A patient has been shown to have a sensorineural hearing loss. During the assessment, it
would be important for the nurse to:
a. Speak loudly so the patient can hear the questions.
b. Assess for middle ear infection as a possible cause.
c. Ask the patient what medications he is currently taking.
d. Look for the source of the obstruction in the external ear.
The nurse is performing a health interview on a patient who has a language barrier, and
no interpreter is available. Which is the best example of an appropriate question for the
nurse to ask in this situation?
a. “Do you take medicine?”
b. “Do you sterilize the bottles?”
c. “Do you have nausea and vomiting?”
d. “You have been taking your medicine, haven”t you?”
When performing a genitourinary assessment on a 16-year-old male adolescent, the
nurse notices a swelling in the scrotum that increases with increased intra-abdominal
pressure and decreases when he is lying down. The patient complains of pain when
straining. The nurse knows that this description is most consistent with a(n) ______
hernia.
a. Femoral
b. Incisional
c. Direct inguinal
d. Indirect inguinal
During an examination, the patient states he is hearing a buzzing sound and says that it
is “driving me crazy!” The nurse recognizes that this symptom indicates:
a. Vertigo.
b. Pruritus.
c. Tinnitus.
d. Cholesteatoma.
The nurse is discussing appropriate foods with the mother of a 3-year-old child. Which
of these foods are recommended?
a. Foods that the child will eat, no matter what they are
b. Foods easy to hold such as hot dogs, nuts, and grapes
c. Any foods, as long as the rest of the family is also eating them
d. Finger foods and nutritious snacks that cannot cause choking
When examining the ear with an otoscope, the nurse notes that the tympanic membrane
should appear:
a. Light pink with a slight bulge.
b. Pearly gray and slightly concave.
c. Pulled in at the base of the cone of light.
d. Whitish with a small fleck of light in the superior portion.
When the nurse is auscultating the carotid artery for bruits, which of these statements
reflects the correct technique?
a. While listening with the bell of the stethoscope, the patient is asked to take a deep
breath and hold it.
b. While auscultating one side with the bell of the stethoscope, the carotid artery is
palpated on the other side to check pulsations.
c. While lightly applying the bell of the stethoscope over the carotid artery and
listening, the patient is asked to take a breath, exhale, and briefly hold it.
d. While firmly placing the bell of the stethoscope over the carotid artery and listening,
the patient is asked to take a breath, exhale, and briefly hold it.
During an assessment of a 20-year-old man, the nurse finds a small palpable lesion with
a tuft of hair located directly over the coccyx. The nurse knows that this lesion would
most likely be a:
a. Rectal polyp.
b. Pruritus ani.
c. Carcinoma.
d. Pilonidal cyst.
A 92-year-old patient has had a stroke. The right side of his face is drooping. The nurse
might also suspect which of these assessment findings?
a. Epistaxis
b. Rhinorrhea
c. Dysphagia
d. Xerostomia
A patient is brought to the emergency department. He is restless, has dilated pupils, is
sweating, has a runny nose and tearing eyes, and complains of muscle and joint pains.
His girlfriend thinks he has influenza, but she became concerned when his temperature
went up to 39.4o C. She admits that he has been a heavy drug user, but he has been
trying to stop on his own. The nurse suspects that the patient is experiencing withdrawal
symptoms from which substance?
a. Alcohol
b. Heroin
c. Crack cocaine
d. Sedatives
A 43-year-old woman is at the clinic for a routine examination. She reports that she has
had a breast lump in her right breast for years. Recently, it has begun to change in
consistency and is becoming harder. She reports that 5 years ago her physician
evaluated the lump and determined that it “was nothing to worry about.” The
examination validates the presence of a mass in the right upper outer quadrant at 1
o”clock, approximately 5 cm from the nipple. It is firm, mobile, and nontender, with
borders that are not well defined. The nurse replies:
a. “Because of the change in consistency of the lump, it should be further evaluated by a
physician.”
b. “The changes could be related to your menstrual cycles. Keep track of the changes in
the mass each month.”
c. “The lump is probably nothing to worry about because it has been present for years
and was determined to be noncancerous 5 years ago.”
d. “Because you are experiencing no pain and the size has not changed, you should
continue to monitor the lump and return to the clinic in 3 months.”
