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The nurse is reviewing the technique of palpating for tactile fremitus with a new
graduate. Which statement by the graduate nurse reflects a correct understanding of
tactile fremitus? "Tactile fremitus:
a. "Is caused by moisture in the alveoli."
b. "Indicates that air is present in the subcutaneous tissues."
c. "Is caused by sounds generated from the larynx."
d. "Reflects the blood flow through the pulmonary arteries."
A 59-year-old patient has a herniated intervertebral disk. Which of the following
findings should the nurse expect to see on physical assessment of this individual?
a. Hyporeflexia
b. Increased muscle tone
c. Positive Babinski sign
d. Presence of pathologic reflexes
In assessing a 70-year-old patient who has had a recent cerebrovascular accident, the
nurse notices right-sided weakness. What might the nurse expect to find when testing
his reflexes on the right side?
a. Lack of reflexes
b. Normal reflexes
c. Diminished reflexes
d. Hyperactive reflexes
A patient with a middle ear infection asks the nurse, "What does the middle ear do?"
The nurse responds by telling the patient that the middle ear functions to:
a. Maintain balance.
b. Interpret sounds as they enter the ear.
c. Conduct vibrations of sounds to the inner ear.
d. Increase amplitude of sound for the inner ear to function.
A patient is unable to differentiate between sharp and dull stimulation to both sides of
her face. The nurse suspects:
a. Bell palsy.
b. Damage to the trigeminal nerve.
c. Frostbite with resultant paresthesia to the cheeks.
d. Scleroderma.
Which statement concerning the anal canal is true? The anal canal:
a. Is approximately 2 cm long in the adult.
b. Slants backward toward the sacrum.
c. Contains hair and sebaceous glands.
d. Is the outlet for the gastrointestinal tract.
The nurse is providing patient teaching about an erectile dysfunction drug. One of the
drug's potential side effects is prolonged, painful erection of the penis without sexual
stimulation, which is known as:
a. Orchitis.
b. Stricture.
c. Phimosis.
d. Priapism.
The nurse just noted from the medical record that the patient has a lesion that is
confluent in nature. On examination, the nurse expects to find:
a. Lesions that run together.
b. Annular lesions that have grown together.
c. Lesions arranged in a line along a nerve route.
d. Lesions that are grouped or clustered together.
A patient comes to the clinic and states that he has noticed that his skin is redder than
normal. The nurse understands that this condition is due to hyperemia and knows that it
can be caused by:
a. Decreased amounts of bilirubin in the blood
b. Excess blood in the underlying blood vessels
c. Decreased perfusion to the surrounding tissues
d. Excess blood in the dilated superficial capillaries
Which of these responses might the nurse expect during a functional assessment of a
patient whose leg is in a cast?
a. "I broke my right leg in a car accident 2 weeks ago."
b. "The pain is decreasing, but I still need to take acetaminophen."
c. "I check the color of my toes every evening just like I was taught."
d. "I"m able to transfer myself from the wheelchair to the bed without help."
During a breast health interview, a patient states that she has noticed pain in her left
breast. The nurse's most appropriate response to this would be:
a. "Don"t worry about the pain; breast cancer is not painful."
b. "I would like some more information about the pain in your left breast."
c. "Oh, I had pain like that after my son was born; it turned out to be a blocked milk
duct."
d. "Breast pain is almost always the result of benign breast disease."
Which of these techniques uses the sense of touch to assess texture, temperature,
moisture, and swelling when the nurse is assessing a patient?
a. Palpation
b. Inspection
c. Percussion
d. Auscultation
During an assessment of the CNs, the nurse finds the following: asymmetry when the
patient smiles or frowns, uneven lifting of the eyebrows, sagging of the lower eyelids,
and escape of air when the nurse presses against the right puffed cheek. This would
indicate dysfunction of which of these CNs?
a. Motor component of CN IV
b. Motor component of CN VII
c. Motor and sensory components of CN XI
d. Motor component of CN X and sensory component of CN VII
When evaluating a patient's pain, the nurse knows that an example of acute pain would
be:
a. Arthritic pain.
b. Fibromyalgia.
c. Kidney stones.
d. Low back pain.
The nurse has completed an assessment on a patient who came to the clinic for a leg
injury. As a result of the assessment, the nurse has determined that the patient has
at-risk alcohol use. Which action by the nurse is most appropriate at this time?
a. Record the results of the assessment, and notify the physician on call.
b. State, "You are drinking more than is medically safe. I strongly recommend that you
quit drinking, and I"m willing to help you."
c. State, "It appears that you may have a drinking problem. Here is the telephone
number of our local Alcoholics Anonymous chapter."
d. Give the patient information about a local rehabilitation clinic.
During an examination of a 7-year-old girl, the nurse notices that the girl is showing
breast budding. What should the nurse do next?
a. Ask the young girl if her periods have started.
b. Assess the girl's weight and body mass index (BMI).
c. Ask the girl's mother at what age she started to develop breasts.
d. Nothing; breast budding is a normal finding.
A woman who has had rheumatoid arthritis for years is starting to notice that her fingers
are drifting to the side. The nurse knows that this condition is commonly referred to as:
a. Radial drift.
b. Ulnar deviation.
c. Swan-neck deformity.
d. Dupuytren contracture.
During an examination, the patient tells the nurse that she sometimes feels as if objects
are spinning around her. The nurse would document that she occasionally experiences:
a. Vertigo.
b. Tinnitus.
c. Syncope.
d. Dizziness.
