A patient with pleuritis has been admitted to the hospital and complains of pain with
breathing. What other key assessment finding would the nurse expect to find upon
auscultation?
a. Stridor
b. Friction rub
c. Crackles
d. Wheezing
When considering the concepts related to blood pressure, the nurse knows that the
concept of mean arterial pressure (MAP) is best described by which statement?
a. MAP is the pressure of the arterial pulse.
b. MAP reflects the stroke volume of the heart.
c. MAP is the pressure forcing blood into the tissues, averaged over the cardiac cycle.
d. MAP is an average of the systolic and diastolic blood pressures and reflects tissue
perfusion.
When performing a musculoskeletal assessment, the nurse knows that the correct
approach for the examination should be:
a. Proximal to distal.
b. Distal to proximal.
c. Posterior to anterior.
d. Anterior to posterior.
A 16-year-old boy is brought to the clinic for a problem that he refused to let his mother
see. The nurse examines him, and finds that he has scrotal swelling on the left side. He
had the mumps the previous week, and the nurse suspects that he has orchitis. Which of
the following assessment findings support this diagnosis? Select all that apply.
a. Swollen testis
b. Mass that transilluminates
c. Mass that does not transilluminate
d. Scrotum that is nontender upon palpation
e. Scrotum that is tender upon palpation
f. Scrotal skin that is reddened
The nurse is providing instructions to newly hired graduates for the mini”mental state
examination (MMSE). Which statement best describes this examination?
a. Scores below 30 indicate cognitive impairment.
b. The MMSE is a good tool to evaluate mood and thought processes.
c. This examination is a good tool to detect delirium and dementia and to differentiate
these from psychiatric mental illness.
d. The MMSE is useful tool for an initial evaluation of mental status. Additional tools
are needed to evaluate cognition changes over time.
During an examination, the nurse notices that a male patient has a red, round,
superficial ulcer with a yellowish serous discharge on his penis. On palpation, the nurse
finds a nontender base that feels like a small button between the thumb and fingers. At
this point the nurse suspects that this patient has:
a. Genital warts.
b. Herpes infection.
c. Syphilitic chancre.
d. Carcinoma lesion.
A patient who is in her first trimester of pregnancy tells the nurse that she is
experiencing significant nausea and vomiting and asks when it will improve. The nurse
should reply:
a. “Did your mother have significant nausea and vomiting?”
b. “Many women experience nausea and vomiting until the third trimester.”
c. “Usually, by the beginning of the second trimester, the nausea and vomiting
improve.”
d. “At approximately the time you begin to feel the baby move, the nausea and
vomiting will subside.”
The nurse is assessing the mental status of a child. Which statement about children and
mental status is true?
a. All aspects of mental status in children are interdependent.
b. Children are highly labile and unstable until the age of 2 years.
c. Children’s mental status is largely a function of their parents’ level of functioning
until the age of 7 years.
d. A child’s mental status is impossible to assess until the child develops the ability to
concentrate.
Which of these statements is true regarding the penis?
a. The urethral meatus is located on the ventral side of the penis.
b. The prepuce is the fold of foreskin covering the shaft of the penis.
c. The penis is made up of two cylindrical columns of erectile tissue.
d. The corpus spongiosum expands into a cone of erectile tissue called the glans.
The nurse has just completed a lymph node assessment on a 60-year-old healthy female
patient. The nurse knows that most lymph nodes in healthy adults are normally:
a. Shotty.
b. Nonpalpable.
c. Large, firm, and fixed to the tissue.
d. Rubbery, discrete, and mobile.
A patient is being seen at the clinic for her 10-week prenatal visit. She asks when she
will be able to hear the baby’s heartbeat. The nurse should reply:
a. “The baby’s heartbeat is not usually heard until the second trimester.”
b. “The baby’s heartbeat may be heard anywhere from the ninth to the twelfth week.”
c. “It is often difficult to hear the heartbeat at this point, but we can try.”
d. “It is normal to hear the heartbeat at 6 weeks. We may be able to hear it today.”
The nurse is performing a nutritional assessment on a 15-year-old girl who tells the
nurse that she is ‘so fat.” Assessment reveals that she is 5 feet 4 inches and weighs 110
pounds. The nurse’s appropriate response would be:
a. “How much do you think you should weigh?”
b. “Don”t worry about it; you”re not that overweight.”
c. “The best thing for you would be to go on a diet.”
d. “I used to always think I was fat when I was your age.”
The nurse is preparing to measure the length, weight, chest, and head circumference of
a 6-month-old infant. Which measurement technique is correct?
a. Measuring the infant’s length by using a tape measure
b. Weighing the infant by placing him or her on an electronic standing scale
c. Measuring the chest circumference at the nipple line with a tape measure
d. Measuring the head circumference by wrapping the tape measure over the nose and
cheekbones
The component of the conduction system referred to as the pacemaker of the heart is
the:
a. Atrioventricular (AV) node.
b. Sinoatrial (SA) node.
c. Bundle of His.
d. Bundle branches.
During the interview with a female patient, the nurse gathers data that indicate the
patient is perimenopausal. Which of these statements made by this patient leads to this
conclusion?
a. “I have noticed that my muscles ache at night when I go to bed.”
b. “I will be very happy when I can stop worrying about having a period.”
c. “I have been noticing that I sweat a lot more than I used to, especially at night.”
d. “I have only been pregnant twice, but both times I had breast tenderness as my first
symptom.”
When the nurse is evaluating the reliability of a patient’s responses, which of these
statements would be correct? The patient:
a. Has a history of drug abuse and therefore is not reliable.
b. Provided consistent information and therefore is reliable.
c. Smiled throughout interview and therefore is assumed reliable.
d. Would not answer questions concerning stress and therefore is not reliable.
