A 75-year-old woman is at the office for a preoperative interview. The nurse is aware
that the interview may take longer than interviews with younger persons. What is the
reason for this?
a. An aged person has a longer story to tell.
b. An aged person is usually lonely and likes to have someone with whom to talk.
c. Aged persons lose much of their mental abilities and require longer time to complete
an interview.
d. As a person ages, he or she is unable to hear; thus the interviewer usually needs to
repeat much of what is said.
The nurse is inspecting the scrotum and testes of a 43-year-old man. Which finding
would require additional follow-up and evaluation?
a. Skin on the scrotum is taut.
b. Left testicle hangs lower than the right testicle.
c. Scrotal skin has yellowish 1-cm nodules that are firm and nontender.
d. Testes move closer to the body in response to cold temperatures.
The nurse is assessing a new patient who has recently immigrated to the United States.
Which question is appropriate to add to the health history?
a. “Why did you come to the United States?”
b. “When did you come to the United States and from what country?”
c. “What made you leave your native country?”
d. “Are you planning to return to your home?”
A patient is newly diagnosed with benign breast disease. The nurse recognizes which
statement about benign breast disease to be true? The presence of benign breast disease:
a. Makes it hard to examine the breasts.
b. Frequently turns into cancer in a woman’s later years.
c. Is easily reduced with hormone replacement therapy.
d. Is usually diagnosed before a woman reaches childbearing age.
During the taking of the health history of a 78-year-old man, his wife states that he
occasionally has problems with short-term memory loss and confusion: “He can”t even
remember how to button his shirt.” When assessing his sensory system, which action by
the nurse is most appropriate?
a. The nurse would not test the sensory system as part of the examination because the
results would not be valid.
b. The nurse would perform the tests, knowing that mental status does not affect
sensory ability.
c. The nurse would proceed with an explanation of each test, making certain that the
wife understands.
d. Before testing, the nurse would assess the patient’s mental status and ability to follow
directions.
The nurse is obtaining a history from a 30-year-old male patient and is concerned about
health promotion activities. Which of these questions would be appropriate to use to
assess health promotion activities for this patient?
a. “Do you perform testicular self-examinations?”
b. “Have you ever noticed any pain in your testicles?”
c. “Have you had any problems with passing urine?”
d. “Do you have any history of sexually transmitted diseases?”
The two parts of the nervous system are the:
a. Motor and sensory.
b. Central and peripheral.
c. Peripheral and autonomic.
d. Hypothalamus and cerebral.
During an assessment of an 80-year-old patient, the nurse notices the following: an
inability to identify vibrations at her ankle and to identify the position of her big toe, a
slower and more deliberate gait, and a slightly impaired tactile sensation. All other
neurologic findings are normal. The nurse should interpret that these findings indicate:
a. CN dysfunction.
b. Lesion in the cerebral cortex.
c. Normal changes attributable to aging.
d. Demyelination of nerves attributable to a lesion.
A patient describes feeling an unreasonable, irrational fear of snakes. His fear is so
persistent that he can no longer comfortably look at even pictures of snakes and has
made an effort to identify all the places he might encounter a snake and avoids them.
The nurse recognizes that he:
a. Has a snake phobia.
b. Is a hypochondriac; snakes are usually harmless.
c. Has an obsession with snakes.
d. Has a delusion that snakes are harmful, which must stem from an early traumatic
incident involving snakes.
A patient is having difficulty swallowing medications and food. The nurse would
document that this patient has:
a. Aphasia.
b. Dysphasia.
c. Dysphagia.
d. Anorexia.
A woman is leaving on a trip to Hawaii and has come in for a checkup. During the
examination the nurse learns that she has diabetes and takes oral hypoglycemic agents.
The patient needs to be concerned about which possible effect of her medications?
a. Increased possibility of bruising
b. Skin sensitivity as a result of exposure to salt water
c. Lack of availability of glucose-monitoring supplies
d. Importance of sunscreen and avoiding direct sunlight
When a light is directed across the iris of a patient’s eye from the temporal side, the
nurse is assessing for:
a. Drainage from dacryocystitis.
b. Presence of conjunctivitis over the iris.
c. Presence of shadows, which may indicate glaucoma.
d. Scattered light reflex, which may be indicative of cataracts.