When listening to heart sounds, the nurse knows the valve closures that can be heard
best at the base of the heart are:
a. Mitral and tricuspid.
b. Tricuspid and aortic.
c. Aortic and pulmonic.
d. Mitral and pulmonic.
A man is at the clinic for a physical examination. He states that he is “very anxious”
about the physical examination. What steps can the nurse take to make him more
comfortable?
a. Appear unhurried and confident when examining him.
b. Stay in the room when he undresses in case he needs assistance.
c. Ask him to change into an examining gown and to take off his undergarments.
d. Defer measuring vital signs until the end of the examination, which allows him time
to become comfortable.
In assessing for an S4 heart sound with a stethoscope, the nurse would listen with the:
a. Bell of the stethoscope at the base with the patient leaning forward.
b. Bell of the stethoscope at the apex with the patient in the left lateral position.
c. Diaphragm of the stethoscope in the aortic area with the patient sitting.
d. Diaphragm of the stethoscope in the pulmonic area with the patient supine.
A patient complains that while studying for an examination he began to notice a severe
headache in the frontotemporal area of his head that is throbbing and is somewhat
relieved when he lies down. He tells the nurse that his mother also had these headaches.
The nurse suspects that he may be suffering from:
a. Hypertension.
b. Cluster headaches.
c. Tension headaches.
d. Migraine headaches.
During an interview, the patient states he has the sensation that “everything around him
is spinning.” The nurse recognizes that the portion of the ear responsible for this
sensation is the:
a. Cochlea.
b. CN VIII.
c. Organ of Corti.
d. Labyrinth.
A mother brings her 4-month-old infant to the clinic with concerns regarding a small
pad in the middle of the upper lip that has been there since 1 month of age. The infant
has no health problems. On physical examination, the nurse notices a 0.5-cm, fleshy,
elevated area in the middle of the upper lip. No evidence of inflammation or drainage is
observed. What would the nurse tell this mother?
a. “This area of irritation is caused from teething and is nothing to worry about.”
b. “This finding is abnormal and should be evaluated by another health care provider.”
c. “This area of irritation is the result of chronic drooling and should resolve within the
next month or two.”
d. “This elevated area is a sucking tubercle caused from the friction of breastfeeding or
bottle-feeding and is normal.”
The nurse is assessing the neurologic status of a patient who has a late-stage brain
tumor. With the reflex hammer, the nurse draws a light stroke up the lateral side of the
sole of the foot and inward, across the ball of the foot. In response, the patient’s toes fan
out, and the big toe shows dorsiflexion. The nurse interprets this result as:
a. Negative Babinski sign, which is normal for adults.
b. Positive Babinski sign, which is abnormal for adults.
c. Clonus, which is a hyperactive response.
d. Achilles reflex, which is an expected response.
While measuring a patient’s blood pressure, the nurse recalls that certain factors, such as
__________, help determine blood pressure.
a. Pulse rate
b. Pulse pressure
c. Vascular output
d. Peripheral vascular resistance
When beginning to assess a person’s spirituality, which question by the nurse would be
most appropriate?
a. “Do you believe in God?”
b. “How does your spirituality relate to your health care decisions?”
c. “What religious faith do you follow?”
d. “Do you believe in the power of prayer?”
A 4-year-old boy is brought to the emergency department by his mother. She says he
points to his stomach and says, “It hurts so bad.” Which pain assessment tool would be
the best choice when assessing this child’s pain?
a. Descriptor Scale
b. Numeric rating scale
c. Brief Pain Inventory
d. Faces Pain ScaleRevised (FPS-R)
A 42-year-old patient of Asian descent is being seen at the clinic for an initial
examination. The nurse knows that including cultural information in his health
assessment is important to:
a. Identify the cause of his illness.
b. Make accurate disease diagnoses.
c. Provide cultural health rights for the individual.
d. Provide culturally sensitive and appropriate care.
