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A 17-year-old student is a swimmer on her high school's swim team. She has had three
bouts of otitis externa this season and wants to know what to do to prevent it. The nurse
instructs her to:
a. Use a cotton-tipped swab to dry the ear canals thoroughly after each swim.
b. Use rubbing alcohol or 2% acetic acid eardrops after every swim.
c. Irrigate the ears with warm water and a bulb syringe after each swim.
d. Rinse the ears with a warmed solution of mineral oil and hydrogen peroxide.
In teaching a patient how to determine total body fat at home, the nurse includes
instructions to obtain measurements of:
a. Height and weight.
b. Frame size and weight.
c. Waist and hip circumferences.
d. Mid-upper arm circumference and arm span.
An adult patient with a history of allergies comes to the clinic complaining of wheezing
and difficulty in breathing when working in his yard. The assessment findings include
tachypnea, the use of accessory neck muscles, prolonged expiration, intercostal
retractions, decreased breath sounds, and expiratory wheezes. The nurse interprets that
these assessment findings are consistent with:
a. Asthma.
b. Atelectasis.
c. Lobar pneumonia.
d. Heart failure.
The nurse is performing a mental status assessment on a 5-year-old girl. Her parents are
undergoing a bitter divorce and are worried about the effect it is having on their
daughter. Which action or statement might lead the nurse to be concerned about the
girl's mental status?
a. She clings to her mother whenever the nurse is in the room.
b. She appears angry and will not make eye contact with the nurse.
c. Her mother states that she has begun to ride a tricycle around their yard.
d. Her mother states that her daughter prefers to play with toddlers instead of kids her
own age while in daycare.
The nurse is performing a general survey. Which action is a component of the general
survey?
a. Observing the patient's body stature and nutritional status
b. Interpreting the subjective information the patient has reported
c. Measuring the patient's temperature, pulse, respirations, and blood pressure
d. Observing specific body systems while performing the physical assessment
Which of these individuals would the nurse consider at highest risk for a suicide
attempt?
a. Man who jokes about death
b. Woman who, during a past episode of major depression, attempted suicide
c. Adolescent who just broke up with her boyfriend and states that she would like to kill
herself
d. Older adult man who tells the nurse that he is going to "join his wife in heaven"
tomorrow and plans to use a gun
When assessing the pupillary light reflex, the nurse should use which technique?
a. Shine a penlight from directly in front of the patient, and inspect for pupillary
constriction.
b. Ask the patient to follow the penlight in eight directions, and observe for bilateral
pupil constriction.
c. Shine a light across the pupil from the side, and observe for direct and consensual
pupillary constriction.
d. Ask the patient to focus on a distant object. Then ask the patient to follow the
penlight to approximately 7 cm from the nose.
When providing culturally competent care, nurses must incorporate cultural
assessments into their health assessments. Which statement is most appropriate to use
when initiating an assessment of cultural beliefs with an older American-Indian patient?
a. "Are you of the Christian faith?"
b. "Do you want to see a medicine man?"
c. "How often do you seek help from medical providers?"
d. "What cultural or spiritual beliefs are important to you?"
A patient is complaining of pain in his joints that is worse in the morning, better after he
moves around for a while, and then gets worse again if he sits for long periods. The
nurse should assess for other signs of what problem?
a. Tendinitis
b. Osteoarthritis
c. Rheumatoid arthritis
d. Intermittent claudication
A patient is unable to read even the largest letters on the Snellen chart. The nurse should
take which action next?
a. Refer the patient to an ophthalmologist or optometrist for further evaluation.
b. Assess whether the patient can count the nurse's fingers when they are placed in front
of his or her eyes.
c. Ask the patient to put on his or her reading glasses and attempt to read the Snellen
chart again.
d. Shorten the distance between the patient and the chart until the letters are seen, and
record that distance.
The nurse needs to palpate the temporomandibular joint for crepitation. This joint is
located just below the temporal artery and anterior to the:
a. Hyoid bone.
b. Vagus nerve.
c. Tragus.
d. Mandible.
