The nurse is preparing to do a functional assessment. Which statement best describes
the purpose of a functional assessment?
a. The functional assessment assesses how the individual is coping with life at home.
b. It determines how children are meeting developmental milestones.
c. The functional assessment can identify any problems with memory the individual
may be experiencing.
d. It helps determine how a person is managing day-to-day activities.
The nurse is reviewing theories of illness. The germ theory, which states that
microscopic organisms such as bacteria and viruses are responsible for specific disease
conditions, is a basic belief of which theory of illness?
a. Holistic
b. Biomedical
c. Naturalistic
d. Magicoreligious
When assessing aging adults, the nurse knows that one of the first things that should be
assessed before making judgments about their mental status is:
a. Presence of phobias
b. General intelligence
c. Presence of irrational thinking patterns
d. Sensory-perceptive abilities
Which statement indicates that the nurse understands the pain experienced by an older
adult?
a. “Older adults must learn to tolerate pain.”
b. “Pain is a normal process of aging and is to be expected.”
c. “Pain indicates a pathologic condition or an injury and is not a normal process of
aging.”
d. “Older individuals perceive pain to a lesser degree than do younger individuals.”
How should the nurse perform a triceps skinfold assessment?
a. After pinching the skin and fat, the calipers are vertically applied to the fat fold.
b. The skin and fat on the front of the patient’s arm are gently pinched, and then the
calipers are applied.
c. After applying the calipers, the nurse waits 3 seconds before taking a reading. After
repeating the procedure three times, an average is recorded.
d. The patient is instructed to stand with his or her back to the examiner and arms
folded across the chest. The skin on the forearm is pinched.
A 15-year-old boy is seen in the clinic for complaints of “dull pain and pulling” in the
scrotal area. On examination, the nurse palpates a soft, irregular mass posterior to and
above the testis on the left. This mass collapses when the patient is supine and refills
when he is upright. This description is consistent with:
a. Epididymitis.
b. Spermatocele.
c. Testicular torsion.
d. Varicocele.
The nurse is performing a breast examination. Which of these statements best describes
the correct procedure to use when screening for nipple and skin retraction during a
breast examination? Have the woman:
a. Bend over and touch her toes.
b. Lie down on her left side and notice any retraction.
c. Shift from a supine position to a standing position, and note any lag or retraction.
d. Slowly lift her arms above her head, and note any retraction or lag in movement.
A 46-year-old woman is in the clinic for her annual gynecologic examination. She
voices a concern about ovarian cancer because her mother and sister died of it. Which
statement does the nurse know to be correct regarding ovarian cancer?
a. Ovarian cancer rarely has any symptoms.
b. The Pap smear detects the presence of ovarian cancer.
c. Women at high risk for ovarian cancer should have annual transvaginal
ultrasonography for screening.
d. Women over age 40 years should have a thorough pelvic examination every 3 years.
When assessing the scrotum of a male patient, the nurse notices the presence of
multiple firm, nontender, yellow 1-cm nodules. The nurse knows that these nodules are
most likely:
a. From urethritis.
b. Sebaceous cysts.
c. Subcutaneous plaques.
d. From an inflammation of the epididymis.
The nurse is reviewing risk factors for breast cancer. Which of these women have risk
factors that place them at a higher risk for breast cancer?
a. 37 year old who is slightly overweight
b. 42 year old who has had ovarian cancer
c. 45 year old who has never been pregnant
d. 65 year old whose mother had breast cancer
In assessing a 70-year-old man, the nurse finds the following: blood pressure 140/100
mm Hg; heart rate 104 beats per minute and slightly irregular; and the split S2 heart
sound. Which of these findings can be explained by expected hemodynamic changes
related to age?
a. Increase in resting heart rate
b. Increase in systolic blood pressure
c. Decrease in diastolic blood pressure
d. Increase in diastolic blood pressure
Barriers to incorporating EBP include:
a. Nurses’ lack of research skills in evaluating the quality of research studies.
b. Lack of significant research studies.
c. Insufficient clinical skills of nurses.
d. Inadequate physical assessment skills.
The nurse is performing an oral assessment on a 40-year-old Black patient and notices
the presence of a 1 cm, nontender, grayish-white lesion on the left buccal mucosa.
Which one of these statements is true? This lesion is:
a. Leukoedema and is common in dark-pigmented persons.
b. The result of hyperpigmentation and is normal.
c. Torus palatinus and would normally be found only in smokers.
d. Indicative of cancer and should be immediately tested.
The nurse asks, “I would like to ask you some questions about your health and your
usual daily activities so that we can better plan your stay here.” This question is found
at the __________ phase of the interview process.
a. Summary
b. Closing
c. Body
d. Opening or introduction
A 2-year-old boy has been diagnosed with physiologic cryptorchidism. Considering this
diagnosis, during assessment the nurse will most likely observe:
a. Testes that are hard and painful to palpation.
b. Atrophic scrotum and a bilateral absence of the testis.
c. Absence of the testis in the scrotum, but the testis can be milked down.
d. Testes that migrate into the abdomen when the child squats or sits cross-legged.
A patient tells the nurse that she has had abdominal pain for the past week. What would
be the nurse’s best response?
a. “Can you point to where it hurts?”
b. “We”ll talk more about that later in the interview.”
c. “What have you had to eat in the last 24 hours?”
d. “Have you ever had any surgeries on your abdomen?”
