The nurse is preparing to examine a 4-year-old child. Which action is appropriate for
this age group?
a. Explain the procedures in detail to alleviate the child’s anxiety.
b. Give the child feedback and reassurance during the examination.
c. Do not ask the child to remove his or her clothes because children at this age are
usually very private.
d. Perform an examination of the ear, nose, and throat first, and then examine the thorax
and abdomen.
During inspection of the posterior chest, the nurse should assess for:
a. Symmetric expansion.
b. Symmetry of shoulders and muscles.
c. Tactile fremitus.
d. Diaphragmatic excursion.
A woman has just entered the emergency department after being battered by her
husband. The nurse needs to get some information from her to begin treatment. What is
the best choice for an opening phase of the interview with this patient?
a. “Hello, Nancy, my name is Mrs. C.”
b. “Hello, Mrs. H., my name is Mrs. C. It sure is cold today!”
c. “Mrs. H., my name is Mrs. C. How are you?”
d. “Mrs. H., my name is Mrs. C. I”ll need to ask you a few questions about what
happened.”
During an assessment of a 20-year-old patient with a 3-day history of nausea and
vomiting, the nurse notices dry mucosa and deep vertical fissures in the tongue. These
findings are reflective of:
a. Dehydration.
b. Irritation by gastric juices.
c. A normal oral assessment.
d. Side effects from nausea medication.
A 4-month-old child is at the clinic for a well-baby check-up and immunizations. Which
of these actions is most appropriate when the nurse is assessing an infant’s vital signs?
a. The infant’s radial pulse should be palpated, and the nurse should notice any
fluctuations resulting from activity or exercise.
b. The nurse should auscultate an apical rate for 1 minute and then assess for any
normal irregularities, such as sinus arrhythmia.
c. The infant’s blood pressure should be assessed by using a stethoscope with a large
diaphragm piece to hear the soft muffled Korotkoff sounds.
d. The infant’s chest should be observed and the respiratory rate counted for 1 minute;
the respiratory pattern may vary significantly.
The nurse is preparing for a class in early detection of breast cancer. Which statement is
truewith regard to breast cancer in black women in the United States?
a. Breast cancer is not a threat to black women.
b. Black women have a lower incidence of regional or distant breast cancer than white
women.
c. Black women are more likely to die of breast cancer at any age.
d. Breast cancer incidence in black women is higher than that of white women after age
45.
During a morning assessment, the nurse notices that a patient’s urine output is below the
expected amount. What should the nurse do next?
a. Obtain an order for a Foley catheter.
b. Obtain an order for a straight catheter.
c. Perform a bladder scan test.
d. Refer the patient to an urologist.
A female American Indian has come to the clinic for follow-up diabetic teaching.
During the interview, the nurse notices that she never makes eye contact and speaks
mostly to the floor. Which statement is true regarding this situation?
a. The woman is nervous and embarrassed.
b. She has something to hide and is ashamed.
c. The woman is showing inconsistent verbal and nonverbal behaviors.
d. She is showing that she is carefully listening to what the nurse is saying.
During an examination, which tests will the nurse collect to screen for cervical cancer?
a. Endocervical specimen, cervical scrape, and vaginal pool
b. Endocervical specimen, vaginal pool, and acetic acid wash
c. Endocervical specimen, potassium hydroxide (KOH) preparation, and acetic acid
wash
d. Cervical scrape, acetic acid wash, saline mount (“wet prep”)
The nurse knows that a common assessment finding in a boy younger than 2 years old
is:
a. Inflamed and tender spermatic cord.
b. Presence of a hernia in the scrotum.
c. Penis that looks large in relation to the scrotum.
d. Presence of a hydrocele, or fluid in the scrotum.
A 50-year-old patient has been brought to the emergency department after a housemate
found that the patient could not get out of bed alone. He has lived in a group home for
years but for several months has not participated in the activities and has stayed in his
room. The nurse assesses for signs of undernutrition, and an x-ray study reveals that he
has osteomalacia, which is a deficiency of:
a. Iron.
b. Riboflavin.
c. Vitamin D and calcium.
d. Vitamin C.
A woman has come to the clinic to seek help with a substance abuse problem. She
admits to using cocaine just before arriving. Which of these assessment findings would
the nurse expect to find when examining this woman?
a. Dilated pupils, pacing, and psychomotor agitation
b. Dilated pupils, unsteady gait, and aggressiveness
c. Pupil constriction, lethargy, apathy, and dysphoria
d. Constricted pupils, euphoria, and decreased temperature
The nurse is nearing the end of an interview. Which statement is appropriate at this
time?
a. “Did we forget something?”
b. “Is there anything else you would like to mention?”
c. “I need to go on to the next patient. I”ll be back.”
d. “While I”m here, let’s talk about your upcoming surgery.”