The nurse is preparing to use the Lawton IADL instrument as part of an assessment.
Which statement about the Lawton IADL instrument is true?
a. The nurse uses direct observation to implement this tool.
b. The Lawton IADL instrument is designed as a self-report measure of performance
rather than ability.
c. This instrument is not useful in the acute hospital setting.
d. This tool is best used for those residing in an institutional setting.
What type of blood pressure measurement error is most likely to occur if the nurse does
not check for the presence of an auscultatory gap?
a. Diastolic blood pressure may not be heard.
b. Diastolic blood pressure may be falsely low.
c. Systolic blood pressure may be falsely low.
d. Systolic blood pressure may be falsely high.
The nurse should use which test to check for large amounts of fluid around the patella?
a. Ballottement
b. Tinel sign
c. Phalen test
d. McMurray test
The nurse is performing an eye assessment on an 80-year-old patient. Which of these
findings is considered abnormal?
a. Decrease in tear production
b. Unequal pupillary constriction in response to light
c. Presence of arcus senilis observed around the cornea
d. Loss of the outer hair on the eyebrows attributable to a decrease in hair follicles
The nurse is preparing to examine the external genitalia of a school-age girl. Which
position would be most appropriate in this situation?
a. In the parent’s lap
b. In a frog-leg position on the examining table
c. In the lithotomy position with the feet in stirrups
d. Lying flat on the examining table with legs extended
During an abdominal assessment, the nurse would consider which of these findings as
normal?
a. Presence of a bruit in the femoral area
b. Tympanic percussion note in the umbilical region
c. Palpable spleen between the ninth and eleventh ribs in the left midaxillary line
d. Dull percussion note in the left upper quadrant at the midclavicular line
During the taking of a health history, the patient states, “It really hurts back there, and
sometimes it itches, too. I have even seen blood on the tissue when I have a bowel
movement. Is there something there?” The nurse should expect to see which of these
upon examination of the anus?
a. Rectal prolapse
b. Internal hemorrhoid
c. External hemorrhoid that has resolved
d. External hemorrhoid that is thrombosed
The nurse is assessing the IV infusion at the beginning of the shift. Which factors
should be included in the assessment of the infusion? Select all that apply.
a. Proper IV solution is infusing, according to the physician’s orders.
b. The IV solution is infusing at the proper rate, according to physician’s orders.
c. The infusion is proper, according to the nurse’s assessment of the patient’s needs.
d. Capillary refill in the fingers is checked and noted.
e. The IV site date is noted.
f. Whether the patient is sufficiently voiding is noted.
The nurse notices that a school-aged child has bluish-white, red-based spots in her
mouth that are elevated approximately 1 to 3 mm. What other signs would the nurse
expect to find in this patient?
a. Pink, papular rash on the face and neck
b. Pruritic vesicles over her trunk and neck
c. Hyperpigmentation on the chest, abdomen, and back of the arms
d. Red-purple, maculopapular, blotchy rash behind the ears and on the face
When preparing to perform a physical examination on an infant, the nurse should:
a. Have the parent remove all clothing except the diaper on a boy.
b. Instruct the parent to feed the infant immediately before the examination.
c. Encourage the infant to suck on a pacifier during the abdominal examination.
d. Ask the parent to leave the room briefly when assessing the infant’s vital signs.
A 30-year-old female patient is describing feelings of hopelessness and depression. She
has attempted self-mutilation and has a history of suicide attempts. She describes
difficulty sleeping at night and has lost 10 pounds in the past month. Which of these
statements or questions is the nurse’s best response in this situation?
a. “Do you have a weapon?”
b. “How do other people treat you?”
c. “Are you feeling so hopeless that you feel like hurting yourself now?”
d. “People often feel hopeless, but the feelings resolve within a few weeks.”