When reviewing the demographics of ethnic groups in the United States, the nurse
recalls that the largest and fastest growing population is:
a. Hispanic.
b. Black.
c. Asian.
d. American Indian.
A 67-year-old patient states that he recently began to have pain in his left calf when
climbing the 10 stairs to his apartment. This pain is relieved by sitting for
approximately 2 minutes; then he is able to resume his activities. The nurse interprets
that this patient is most likely experiencing:
a. Claudication.
b. Sore muscles.
c. Muscle cramps.
d. Venous insufficiency.
A 25-year-old woman comes to the emergency department with a sudden fever of 38.3
C and abdominal pain. Upon examination, the nurse notices that she has rigid, boardlike
lower abdominal musculature. When the nurse tries to perform a vaginal examination,
the patient has severe pain when the uterus and cervix are moved. The nurse knows that
these signs and symptoms are suggestive of:
a. Endometriosis.
b. Uterine fibroids.
c. Ectopic pregnancy.
d. Pelvic inflammatory disease.
When assessing a patient's pulse, the nurse notes that the amplitude is weaker during
inspiration and stronger during expiration. When the nurse measures the blood pressure,
the reading decreases 20 mm Hg during inspiration and increases with expiration. This
patient is experiencing pulsus:
a. Alternans.
b. Bisferiens.
c. Bigeminus.
d. Paradoxus.
During an oral examination of a 4-year-old Native-American child, the nurse notices
that her uvula is partially split. Which of these statements is accurate?
a. This condition is a cleft palate and is common in Native Americans.
b. A bifid uvula may occur in some Native-American groups.
c. This condition is due to an injury and should be reported to the authorities.
d. A bifid uvula is palatinus, which frequently occurs in Native Americans.
The nurse makes this comment to a patient, "I know it may be hard, but you should do
what the doctor ordered because she is the expert in this field." Which statement is
correct about the nurse's comment?
a. This comment is inappropriate because it shows the nurse's bias.
b. This comment is appropriate because members of the health care team are experts in
their area of patient care.
c. This type of comment promotes dependency and inferiority on the part of the patient
and is best avoided in an interview situation.
d. Using authority statements when dealing with patients, especially when they are
undecided about an issue, is necessary at times.
During a mental status assessment, which question by the nurse would best assess a
person's judgment?
a. "Do you feel that you are being watched, followed, or controlled?"
b. "Tell me what you plan to do once you are discharged from the hospital."
c. "What does the statement, "People in glass houses shouldn"t throw stones," mean to
you?"
d. "What would you do if you found a stamped, addressed envelope lying on the
sidewalk?"
A woman brings her husband to the clinic for an examination. She is particularly
worried because after a recent fall, he seems to have lost a great deal of his memory of
recent events. Which statement reflects the nurse's best course of action?
a. Perform a complete mental status examination.
b. Refer him to a psychometrician.
c. Plan to integrate the mental status examination into the history and physical
examination.
d. Reassure his wife that memory loss after a physical shock is normal and will soon
subside.
A patient's vision is recorded as 20/80 in each eye. The nurse interprets this finding to
mean that the patient:
a. Has poor vision.
b. Has acute vision.
c. Has normal vision.
d. Is presbyopic.
Which term refers to a wound produced by the tearing or splitting of body tissue,
usually from blunt impact over a bony surface?
a. Abrasion
b. Contusion
c. Laceration
d. Hematoma
The nurse is reviewing the nutritional assessment of an 82-year-old patient. Which of
these factors will most likely affect the nutritional status of an older adult?
a. Increase in taste and smell
b. Living alone on a fixed income
c. Change in cardiovascular status
d. Increase in gastrointestinal motility and absorption
When performing an examination of a woman who is 34 weeks' pregnant, the nurse
notices a midline linear protrusion in the abdomen over the area of the rectus abdominis
muscles as the woman raises her head and shoulders off of the bed. Which response by
the nurse is correct?
a. The presence of diastasis recti should be documented.
b. This condition should be discussed with the physician because it will most likely
need to be surgically repaired.
c. The possibility that the woman has a hernia attributable to the increased pressure
within the abdomen from the pregnancy should be suspected.
d. The woman should be told that she may have a difficult time with delivery because of
the weakness in her abdominal muscles.