The nurse is conducting an interview. Which of these statements is true regarding
open-ended questions? Select all that apply.
a. Open-ended questions elicit cold facts.
b. They allow for self-expression.
c. Open-ended questions build and enhance rapport.
d. They leave interactions neutral.
e. Open-ended questions call for short one- to two-word answers.
f. They are used when narrative information is needed.
Which of these assessment findings would the nurse expect to see when examining the
eyes of a black patient?
a. Increased night vision
b. Dark retinal background
c. Increased photosensitivity
d. Narrowed palpebral fissures
A patient is complaining of severe knee pain after twisting it during a basketball game
and is requesting pain medication. Which action by the nurse is appropriate?
a. Completing the physical examination first and then giving the pain medication
b. Telling the patient that the pain medication must wait until after the x-ray images are
completed
c. Evaluating the full range of motion of the knee and then medicating for pain
d. Administering pain medication and then proceeding with the assessment
During a health history, a patient tells the nurse that he has trouble in starting his urine
stream. This problem is known as:
a. Urgency.
b. Dribbling.
c. Frequency.
d. Hesitancy.
In a patient with acromegaly, the nurse will expect to discover which assessment
findings?
a. Heavy, flattened facial features
b. Growth retardation and a delayed onset of puberty
c. Overgrowth of bone in the face, head, hands, and feet
d. Increased height and weight and delayed sexual development
A man who has had gout for several years comes to the clinic with a problem with his
toe. On examination, the nurse notices the presence of hard, painless nodules over the
great toe; one has burst open with a chalky discharge. This finding is known as:
a. Callus.
b. Plantar wart.
c. Bunion.
d. Tophi.
An 80-year-old woman is visiting the clinic for a checkup. She states, “I can”t walk as
much as I used to.” The nurse is observing for motor dysfunction in her hip and should
ask her to:
a. Internally rotate her hip while she is sitting.
b. Abduct her hip while she is lying on her back.
c. Adduct her hip while she is lying on her back.
d. Externally rotate her hip while she is standing.
Of the 33 vertebrae in the spinal column, there are:
a. 5 lumbar.
b. 5 thoracic.
c. 7 sacral.
d. 12 cervical.
A patient repeatedly seems to have difficulty coming up with a word. He says, “I was
on my way to work, and when I got there, the thing that you step into that goes up in the
air was so full that I decided to take the stairs.” The nurse will note on his chart that he
is using or experiencing:
a. Blocking
b. Neologism
c. Circumlocution
d. Circumstantiality
The nurse is teaching a health class to high-school boys. When discussing the topic of
using smokeless tobacco (SLT), which of these statements are accurate? Select all that
apply.
a. One pinch of SLT in the mouth for 30 minutes delivers the equivalent of one
cigarette.
b. Using SLT has been associated with a greater risk of oral cancer than smoking.
c. Pain is an early sign of oral cancer.
d. Pain is rarely an early sign of oral cancer.
e. Tooth decay is another risk of SLT because of the use of sugar as a sweetener.
f. SLT is considered a healthy alternative to smoking.
How should the nurse document mild, slight pitting edema the ankles of a pregnant
patient?
a. 1+/0-4+
b. 3+/0-4+
c. 4+/0-4+
d. Brawny edema
The nurse discovers speech problems in a patient during an assessment. The patient has
spontaneous speech, but it is mostly absent or is reduced to a few stereotypical words or
sounds. This finding reflects which type of aphasia?
a. Global
b. Broca’s
c. Dysphonic
d. Wernicke’s
The ankle joint is the articulation of the tibia, fibula, and:
a. Talus.
b. Cuboid.
c. Calcaneus.
d. Cuneiform bones.
The nurse is preparing to complete a health assessment on a 16-year-old girl whose
parents have brought her to the clinic. Which instruction would be appropriate for the
parents before the interview begins?
a. “Please stay during the interview; you can answer for her if she does not know the
answer.”
b. “It would help to interview the three of you together.”
c. “While I interview your daughter, will you please stay in the room and complete
these family health history questionnaires?”
d. “While I interview your daughter, will you step out to the waiting room and complete
these family health history questionnaires?”
During an assessment of a patient’s family history, the nurse constructs a genogram.
Which statement best describes a genogram?
a. List of diseases present in a person’s near relatives
b. Graphic family tree that uses symbols to depict the gender, relationship, and age of
immediate family members
c. Drawing that depicts the patient’s family members up to five generations back
d. Description of the health of a person’s children and grandchildren
The nurse is examining a patient who tells the nurse, “I sure sweat a lot, especially on
my face and feet but it doesn”t have an odor.” The nurse knows that this condition could
be related to:
a. Eccrine glands.
b. Apocrine glands.
c. Disorder of the stratum corneum.
d. Disorder of the stratum germinativum.
A patient repeats, “I feel hot. Hot, cot, rot, tot, got. I”m a spot.” The nurse documents
this as an illustration of:
a. Blocking
b. Clanging
c. Echolalia
d. Neologism