During the examination of a patient's mouth, the nurse observes a nodular bony ridge
down the middle of the hard palate. The nurse would chart this finding as:
a. Cheilosis.
b. Leukoplakia.
c. Ankyloglossia.
d. Torus palatinus.
The nurse is preparing to assess the visual acuity of a 16-year-old patient. How should
the nurse proceed?
a. Perform the confrontation test.
b. Ask the patient to read the print on a handheld Jaeger card.
c. Use the Snellen chart positioned 20 feet away from the patient.
d. Determine the patient's ability to read newsprint at a distance of 12 to 14 inches.
During an assessment of a 62-year-old man, the nurse notices the patient has a stooped
posture, shuffling walk with short steps, flat facial expression, and pill-rolling finger
movements. These findings would be consistent with:
a. Parkinsonism.
b. Cerebral palsy.
c. Cerebellar ataxia.
d. Muscular dystrophy.
The nurse is performing the Denver II screening test on a 12-month-old infant during a
routine well-child visit. The nurse should tell the infant's parents that the Denver II:
a. Tests three areas of development: cognitive, physical, and psychological
b. Will indicate whether the child has a speech disorder so that treatment can begin.
c. Is a screening instrument designed to detect children who are slow in development.
d. Is a test to determine intellectual ability and may indicate whether problems will
develop later in school.
When discussing the use of the term subculture, the nurse recognizes that it is best
described as:
a. Fitting as many people into the majority culture as possible.
b. Defining small groups of people who do not want to be identified with the larger
culture.
c. Singling out groups of people who suffer differential and unequal treatment as a
result of cultural variations.
d. Identifying fairly large groups of people with shared characteristics that are not
common to all members of a culture.
A patient's abdomen is bulging and stretched in appearance. The nurse should describe
this finding as:
a. Obese.
b. Herniated.
c. Scaphoid.
d. Protuberant.
Which of these interventions is most appropriate when the nurse is planning nutritional
interventions for a healthy, active 74-year-old woman?
a. Decreasing the amount of carbohydrates to prevent lean muscle catabolism
b. Increasing the amount of soy and tofu in her diet to promote bone growth and reverse
osteoporosis
c. Decreasing the number of calories she is eating because of the decrease in energy
requirements from the loss of lean body mass
d. Increasing the number of calories she is eating because of the increased energy needs
of the older adult
The nurse is performing an eye-screening clinic at a daycare center. When examining a
2-year-old child, the nurse suspects that the child has a "lazy eye" and should:
a. Examine the external structures of the eye.
b. Assess visual acuity with the Snellen eye chart.
c. Assess the child's visual fields with the confrontation test.
d. Test for strabismus by performing the corneal light reflex test.
The nurse is examining a 3-year-old child who was brought to the emergency
department after a fall. Which bruise, if found, would be of most concern?
a. Bruise on the knee
b. Bruise on the elbow
c. Bruising on the abdomen
d. Bruise on the shin
The nurse is caring for a patient who has just had neurosurgery. To assess for increased
intracranial pressure, what would the nurse include in the assessment?
a. CNs, motor function, and sensory function
b. Deep tendon reflexes, vital signs, and coordinated movements
c. Level of consciousness, motor function, pupillary response, and vital signs
d. Mental status, deep tendon reflexes, sensory function, and pupillary response
The nurse is assessing for clubbing of the fingernails and expects to find:
a. Nail bases that are firm and slightly tender.
b. Curved nails with a convex profile and ridges across the nails.
c. Nail bases that feel spongy with an angle of the nail base of 150 degrees.
d. Nail bases with an angle of 180 degrees or greater and nail bases that feel spongy.
The nurse is listening to bowel sounds. Which of these statements is true of bowel
sounds? Bowel sounds:
a. Are usually loud, high-pitched, rushing, and tinkling sounds.
b. Are usually high-pitched, gurgling, and irregular sounds.
c. Sound like two pieces of leather being rubbed together.
d. Originate from the movement of air and fluid through the large intestine.
While the nurse is taking the history of a 68-year-old patient who sustained a head
injury 3 days earlier, he tells the nurse that he is on a cruise ship and is 30 years old.
The nurse knows that this finding is indicative of a(n):
a. Great sense of humor.
b. Uncooperative behavior.
c. Inability to understand questions.
d. Decreased level of consciousness.
The nurse is preparing for a class on risk factors for hypertension and reviews recent
statistics. Which racial group has the highest prevalence of hypertension in the world?
a. Blacks
b. Whites
c. American Indians
d. Hispanics
The nurse is conducting a class on priority setting for a group of new graduate nurses.
Which is an example of a first-level priority problem?
a. Patient with postoperative pain
b. Newly diagnosed patient with diabetes who needs diabetic teaching
c. Individual with a small laceration on the sole of the foot
d. Individual with shortness of breath and respiratory distress
The nursing process is a sequential method of problem solving that nurses use and
includes which steps?
a. Assessment, treatment, planning, evaluation, discharge, and follow-up
b. Admission, assessment, diagnosis, treatment, and discharge planning
c. Admission, diagnosis, treatment, evaluation, and discharge planning
d. Assessment, diagnosis, outcome identification, planning, implementation, and
evaluation
A 19-year-old college student is brought to the emergency department with a severe
headache he describes as, "Like nothing I"ve ever had before." His temperature is 40 C,
and he has a stiff neck. The nurse looks for other signs and symptoms of which
problem?
a. Head injury
b. Cluster headache
c. Migraine headache
d. Meningeal inflammation
