A patient has been admitted to a hospital after the staff in the nursing home noticed a
pressure ulcer in his sacral area. The nurse examines the pressure ulcer and determines
that it is a stage II ulcer. Which of these findings are characteristic of a stage II pressure
ulcer? Select all that apply.
a. Intact skin appears red but is not broken.
b. Partial thickness skin erosion is observed with a loss of epidermis or dermis.
c. Ulcer extends into the subcutaneous tissue.
d. Localized redness in light skin will blanch with fingertip pressure.
e. Open blister areas have a red-pink wound bed.
f. Patches of eschar cover parts of the wound.
During an examination of an aging man, the nurse recognizes that normal changes to
expect would be:
a. Enlarged scrotal sac.
b. Increased pubic hair.
c. Decreased penis size.
d. Increased rugae over the scrotum.
The nurse is palpating the uterus of a woman who is 8 weeks’ pregnant. Which finding
would be considered to be most consistent with this stage of pregnancy?
a. The uterus seems slightly enlarged and softened.
b. It reaches the pelvic brim and is approximately the size of a grapefruit.
c. The uterus rises above the pelvic brim and is approximately the size of a cantaloupe.
d. It is about the size of an avocado, approximately 8 cm across the fundus.
A woman who is 8 weeks’ pregnant is visiting the clinic for a checkup. Her systolic
blood pressure is 30 mm Hg higher than her prepregnancy systolic blood pressure. The
nurse should:
a. Consider this a normal finding.
b. Expect the blood pressure to decrease as the estrogen levels increase throughout the
pregnancy.
c. Consider this an abnormal finding because blood pressure is typically lower at this
point in the pregnancy.
d. Recommend that she decrease her salt intake in an attempt to decrease her peripheral
vascular resistance.
The nurse is teaching a review class on the lymphatic system. A participant shows
correct understanding of the material with which statement?
a. “Lymph flow is propelled by the contraction of the heart.”
b. “The flow of lymph is slow, compared with that of the blood.”
c. “One of the functions of the lymph is to absorb lipids from the biliary tract.”
d. “Lymph vessels have no valves; therefore, lymph fluid flows freely from the tissue
spaces into the bloodstream.”
During a session on substance abuse, the nurse is reviewing statistics with the class. For
persons aged 12 years and older, which illicit substance was most commonly used?
a. Crack cocaine
b. Heroin
c. Marijuana
d. Hallucinogens
The nurse recognizes that the concept of prevention in describing health is essential
because:
a. Disease can be prevented by treating the external environment.
b. The majority of deaths among Americans under age 65 years are not preventable.
c. Prevention places the emphasis on the link between health and personal behavior.
d. The means to prevention is through treatment provided by primary health care
practitioners.
A 78-year-old man has a history of a cerebrovascular accident. The nurse notes that
when he walks, his left arm is immobile against the body with flexion of the shoulder,
elbow, wrist, and fingers and adduction of the shoulder. His left leg is stiff and extended
and circumducts with each step. What type of gait disturbance is this individual
experiencing?
a. Scissors gait
b. Cerebellar ataxia
c. Parkinsonian gait
d. Spastic hemiparesis
Which of these findings would the nurse expect to notice during a cardiac assessment
on a 4-year-old child?
a. S3 when sitting up
b. Persistent tachycardia above 150 beats per minute
c. Murmur at the second left intercostal space when supine
d. Palpable apical impulse in the fifth left intercostal space lateral to midclavicular line
A 30-year-old woman tells the nurse that she has been very unsteady and has had
difficulty in maintaining her balance. Which area of the brain that is related to these
findings would concern the nurse?
a. Thalamus
b. Brainstem
c. Cerebellum
d. Extrapyramidal tract
The mother of a 2-year-old toddler is concerned about the upcoming placement of
tympanostomy tubes in her son’s ears. The nurse would include which of these
statements in the teaching plan?
a. The tubes are placed in the inner ear.
b. The tubes are used in children with sensorineural loss.
c. The tubes are permanently inserted during a surgical procedure.
d. The purpose of the tubes is to decrease the pressure and allow for drainage.
When the nurse is performing a genital examination on a male patient, which action is
correct?
a. Auscultating for the presence of a bruit over the scrotum
b. Palpating for the vertical chain of lymph nodes along the groin, inferior to the
inguinal ligament
c. Palpating the inguinal canal only if a bulge is present in the inguinal region during
inspection
d. Having the patient shift his weight onto the left (unexamined) leg when palpating for
a hernia on the right side
The nurse is reviewing a patient’s medical record and notes that he is in a coma. Using
the Glasgow Coma Scale, which number indicates that the patient is in a coma?
a. 6
b. 12
c. 15
d. 24
During an assessment, the nurse is unable to palpate pulses in the left lower leg. What
should the nurse do next?
a. Document that the pulses are nonpalpable.
b. Reassess the pulses in 1 hour.
c. Ask the patient turn to the side, and then palpate for the pulses again.
d. Use a Doppler device to assess the pulses.
A woman has just been diagnosed with HPV or genital warts. The nurse should counsel
her to receive regular examinations because this virus makes her at a higher risk for
_______ cancer.
a. Uterine
b. Cervical
c. Ovarian
d. Endometrial
A patient is admitted to the unit after an automobile accident. The nurse begins the
mental status examination and finds that the patient has dysarthric speech and is
lethargic. The nurse’s best approach regarding this examination is to:
a. Plan to defer the rest of the mental status examination.
b. Skip the language portion of the examination, and proceed onto assessing mood and
affect.
c. Conduct an in-depth speech evaluation, and defer the mental status examination to
another time.
d. Proceed with the examination, and assess the patient for suicidal thoughts because
dysarthria is often accompanied by severe depression.
