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During a discussion about BSEs with a 30-year-old woman, which of these statements
by the nurse is most appropriate?
a. "The best time to examine your breasts is during ovulation."
b. "Examine your breasts every month on the same day of the month."
c. "Examine your breasts shortly after your menstrual period each month."
d. "The best time to examine your breasts is immediately before menstruation."
The nurse is completing an assessment on a patient who was just admitted from the
emergency department. Which assessment findings would require immediate attention?
Select all that apply.
a. Temperature: 38.6o C
b. Systolic blood pressure: 150 mm Hg
c. Respiratory rate: 22 breaths per minute
d. Heart rate: 130 beats per minute
e. Oxygen saturation: 95%
f. Sudden restlessness
During an assessment, the nurse notices that an older adult patient has tears rolling
down his face from his left eye. Closer examination shows that the lower lid is loose
and rolling outward. The patient complains of his eye feeling "dry and itchy." Which
action by the nurse is correct?
a. Assessing the eye for a possible foreign body
b. Documenting the finding as ptosis
c. Assessing for other signs of ectropion
d. Contacting the prescriber; these are signs of basal cell carcinoma
During an interview, the nurse notes that the patient gets up several times to wash her
hands even though they are not dirty. This behavior is an example of:
a. Social phobia
b. Compulsive disorder
c. Generalized anxiety disorder
d. Posttraumatic stress disorder
A patient has been admitted to the emergency department with a possible medical
diagnosis of pulmonary embolism. The nurse expects to see which assessment findings
related to this condition?
a. Absent or decreased breath sounds
b. Productive cough with thin, frothy sputum
c. Chest pain that is worse on deep inspiration and dyspnea
d. Diffuse infiltrates with areas of dullness upon percussion
In a person with an upper motor neuron lesion such as a cerebrovascular accident,
which of these physical assessment findings should the nurse expect?
a. Hyperreflexia
b. Fasciculations
c. Loss of muscle tone and flaccidity
d. Atrophy and wasting of the muscles
During palpation of the anterior chest wall, the nurse notices a coarse, crackling
sensation over the skin surface. On the basis of these findings, the nurse suspects:
a. Tactile fremitus.
b. Crepitus.
c. Friction rub.
d. Adventitious sounds.
When performing a respiratory assessment on a patient, the nurse notices a costal angle
of approximately 90 degrees. This characteristic is:
a. Observed in patients with kyphosis.
b. Indicative of pectus excavatum.
c. A normal finding in a healthy adult.
d. An expected finding in a patient with a barrel chest.
What should the nurse assess before entering the patient's room on morning rounds?
a. Posted conditions, such as isolation precautions
b. Patient's input and output chart from the previous shift
c. Patient's general appearance
d. Presence of any visitors in the room
During an external genitalia examination of a woman, the nurse notices several lesions
around the vulva. The lesions are pink, moist, soft, and pointed papules. The patient
states that she is not aware of any problems in that area. The nurse recognizes that these
lesions may be:
a. Syphilitic chancre.
b. Herpes simplex virus type 2 (herpes genitalis).
c. HPV or genital warts.
d. Pediculosis pubis (crab lice).
A 70-year-old woman who loves to garden has small, flat, brown macules over her arms
and hands. She asks, "What causes these liver spots?" The nurse tells her, "They are:
a. "Signs of decreased hematocrit related to anemia."
b. "Due to the destruction of melanin in your skin from exposure to the sun."
c. "Clusters of melanocytes that appear after extensive sun exposure."
d. "Areas of hyperpigmentation related to decreased perfusion and vasoconstriction."
The nurse is describing a scaphoid abdomen. To the horizontal plane, a scaphoid
contour of the abdomen depicts a ______ profile.
a. Flat
b. Convex
c. Bulging
d. Concave
During an assessment, a patient mentions that "I just can"t smell like I used to. I can
barely smell the roses in my garden. Why is that?" For which possible causes of
changes in the sense of smell will the nurse assess? Select all that apply.
a. Chronic alcohol use
b. Cigarette smoking
c. Frequent episodes of strep throat
d. Chronic allergies
e. Aging
f. Herpes simplex virus I
Which of these is included in an assessment of general appearance?
a. Height
b. Weight
c. Skin color
d. Vital signs
During an internal examination of a woman's genitalia, the nurse will use which
technique for proper insertion of the speculum?
a. The woman is instructed to bear down, the speculum blades are opened and applied
in a swift, upward movement.
b. The blades of the speculum are inserted on a horizontal plane, turning them to a
30-degree angle while continuing to insert them. The woman is asked to bear down
after the speculum is inserted.
c. The woman is instructed to bear down, the width of the blades are horizontally
turned, and the speculum is inserted downward at a 45-degree angle toward the small of
the woman's back.
d. The blades are locked open by turning the thumbscrew. Once the blades are open,
pressure is applied to the introitus and the blades are inserted downward at a 45-degree
angle to bring the cervix into view.
After completing an assessment of a 60-year-old man with a family history of colon
cancer, the nurse discusses with him early detection measures for colon cancer. The
nurse should mention the need for a(n):
a. Annual proctoscopy.
b. Colonoscopy every 10 years.
c. Fecal test for blood every 6 months.
d. DREs every 2 years.
