A 70-year-old patient is being seen in the clinic for severe exacerbation of his heart
failure. Which of these findings is the nurse most likely to observe in this patient?
a. Shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, and ankle edema
b. Rasping cough, thick mucoid sputum, wheezing, and bronchitis
c. Productive cough, dyspnea, weight loss, anorexia, and tuberculosis
d. Fever, dry nonproductive cough, and diminished breath sounds
The nurse knows that a normal finding when assessing the respiratory system of an
older adult is:
a. Increased thoracic expansion.
b. Decreased mobility of the thorax.
c. Decreased anteroposterior diameter.
d. Bronchovesicular breath sounds throughout the lungs.
A 52-year-old woman has a papule on her nose that has rounded, pearly borders and a
central red ulcer. She said she first noticed it several months ago and that it has slowly
grown larger. The nurse suspects which condition?
a. Acne
b. Basal cell carcinoma
c. Melanoma
d. Squamous cell carcinoma
A woman who has lived in the United States for a year after moving from Europe has
learned to speak English and is almost finished with her college studies. She now
dresses like her peers and says that her family in Europe would hardly recognize her.
This nurse recognizes that this situation illustrates which concept?
a. Assimilation
b. Heritage consistency
c. Biculturalism
d. Acculturation
The nurse has collected the following information on a patient: palpated blood
pressure”180 mm Hg; auscultated blood pressure”170/100 mm Hg; apical pulse”60
beats per minute; radial pulse”70 beats per minute. What is the patient’s pulse pressure?
a. 10
b. 70
c. 80
d. 100
A 16-year-old girl is being seen at the clinic for gastrointestinal complaints and weight
loss. The nurse determines that many of her complaints may be related to erratic eating
patterns, eating predominantly fast foods, and high caffeine intake. In this situation,
which is most appropriate when collecting current dietary intake information?
a. Scheduling a time for direct observation of the adolescent during meals
b. Asking the patient for a 24-hour diet recall, and assuming it to be reflective of a
typical day for her
c. Having the patient complete a food diary for 3 days, including 2 weekdays and 1
weekend day
d. Using the food frequency questionnaire to identify the amount of intake of specific
foods
The nurse has implemented several planned interventions to address the nursing
diagnosis of acute pain. Which would be the next appropriate action?
a. Establish priorities.
b. Identify expected outcomes.
c. Evaluate the individual’s condition, and compare actual outcomes with expected
outcomes.
d. Interpret data, and then identify clusters of cues and make inferences.
An 18-year-old patient is having her first pelvic examination. Which action by the nurse
is appropriate?
a. Inviting her mother to be present during the examination
b. Avoiding the lithotomy position for this first time because it can be uncomfortable
and embarrassing
c. Raising the head of the examination table and giving her a mirror so that she can
view the examination
d. Fully draping her, leaving the drape between her legs elevated to avoid embarrassing
her with eye contact
In assessing the carotid arteries of an older patient with cardiovascular disease, the
nurse would:
a. Palpate the artery in the upper one third of the neck.
b. Listen with the bell of the stethoscope to assess for bruits.
c. Simultaneously palpate both arteries to compare amplitude.
d. Instruct the patient to take slow deep breaths during auscultation.
The nurse is assessing a patient’s headache pain. Which questions reflect one or more of
the critical characteristics of symptoms that should be assessed? Select all that apply.
a. “Where is the headache pain?”
b. “Did you have these headaches as a child?”
c. “On a scale of 1 to 10, how bad is the pain?”
d. “How often do the headaches occur?”
e. “What makes the headaches feel better?”
f. “Do you have any family history of headaches?”
During an assessment of a 26 year old at the clinic for “a spot on my lip I think is
cancer,” the nurse notices a group of clear vesicles with an erythematous base around
them located at the lip-skin border. The patient mentions that she just returned from
Hawaii. What would be the most appropriate response by the nurse?
a. Tell the patient she needs to see a skin specialist.
b. Discuss the benefits of having a biopsy performed on any unusual lesion.
c. Tell the patient that these vesicles are indicative of herpes simplex I or cold sores and
that they will heal in 4 to 10 days.
d. Tell the patient that these vesicles are most likely the result of a riboflavin deficiency
and discuss nutrition.
The mother of a 3-month-old infant states that her baby has not been gaining weight.
With further questioning, the nurse finds that the infant falls asleep after nursing and
wakes up after a short time, hungry again. What other information would the nurse want
to have?
a. Infant’s sleeping position
b. Sibling history of eating disorders
c. Amount of background noise when eating
d. Presence of dyspnea or diaphoresis when sucking
The nurse is conducting a child safety class for new mothers. Which factor places
young children at risk for ear infections?
a. Family history
b. Air conditioning
c. Excessive cerumen
d. Passive cigarette smoke
When the nurse is assessing the deep tendon reflexes (DTRs) on a woman who is 32
weeks’ pregnant, which of these would be considered a normal finding on a 0 to 4+
scale?
a. Absent DTRs
b. 2+
c. 4+
d. Brisk reflexes and the presence of clonus
A patient comes into the clinic complaining of facial pain, fever, and malaise. On
examination, the nurse notes swollen turbinates and purulent discharge from the nose.