During an assessment of a hospitalized patient, the nurse pinches a fold of skin under
the clavicle or on the forearm to test the:
a. Mobility and turgor.
b. Patient’s response to pain.
c. Percentage of the patient’s fat-to-muscle ratio.
d. Presence of edema.
The nurse is examining a 2-month-old infant and notices asymmetry of the infant’s
gluteal folds. The nurse should assess for other signs of what disorder?
a. Fractured clavicle
b. Down syndrome
c. Spina bifida
d. Hip dislocation
A 65-year-old man with emphysema and bronchitis has come to the clinic for a
follow-up appointment. On assessment, the nurse might expect to see which finding?
a. Anasarca
b. Scleroderma
c. Pedal erythema
d. Clubbing of the nails
The nurse has just completed an inspection of a nulliparous woman’s external genitalia.
Which of these would be a description of a finding within normal limits?
a. Redness of the labia majora
b. Multiple nontender sebaceous cysts
c. Discharge that is foul smelling and irritating
d. Gaping and slightly shriveled labia majora
A mother brings her newborn baby boy in for a checkup; she tells the nurse that he does
not seem to be moving his right arm as much as his left and that he seems to have pain
when she lifts him up under the arms. The nurse suspects a fractured clavicle and would
observe for:
a. Negative Allis test.
b. Positive Ortolani sign.
c. Limited range of motion during the Moro reflex.
d. Limited range of motion during Lasgue test.
A patient comes to the clinic and tells the nurse that he has been confined to his recliner
chair for approximately 3 days with his feet down and he asks the nurse to evaluate his
feet. During the assessment, the nurse might expect to find:
a. Pallor
b. Coolness
c. Distended veins
d. Prolonged capillary filling time
The nurse knows that during an abdominal assessment, deep palpation is used to
determine:
a. Bowel motility.
b. Enlarged organs.
c. Superficial tenderness.
d. Overall impression of skin surface and superficial musculature.
A patient’s annual physical examination reveals a lateral curvature of the thoracic and
lumbar segments of his spine; however, this curvature disappears with forward bending.
The nurse knows that this abnormality of the spine is called:
a. Structural scoliosis.
b. Functional scoliosis.
c. Herniated nucleus pulposus.
d. Dislocated hip.
After a symptom is recognized, the first effort at treatment is often self-care. Which of
the following statements about self-care is true? “Self-care is:
a. Not recognized as valuable by most health care providers.”
b. Usually ineffective and may delay more effective treatment.”
c. Always less expensive than biomedical alternatives.”
d. Influenced by the accessibility of over-the-counter medicines.”
During an examination, the nurse can assess mental status by which activity?
a. Examining the patient’s electroencephalogram
b. Observing the patient as he or she performs an intelligence quotient (IQ) test
c. Observing the patient and inferring health or dysfunction
d. Examining the patient’s response to a specific set of questions
The patient’s record, laboratory studies, objective data, and subjective data combine to
form the:
a. Data base.
b. Admitting data.
c. Financial statement.
d. Discharge summary.
The nurse is assisting with a BSE clinic. Which of these women reflect abnormal
findings during the inspection phase of breast examination?
a. Woman whose nipples are in different planes (deviated).
b. Woman whose left breast is slightly larger than her right.
c. Nonpregnant woman whose skin is marked with linear striae.
d. Pregnant woman whose breasts have a fine blue network of veins visible under the
skin.
A patient visits the clinic because he has recently noticed that the left side of his mouth
is paralyzed. He states that he cannot raise his eyebrow or whistle. The nurse suspects
that he has:
a. Cushing syndrome.
b. Parkinson disease.
c. Bell palsy.
d. Experienced a cerebrovascular accident (CVA) or stroke.
The nurse is reviewing aspects of cultural care. Which statements illustrate proper
cultural care? Select all that apply.
a. Examine the patient within the context of one’s own cultural health and illness
practices.
b. Select questions that are not complex.
c. Ask questions rapidly.
d. Touch patients within the cultural boundaries of their heritage.
e. Pace questions throughout the physical examination.
A patient is recovering from several hours of orthopedic surgery. During an assessment
of the patient’s lower legs, the nurse will monitor for signs of acute venous symptoms.
Signs of acute venous symptoms include which of the following? Select all that apply.
a. Intense, sharp pain, with the deep muscle tender to the touch
b. Aching, tired pain, with a feeling of fullness
c. Pain that is worse at the end of the day
d. Sudden onset
e. Warm, red, and swollen calf
f. Pain that is relieved with elevation of the leg
The nurse is performing an assessment on a 65-year-old man. He reports a crusty
nodule behind the pinna. It intermittently bleeds and has not healed over the past 6
months. On physical assessment, the nurse finds an ulcerated crusted nodule with an
indurated base. The preliminary analysis in this situation is that this:
a. Is most likely a benign sebaceous cyst.
b. Is most likely a keloid.
c. Could be a potential carcinoma, and the patient should be referred for a biopsy.
d. Is a tophus, which is common in the older adult and is a sign of gout.