A patient is being assessed for range-of-joint movement. The nurse asks him to move
his arm in toward the center of his body. This movement is called:
a. Flexion.
b. Abduction.
c. Adduction.
d. Extension.
During a digital examination of the rectum, the nurse notices that the patient has hard
feces in the rectum. The patient complains of feeling “full,” has a distended abdomen,
and states that she has not had a bowel movement “for several days.” The nurse
suspects which condition?
a. Rectal polyp
b. Fecal impaction
c. Rectal abscess
d. Rectal prolapse
The nurse is assessing orientation in a 79-year-old patient. Which of these responses
would lead the nurse to conclude that this patient is oriented?
a. “I know my name is John. I couldn”t tell you where I am. I think it is 2010, though.”
b. “I know my name is John, but to tell you the truth, I get kind of confused about the
date.”
c. “I know my name is John; I guess I”m at the hospital in Spokane. No, I don”t know
the date.”
d. “I know my name is John. I am at the hospital in Spokane. I couldn”t tell you what
date it is, but I know that it is February of a new year2010.”
A 16-year-old boy has just been admitted to the unit for overnight observation after
being in an automobile accident. What is the nurse’s best approach to communicating
with him?
a. Use periods of silence to communicate respect for him.
b. Be totally honest with him, even if the information is unpleasant.
c. Tell him that everything that is discussed will be kept totally confidential.
d. Use slang language when possible to help him open up.
The nurse is assessing a 1-week-old infant and is testing his muscle strength. The nurse
lifts the infant with hands under the axillae and notices that the infant starts to ‘slip”
between the hands. The nurse should:
a. Suspect a fractured clavicle.
b. Suspect that the infant may have a deformity of the spine.
c. Suspect that the infant may have weakness of the shoulder muscles.
d. Conclude that this is a normal finding because the musculature of an infant at this age
is undeveloped.
When assessing a patient’s lungs, the nurse recalls that the left lung:
a. Consists of two lobes.
b. Is divided by the horizontal fissure.
c. Primarily consists of an upper lobe on the posterior chest.
d. Is shorter than the right lung because of the underlying stomach.
A patient comes into the clinic complaining of pain in her right eye. On examination,
the nurse sees a pustule at the lid margin that is painful to touch, red, and swollen. The
nurse recognizes that this is a:
a. Chalazion.
b. Hordeolum (stye).
c. Dacryocystitis.
d. Blepharitis.
The nurse is asking a patient for his reason for seeking care and asks about the signs
and symptoms he is experiencing. Which of these is an example of a symptom?
a. Chest pain
b. Clammy skin
c. Serum potassium level at 4.2 mEq/L
d. Body temperature of 100oF
A patient comes into the emergency department after an accident at work. A machine
blew dust into his eyes, and he was not wearing safety glasses. The nurse examines his
corneas by shining a light from the side across the cornea. What findings would suggest
that he has suffered a corneal abrasion?
a. Smooth and clear corneas
b. Opacity of the lens behind the cornea
c. Bleeding from the areas across the cornea
d. Shattered look to the light rays reflecting off the cornea
The nurse is testing the deep tendon reflexes of a 30-year-old woman who is in the
clinic for an annual physical examination. When striking the Achilles heel and
quadriceps muscle, the nurse is unable to elicit a reflex. The nurse’s next response
should be to:
a. Ask the patient to lock her fingers and pull.
b. Complete the examination, and then test these reflexes again.
c. Refer the patient to a specialist for further testing.
d. Document these reflexes as 0 on a scale of 0 to 4+.
When assessing the tongue of an adult, the nurse knows that an abnormal finding would
be:
a. Smooth glossy dorsal surface.
b. Thin white coating over the tongue.
c. Raised papillae on the dorsal surface.
d. Visible venous patterns on the ventral surface.
While performing a rectal examination, the nurse notices a firm, irregularly shaped
mass. What should the nurse do next?
a. Continue with the examination, and document the finding in the chart.
b. Instruct the patient to return for a repeat assessment in 1 month.
c. Tell the patient that a mass was felt, but it is nothing to worry about.
d. Report the finding, and refer the patient to a specialist for further examination.