Which of these actions is most appropriate to perform on a 9-month-old infant at a
well-child checkup?
a. Testing for Ortolani sign
b. Assessment for stereognosis
c. Blood pressure measurement
d. Assessment for the presence of the startle reflex
When examining an older adult, the nurse should use which technique?
a. Avoid touching the patient too much.
b. Attempt to perform the entire physical examination during one visit.
c. Speak loudly and slowly because most aging adults have hearing deficits.
d. Arrange the sequence of the examination to allow as few position changes as
possible.
The nurse is assessing the vital signs of a 20-year-old male marathon runner and
documents the following vital signs: temperature”36o C; pulse”48 beats per minute;
respirations”14 breaths per minute; blood pressure”104/68 mm Hg. Which statement is
true concerning these results?
a. The patient is experiencing tachycardia.
b. These are normal vital signs for a healthy, athletic adult.
c. The patient’s pulse rate is not normalhis physician should be notified.
d. On the basis of these readings, the patient should return to the clinic in 1 week.
The nurse documents that a patient has coarse, thickened skin and brown discoloration
over the lower legs. Pulses are present. This finding is probably the result of:
a. Lymphedema.
b. Raynaud disease.
c. Chronic arterial insufficiency.
d. Chronic venous insufficiency.
During an interview, a parent of a hospitalized child is sitting in an open position. As
the interviewer begins to discuss his son’s treatment, however, he suddenly crosses his
arms against his chest and crosses his legs. This changed posture would suggest that the
parent is:
a. Simply changing positions.
b. More comfortable in this position.
c. Tired and needs a break from the interview.
d. Uncomfortable talking about his son’s treatment.
A patient has had three pregnancies and two live births. The nurse would record this
information as grav _____, para _____, AB _____.
a. 2; 2; 1
b. 3; 2; 0
c. 3; 2; 1
d. 3; 3; 1
The nurse is explaining to a patient that there are shock absorbers in his back to cushion
the spine and to help it move. The nurse is referring to his:
a. Vertebral column.
b. Nucleus pulposus.
c. Vertebral foramen.
d. Intervertebral disks.
The nurse is examining a 2-year-old child and asks, “May I listen to your heart now?”
Which critique of the nurse’s technique is most accurate?
a. Asking questions enhances the child’s autonomy
b. Asking the child for permission helps develop a sense of trust
c. This question is an appropriate statement because children at this age like to have
choices
d. Children at this age like to say, “No.” The examiner should not offer a choice when
no choice is available
During an assessment, the nurse notices that a patient’s umbilicus is enlarged and
everted. It is positioned midline with no change in skin color. The nurse recognizes that
the patient may have which condition?
a. Intra-abdominal bleeding
b. Constipation
c. Umbilical hernia
d. Abdominal tumor
The nurse is preparing to perform a modified Allen test. Which is an appropriate reason
for this test?
a. To measure the rate of lymphatic drainage
b. To evaluate the adequacy of capillary patency before venous blood draws
c. To evaluate the adequacy of collateral circulation before cannulating the radial artery
d. To evaluate the venous refill rate that occurs after the ulnar and radial arteries are
temporarily occluded
During the taking of the health history, a patient tells the nurse that “it feels like the
room is spinning around me.” The nurse would document this finding as:
a. Vertigo.
b. Syncope.
c. Dizziness.
d. Seizure activity.
The nurse is observing the auscultation technique of another nurse. The correct method
to use when progressing from one auscultatory site on the thorax to another is _______
comparison.
a. Side-to-side
b. Top-to-bottom
c. Posterior-to-anterior
d. Interspace-by-interspace