary, and suprascapular
The nurse will measure a patient’s near vision with which tool?
a. Snellen eye chart with letters
b. Snellen “E” chart
c. Jaeger card
d. Ophthalmoscope