Which critical thinking skill helps the nurse see relationships among the data?
a. Validation
b. Clustering related cues
c. Identifying gaps in data
d. Distinguishing relevant from irrelevant
The nurse should wear gloves for which of these examinations?
a. Measuring vital signs
b. Palpation of the sinuses
c. Palpation of the mouth and tongue
d. Inspection of the eye with an ophthalmoscope
A newborn infant is in the clinic for a well-baby checkup. The nurse observes the infant
for the possibility of fluid loss because of which of these factors?
a. Subcutaneous fat deposits are high in the newborn.
b. Sebaceous glands are overproductive in the newborn.
c. The newborn's skin is more permeable than that of the adult.
d. The amount of vernix caseosa dramatically rises in the newborn.
The nurse educator is preparing an education module for the nursing staff on the
epidermal layer of skin. Which of these statements would be included in the module?
The epidermis is:
a. Highly vascular.
b. Thick and tough.
c. Thin and nonstratified.
d. Replaced every 4 weeks.
During a mental status examination, the nurse wants to assess a patient's affect. The
nurse should ask the patient which question?
a. "How do you feel today?"
b. "Would you please repeat the following words?"
c. "Have these medications had any effect on your pain?"
d. "Has this pain affected your ability to get dressed by yourself?"
The nurse is conducting an interview with a woman who has recently learned that she is
pregnant and who has come to the clinic today to begin prenatal care. The woman states
that she and her husband are excited about the pregnancy but have a few questions. She
looks nervously at her hands during the interview and sighs loudly. Considering the
concept of communication, which statement does the nurse know to be most accurate?
The woman is:
a. Excited about her pregnancy but nervous about the labor.
b. Exhibiting verbal and nonverbal behaviors that do not match.
c. Excited about her pregnancy, but her husband is not and this is upsetting to her.
d. Not excited about her pregnancy but believes the nurse will negatively respond to her
if she states this.
When examining the mouth of an older patient, the nurse recognizes which finding is
due to the aging process?
a. Teeth appearing shorter
b. Tongue that looks smoother in appearance
c. Buccal mucosa that is beefy red in appearance
d. Small, painless lump on the dorsum of the tongue
A woman who is 28 weeks' pregnant has bilateral edema in her lower legs after working
8 hours a day as a cashier at a local grocery store. She is worried about her legs. What is
the nurse's best response?
a. "You will be at risk for development of varicose veins when your legs are
edematous."
b. "I would like to listen to your heart sounds. Edema can indicate a problem with your
heart."
c. "Edema is usually the result of too much salt and fluids in your diet. You may need to
cut down on salty foods."
d. "As your baby grows, it slows blood return from your legs, causing the swelling. This
often occurs with prolonged standing."
During an assessment of a patient who has been homeless for several years, the nurse
notices that his tongue is magenta in color, which is an indication of a deficiency in
what mineral and/or vitamin?
a. Iron
b. Riboflavin
c. Vitamin D and calcium
d. Vitamin C
A newly admitted patient is in acute pain, has not been sleeping well lately, and is
having difficulty breathing. How should the nurse prioritize these problems?
a. Breathing, pain, and sleep
b. Breathing, sleep, and pain
c. Sleep, breathing, and pain
d. Sleep, pain, and breathing
A 14-year-old girl is anxious about not having reached menarche. When taking the
health history, the nurse should ascertain which of the following? The age that:
a. The girl began to develop breasts.
b. Her mother developed breasts.
c. She began to develop pubic hair.
d. She began to develop axillary hair.
A 22-year-old man comes to the clinic for an examination after falling off his
motorcycle and landing on his left side on the handle bars. The nurse suspects that he
may have injured his spleen. Which of these statements is true regarding assessment of
the spleen in this situation?
a. The spleen can be enlarged as a result of trauma.
b. The spleen is normally felt on routine palpation.
c. If an enlarged spleen is noted, then the nurse should thoroughly palpate to determine
its size.
d. An enlarged spleen should not be palpated because it can easily rupture.
A 5-year-old child is in the clinic for a checkup. The nurse would expect him to:
a. Need to be held on his mother's lap.
b. Be able to sit on the examination table.
c. Be able to stand on the floor for the examination.
d. Be able to remain alone in the examination room.
A woman is in the clinic for an annual gynecologic examination. The nurse should plan
to begin the interview with the:
a. Menstrual history, because it is generally nonthreatening.
b. Obstetric history, because it includes the most important information.
c. Urinary system history, because problems may develop in this area as well.
d. Sexual history, because discussing it first will build rapport.
A visitor from Poland who does not speak English seems to be somewhat apprehensive
about the nurse examining his neck. He would probably be more comfortable with the
nurse examining his thyroid gland from:
a. Behind with the nurse's hands placed firmly around his neck.
b. The side with the nurse's eyes averted toward the ceiling and thumbs on his neck.
c. The front with the nurse's thumbs placed on either side of his trachea and his head
tilted forward.
d. The front with the nurse's thumbs placed on either side of his trachea and his head
tilted backward.
A patient tells the nurse that he is very nervous, is nauseated, and "feels hot." These
types of data would be:
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.
When listening to a patient's breath sounds, the nurse is unsure of a sound that is heard.
The nurse's next action should be to:
a. Immediately notify the patient's physician.
b. Document the sound exactly as it was heard.
c. Validate the data by asking a coworker to listen to the breath sounds.
d. Assess again in 20 minutes to note whether the sound is still present.