The patient also complains of a dull, throbbing pain in his cheeks and teeth on the right
side and pain when the nurse palpates the areas. The nurse recognizes that this patient
has:
a. Posterior epistaxis.
b. Frontal sinusitis.
c. Maxillary sinusitis.
d. Nasal polyps.
A woman at 25 weeks’ gestation comes to the clinic for her prenatal visit. The nurse
notices that her face and lower extremities are swollen, and her blood pressure is 154/94
mm Hg. The woman states that she has had headaches and blurry vision but thought she
was just tired. What should the nurse suspect?
a. Eclampsia
b. Preeclampsia
c. Diabetes type 1
d. Preterm labor
The physician comments that a patient has abdominalborborygmi. The nurse knows that
this term refers to:
a. Loud continual hum.
b. Peritoneal friction rub.
c. Hypoactive bowel sounds.
d. Hyperactive bowel sounds.
When the nurse asks a 68-year-old patient to stand with his feet together and arms at his
side with his eyes closed, he starts to sway and moves his feet farther apart. The nurse
would document this finding as:
a. Ataxia.
b. Lack of coordination.
c. Negative Homans sign.
d. Positive Romberg sign.
The assessment of a 60-year-old patient has taken longer than anticipated. In testing his
pain perception, the nurse decides to complete the test as quickly as possible. When the
nurse applies the sharp point of the pin on his arm several times, he is only able to
identify these as one “very sharp prick.” What would be the most accurate explanation
for this?
a. The patient has hyperesthesia as a result of the aging process.
b. This response is most likely the result of the summation effect.
c. The nurse was probably not poking hard enough with the pin in the other areas.
d. The patient most likely has analgesia in some areas of arm and hyperalgesia in
others.
A 5-year-old boy is being admitted to the hospital to have his tonsils removed. Which
information should the nurse collect before this procedure?
a. Child’s birth weight
b. Age at which he crawled
c. Whether the child has had the measles
d. Child’s reactions to previous hospitalizations
The nurse is assessing bruising on an injured patient. Which color indicates a new
bruise that is less than 2 hours old?
a. Red
b. Purple-blue
c. Greenish-brown
d. Brownish-yellow
The nurse is conducting a health fair for older adults. Which statement is true regarding
vital sign measurements in aging adults?
a. The pulse is more difficult to palpate because of the stiffness of the blood vessels.
b. An increased respiratory rate and a shallower inspiratory phase are expected findings.
c. A decreased pulse pressure occurs from changes in the systolic and diastolic blood
pressures.
d. Changes in the body’s temperature regulatory mechanism leave the older person more
likely to develop a fever.
During an interview, the nurse would expect that most of the interview will take place at
what distance?
a. Intimate zone
b. Personal distance
c. Social distance
d. Public distance
The nurse is assessing an older adult’s advanced activities of daily living (AADLs),
which would include:
a. Recreational activities.
b. Meal preparation.
c. Balancing the checkbook.
d. Self-grooming activities.
During an examination, the nurse notices that the patient stumbles a little while
walking, and, when she sits down, she holds on to the sides of the chair. The patient
states, “It feels like the room is spinning!” The nurse notices that the patient is
experiencing:
a. Objective vertigo.
b. Subjective vertigo.
c. Tinnitus.
d. Dizziness.
A 25-year-old woman in her fifth month of pregnancy has a blood pressure of 100/70
mm Hg. In reviewing her previous examination, the nurse notes that her blood pressure
in her second month was 124/80 mm Hg. In evaluating this change, what does the nurse
know to be true?
a. This decline in blood pressure is the result of peripheral vasodilatation and is an
expected change.
b. Because of increased cardiac output, the blood pressure should be higher at this time.
c. This change in blood pressure is not an expected finding because it means a decrease
in cardiac output.
d. This decline in blood pressure means a decrease in circulating blood volume, which
is dangerous for the fetus.
The nurse is preparing to percuss the abdomen of a patient. The purpose of the
percussion is to assess the __________ of the underlying tissue.
a. Turgor
b. Texture
c. Density
d. Consistency
A patient has had a “terrible itch” for several months that he has been continuously
scratching. On examination, the nurse might expect to find:
a. A keloid.
b. A fissure.
c. Keratosis.
d. Lichenification.
A 59-year-old patient tells the nurse that he has ulcerative colitis. He has been having
“black stools” for the last 24 hours. How would the nurse best document his reason for
seeking care?
a. J.M. is a 59-year-old man seeking treatment for ulcerative colitis.
b. J.M. came into the clinic complaining of having black stools for the past 24 hours.
c. J.M. is a 59-year-old man who states that he has ulcerative colitis and wants it
checked.
d. J.M. is a 59-year-old man who states that he has been having “black stools” for the
past 24 hours.
A 40-year-old black man is in the office for his annual physical examination. Which
statement regarding the PSA blood test is true, according to the American Cancer
Society? The PSA:
a. Should be performed with this visit.
b. Should be performed at age 45 years.
c. Should be performed at age 50 years.
d. Is only necessary if a family history of prostate cancer exists.