The nurse is reviewing the development of the newborn infant. Regarding the sinuses,
which statement is true in relation to a newborn infant?
a. Sphenoid sinuses are full size at birth.
b. Maxillary sinuses reach full size after puberty.
c. Frontal sinuses are fairly well developed at birth.
d. Maxillary and ethmoid sinuses are the only sinuses present at birth.
Which of these tests would the nurse use to check the motor coordination of an
11-month-old infant?
a. Denver II
b. Stereognosis
c. Deep tendon reflexes
d. Rapid alternating movements
The nurse places a key in the hand of a patient and he identifies it as a penny. What
term would the nurse use to describe this finding?
a. Extinction
b. Astereognosis
c. Graphesthesia
d. Tactile discrimination
An ophthalmic examination reveals papilledema. The nurse is aware that this finding
indicates:
a. Retinal detachment.
b. Diabetic retinopathy.
c. Acute-angle glaucoma.
d. Increased intracranial pressure.
During an assessment of a newborn infant, the nurse recalls that pyloric stenosis would
be exhibited by:
a. Projectile vomiting.
b. Hypoactive bowel activity.
c. Palpable olive-sized mass in the right lower quadrant.
d. Pronounced peristaltic waves crossing from right to left.
The nurse is obtaining a health history on an 87-year-old woman. Which of the
following areas of questioning would be most useful at this time?
a. Obstetric history
b. Childhood illnesses
c. General health for the past 20 years
d. Current health promotion activities
The nurse is performing a review of systems on a 76-year-old patient. Which of these
statements is correctfor this situation?
a. The questions asked are identical for all ages.
b. The interviewer will start incorporating different questions for patients 70 years of
age and older.
c. Questions that are reflective of the normal effects of aging are added.
d. At this age, a review of systems is not necessarythe focus should be on current
problems.
The nurse is performing an ear examination of an 80-year-old patient. Which of these
findings would be considered normal?
a. High-tone frequency loss
b. Increased elasticity of the pinna
c. Thin, translucent membrane
d. Shiny, pink tympanic membrane
The nurse is conducting a patient interview. Which statement made by the patient
should the nurse more fully explore during the interview?
a. “I sleep like a baby.”
b. “I have no health problems.”
c. “I never did too good in school.”
d. “I am not currently taking any medications.”
The nurse has used interpretation regarding a patient’s statement or actions. After using
this technique, it would be best for the nurse to:
a. Apologize, because using interpretation can be demeaning for the patient.
b. Allow time for the patient to confirm or correct the inference.
c. Continue with the interview as though nothing has happened.
d. Immediately restate the nurse’s conclusion on the basis of the patient’s nonverbal
response.
In using the ophthalmoscope to assess a patient’s eyes, the nurse notices a red glow in
the patient’s pupils. On the basis of this finding, the nurse would:
a. Suspect that an opacity is present in the lens or cornea.
b. Check the light source of the ophthalmoscope to verify that it is functioning.
c. Consider the red glow a normal reflection of the ophthalmoscope light off the inner
retina.
d. Continue with the ophthalmoscopic examination, and refer the patient for further
evaluation.
The nurse is palpating a female patient’s adnexa. The findings include a firm, smooth
uterine wall; the ovaries are palpable and feel smooth and firm. The fallopian tube is
firm and pulsating. The nurse’s most appropriate course of action would be to:
a. Tell the patient that her examination is normal.
b. Give her an immediate referral to a gynecologist.
c. Suggest that she return in a month for a recheck to verify the findings.
d. Tell the patient that she may have an ovarian cyst that should be evaluated further.
When considering a nutritional assessment, the nurse is aware that the most common
anthropometric measurements include:
a. Height and weight.
b. Leg circumference.
c. Skinfold thickness of the biceps.
d. Hip and waist measurements.
During a genital examination, the nurse notices that a male patient has clusters of small
vesicles on the glans, surrounded by erythema. The nurse recognizes that these lesions
are:
a. Peyronie disease.
b. Genital warts.
c. Genital herpes.
d. Syphilitic cancer.
A woman is discussing the problems she is having with her 2-year-old son. She says,
“He won”t go to sleep at night, and during the day he has several fits. I get so upset
when that happens.” The nurse’s best verbal response would be:
a. “Go on, I”m listening.”
b. “Fits? Tell me what you mean by this.”
c. “Yes, it can be upsetting when a child has a fit.”
d. “Don”t be upset when he has a fit; every 2 year old has fits.”
The nurse knows that the best time to assess a woman’s blood pressure during an initial
prenatal visit is:
a. At the end of the examination when she will be the most relaxed.
b. At the beginning of the interview as a nonthreatening method of gaining rapport.
c. During the middle of the physical examination when she is the most comfortable.
d. Before beginning the pelvic examination because her blood pressure will be higher
after the pelvic examination.
What is the pulse pressure for a patient whose blood pressure is 158/96 mm Hg and
whose pulse rate is 72 beats per minute?
During the assessment of deep tendon reflexes, the nurse finds that a patient’s responses
are bilaterally normal. What number is used to indicate normal deep tendon reflexes
when the documenting this finding? ____+
A patient has been unable to eat solid food for 2 weeks and is in the clinic today
complaining of weakness, tiredness, and hair loss. The patient states that her usual
weight is 175 pounds, but today she weighs 161 pounds. What is her recent weight
change percentage? To calculate recent weight change percentage, use this formula:
Usual weight ” current weight x 100
usual weight
The nurse is assessing a patient’s pulses and notices a difference between the patient’s
apical pulse and radial pulse. The apical pulse was 118 beats per minute, and the radial
pulse was 105 beats per minute. What is the pulse deficit?