A patient who is 20 weeks' pregnant tells the nurse that she feels more shortness of
breath as her pregnancy progresses. The nurse recognizes which statement to be true?
a. High levels of estrogen cause shortness of breath.
b. Feelings of shortness of breath are abnormal during pregnancy.
c. Hormones of pregnancy cause an increased respiratory effort.
d. The patient should get more exercise in an attempt to increase her respiratory reserve.
An older Mexican-American woman with traditional beliefs has been admitted to an
inpatient care unit. A culturally sensitive nurse would:
a. Contact the hospital administrator about the best course of action.
b. Automatically get a curandero for her, because requesting one herself is not culturally
appropriate.
c. Further assess the patient's cultural beliefs and offer the patient assistance in
contacting a curandero or priest if she desires.
d. Ask the family what they would like to do because Mexican-Americans traditionally
give control of decision making to their families.
A patient has had a cerebrovascular accident (stroke). He is trying very hard to
communicate. He seems driven to speak and says, "I buy obie get spirding and take my
train." What is the best description of this patient's problem?
a. Global aphasia
b. Broca's aphasia
c. Echolalia
d. Wernicke's aphasia
The nurse recognizes that working with children with a different cultural perspective
may be especially difficult because:
a. Children have spiritual needs that are influenced by their stages of development.
b. Children have spiritual needs that are direct reflections of what is occurring in their
homes.
c. Religious beliefs rarely affect the parents' perceptions of the illness.
d. Parents are often the decision makers, and they have no knowledge of their children's
spiritual needs.
The nurse is preparing for a certification course in skin care and needs to be familiar
with the various lesions that may be identified on assessment of the skin. Which of the
following definitions are correct? Select all that apply.
a. Petechiae: Tiny punctate hemorrhages, 1 to 3 mm, round and discrete, dark red,
purple, or brown in color
b. Bulla: Elevated, circumscribed lesion filled with turbid fluid (pus)
c. Papule: Hypertrophic scar
d. Vesicle: Known as a friction blister
e. Nodule: Solid, elevated, and hard or soft growth that is larger than 1 cm
A patient drifts off to sleep when she is not being stimulated. The nurse can easily
arouse her by calling her name, but the patient remains drowsy during the conversation.
The best description of this patient's level of consciousness would be:
a. Lethargic
b. Obtunded
c. Stuporous
d. Semialert
A patient has come in for an examination and states, "I have this spot in front of my ear
lobe on my cheek that seems to be getting bigger and is tender. What do you think it
is?" The nurse notes swelling below the angle of the jaw and suspects that it could be an
inflammation of his:
a. Thyroid gland.
b. Parotid gland.
c. Occipital lymph node.
d. Submental lymph node.
During an oral assessment of a 30-year-old Black patient, the nurse notices bluish lips
and a dark line along the gingival margin. What action would the nurse perform in
response to this finding?
a. Check the patient's hemoglobin for anemia.
b. Assess for other signs of insufficient oxygen supply.
c. Proceed with the assessment, knowing that this appearance is a normal finding.
d. Ask if he has been exposed to an excessive amount of carbon monoxide.
The nurse suspects abuse when a 10-year-old child is taken to the urgent care center for
a leg injury. The best way to document the history and physical findings is to:
a. Document what the child's caregiver tells the nurse.
b. Use the words the child has said to describe how the injury occurred.
c. Record what the nurse observes during the conversation.
d. Rely on photographs of the injuries.
The nurse is assessing the breasts of a 68-year-old woman and discovers a mass in the
upper outer quadrant of the left breast. When assessing this mass, the nurse is aware
that characteristics of a cancerous mass include which of the following? Select all that
apply.
a. Nontender mass
b. Dull, heavy pain on palpation
c. Rubbery texture and mobile
d. Hard, dense, and immobile
e. Regular border
f. Irregular, poorly delineated border