The nurse is reviewing the principles of nociception. During which phase of
nociception does the conscious awareness of a painful sensation occur?
a. Perception
b. Modulation
c. Transduction
d. Transmission
What step of the nursing process includes data collection by health history, physical
examination, and interview?
a. Planning
b. Diagnosis
c. Evaluation
d. Assessment
The nurse is aware that the four areas in the body where lymph nodes are accessible are
the:
a. Head, breasts, groin, and abdomen.
b. Arms, breasts, inguinal area, and legs.
c. Head and neck, arms, breasts, and axillae.
d. Head and neck, arms, inguinal area, and axillae.
A man who was found wandering in a park at 2 AM has been brought to the emergency
department for an examination; he said he fell and hit his head. During the examination,
the nurse asks him to use his index finger to touch the nurse’s finger, then his own nose,
then the nurse’s finger again (which has been moved to a different location). The patient
is clumsy, unable to follow the instructions, and overshoots the mark, missing the
finger. The nurse should suspect which of the following?
a. Cerebral injury
b. Cerebrovascular accident
c. Acute alcohol intoxication
d. Peripheral neuropathy
The nurse is examining only the rectal area of a woman and should place the woman in
what position?
a. Lithotomy
b. Prone
c. Left lateral decubitus
d. Bending over the table while standing
The nurse is preparing to perform a physical assessment. The correct action by the
nurse is reflected by which statement? The nurse:
a. Performs the examination from the left side of the bed.
b. Examines tender or painful areas first to help relieve the patient’s anxiety.
c. Follows the same examination sequence, regardless of the patient’s age or condition.
d. Organizes the assessment to ensure that the patient does not change positions too
often.
The nurse is teaching a pregnant woman about breast milk. Which statement by the
nurse is correct?
a. “Your breast milk is immediately present after the delivery of your baby.”
b. “Breast milk is rich in protein and sugars (lactose) but has very little fat.”
c. “The colostrum, which is present right after birth, does not contain the same nutrients
as breast milk.”
d. “You may notice a thick, yellow fluid expressed from your breasts as early as the
fourth month of pregnancy.”
The nurse is examining a 35-year-old female patient. During the health history, the
nurse notices that she has had two term pregnancies, and both babies were delivered
vaginally. During the internal examination, the nurse observes that the cervical os is a
horizontal slit with some healed lacerations and that the cervix has some nabothian
cysts that are small, smooth, and yellow. In addition, the nurse notices that the cervical
surface is granular and red, especially around the os. Finally, the nurse notices the
presence of stringy, opaque, odorless secretions. Which of these findings are abnormal?
a. Nabothian cysts are present.
b. The cervical os is a horizontal slit.
c. The cervical surface is granular and red.
d. Stringy and opaque secretions are present.
A patient has been admitted to the emergency department for a suspected drug
overdose. His respirations are shallow, with an irregular pattern, with a rate of 12
respirations per minute. The nurse interprets this respiration pattern as which of the
following?
a. Bradypnea
b. Cheyne-Stokes respirations
c. Hypoventilation
d. Chronic obstructive breathing
The nurse is palpating the abdomen of a woman who is 35 weeks’ pregnant and notices
that the fetal head is facing downward toward the pelvis. The nurse would document
this as fetal:
a. Lie.
b. Variety.
c. Attitude.
d. Presentation.
The nurse is assessing for inflammation in a dark-skinned person. Which technique is
the best?
a. Assessing the skin for cyanosis and swelling
b. Assessing the oral mucosa for generalized erythema
c. Palpating the skin for edema and increased warmth
d. Palpating for tenderness and local areas of ecchymosis
When observing a patient’s verbal and nonverbal communication, the nurse notices a
discrepancy. Which statement is true regarding this situation? The nurse should:
a. Ask someone who knows the patient well to help interpret this discrepancy.
b. Focus on the patient’s verbal message, and try to ignore the nonverbal behaviors.
c. Try to integrate the verbal and nonverbal messages and then interpret them as an
average.
d. Focus on the patient’s nonverbal behaviors, because these are often more reflective of
a patient’s true feelings.
When measuring a patient’s body temperature, the nurse keeps in mind that body
temperature is influenced by:
a. Constipation.
b. Patient’s emotional state.
c. Diurnal cycle.
d. Nocturnal cycle.
The nurse is palpating a female patient’s breasts during an examination. Which of these
positions is most likely to make significant lumps more distinct during breast palpation?
a. Supine with the arms raised over her head
b. Sitting with the arms relaxed at her sides
c. Supine with the arms relaxed at her sides
d. Sitting with the arms flexed and fingertips touching her shoulders
The nurse is performing an otoscopic examination on an adult. Which of these actions
is correct?
a. Tilting the person’s head forward during the examination
b. Once the speculum is in the ear, releasing the traction
c. Pulling the pinna up and back before inserting the speculum
d. Using the smallest speculum to decrease the amount of discomfort
During the examination portion of a patient’s visit, she will be in lithotomy position.
Which statement reflects some things that the nurse can do to make this position more
comfortable for her?
a. Ask her to place her hands and arms over her head.
b. Elevate her head and shoulders to maintain eye contact.
c. Allow her to choose to have her feet in the stirrups or have them resting side by side
on the edge of the table.
d. Allow her to keep her buttocks approximately 6 inches from the edge of the table to
prevent her from feeling as if she will fall off.
The nurse notices that a patient has had a black, tarry stool and recalls that a possible
cause would be:
a. Gallbladder disease.
b. Overuse of laxatives.
c. Gastrointestinal bleeding.
d. Localized bleeding around the anus.