The nurse is reviewing statistics regarding breast cancer. Which woman, aged 40 years
in the United States, has the highest risk for developing breast cancer?
a. Black
b. White
c. Asian
d. American Indian
The nurse is aware that intimate partner violence (IPV) screening should occur with
which situation?
a. When IPV is suspected
b. When a woman has an unexplained injury
c. As a routine part of each health care encounter
d. When a history of abuse in the family is known
The nurse is percussing the seventh right intercostal space at the midclavicular line over
the liver. Which sound should the nurse expect to hear?
a. Dullness
b. Tympany
c. Resonance
d. Hyperresonance
The nurse is performing a mental status examination. Which statement is true regarding
the assessment of mental status?
a. Mental status assessment diagnoses specific psychiatric disorders.
b. Mental disorders occur in response to everyday life stressors.
c. Mental status functioning is inferred through the assessment of an individual’s
behaviors.
d. Mental status can be directly assessed, similar to other systems of the body (e.g.,
heart sounds, breath sounds).
The functional units of the musculoskeletal system are the:
a. Joints.
b. Bones.
c. Muscles.
d. Tendons.
During an assessment of the newborn, the nurse expects to see which finding when the
anal area is slightly stroked?
a. Jerking of the legs
b. Flexion of the knees
c. Quick contraction of the sphincter
d. Relaxation of the external sphincter
The nurse is performing percussion during an abdominal assessment. Percussion notes
heard during the abdominal assessment may include:
a. Flatness, resonance, and dullness.
b. Resonance, dullness, and tympany.
c. Tympany, hyperresonance, and dullness.
d. Resonance, hyperresonance, and flatness.
The nurse is assessing an 80-year-old male patient. Which assessment findings would
be considered normal?
a. Increase in body weight from his younger years
b. Additional deposits of fat on the thighs and lower legs
c. Presence of kyphosis and flexion in the knees and hips
d. Change in overall body proportion, including a longer trunk and shorter extremities
A 60-year-old man has just been told that he has benign prostatic hypertrophy (BPH).
He has a friend who just died from cancer of the prostate. He is concerned this will
happen to him. How should the nurse respond?
a. “The swelling in your prostate is only temporary and will go away.”
b. “We will treat you with chemotherapy so we can control the cancer.”
c. “It would be very unusual for a man your age to have cancer of the prostate.”
d. “The enlargement of your prostate is caused by hormonal changes, and not cancer.”
A patient is describing his symptoms to the nurse. Which of these statements reflects a
description of the setting of his symptoms?
a. “It is a sharp, burning pain in my stomach.”
b. “I also have the sweats and nausea when I feel this pain.”
c. “I think this pain is telling me that something bad is wrong with me.”
d. “This pain happens every time I sit down to use the computer.”
When assessing a newborn infant’s genitalia, the nurse notices that the genitalia are
somewhat engorged. The labia majora are swollen, the clitoris looks large, and the
hymen is thick. The vaginal opening is difficult to visualize. The infant’s mother states
that she is worried about the labia being swollen. The nurse should reply:
a. “This is a normal finding in newborns and should resolve within a few weeks.”
b. “This finding could indicate an abnormality and may need to be evaluated by a
physician.”
c. “We will need to have estrogen levels evaluated to ensure that they are within normal
limits.”
d. “We will need to keep close watch over the next few days to see if the genitalia
decrease in size.”
The nurse is assessing a patient’s ischial tuberosity. To palpate the ischial tuberosity, the
nurse knows that it is best to have the patient:
a. Standing.
b. Flexing the hip.
c. Flexing the knee.
d. Lying in the supine position.
The nurse is assessing the pulses of a patient who has been admitted for untreated
hyperthyroidism. The nurse should expect to find a(n) _______ pulse.
a. Normal
b. Absent
c. Bounding
d. Weak, thready
A 23-year-old patient in the clinic appears anxious. Her speech is rapid, and she is
fidgety and in constant motion. Which of these questions or statements would be most
appropriate for the nurse to use in this situation to assess attention span?
a. “How do you usually feel? Is this normal behavior for you?”
b. “I am going to say four words. In a few minutes, I will ask you to recall them.”
c. “Describe the meaning of the phrase, “Looking through rose-colored glasses.””
d. “Pick up the pencil in your left hand, move it to your right hand, and place it on the
table.”
When examining the nares of a 45-year-old patient who has complaints of rhinorrhea,
itching of the nose and eyes, and sneezing, the nurse notices the following: pale
turbinates, swelling of the turbinates, and clear rhinorrhea. Which of these conditions is
most likely the cause?
a. Nasal polyps
b. Acute sinusitis
c. Allergic rhinitis
d. Acute rhinitis
A 35-year-old recent immigrant is being seen in the clinic for complaints of a cough
that is associated with rust-colored sputum, low-grade afternoon fevers, and night
sweats for the past 2 months. The nurse’s preliminary analysis, based on this history, is
that this patient may be suffering from:
a. Bronchitis.
b. Pneumonia.
c. Tuberculosis.
d. Pulmonary edema.
Fibrous bands running directly from one bone to another that strengthen the joint and
help prevent movement in undesirable directions are called:
a. Bursa.
b. Tendons.
c. Cartilage.
d. Ligaments.
When assessing a patient’s general appearance, the nurse should include which
question?
a. Is the patient’s muscle strength equal in both arms?
b. Is ptosis or facial droop present?
c. Does the patient appropriately respond to questions?
d. Are the pupils equal in reaction and size?
A patient contacts the office and tells the nurse that she is worried about her 10-year-old
daughter having breast cancer. She describes a unilateral enlargement of the right breast
with associated tenderness. She is worried because the left breast is not enlarged. What
would be the nurse’s best response? Tell the mother that:
a. Breast development is usually fairly symmetric and that the daughter should be
examined right away.
b. She should bring in her daughter right away because breast cancer is fairly common
in preadolescent girls.
c. Although an examination of her daughter would rule out a problem, her breast
development is most likely normal.
d. It is unusual for breasts that are first developing to feel tender because they haven”t
developed much fibrous tissue.
The projections in the nasal cavity that increase the surface area are called the:
a. Meatus.
b. Septum.
c. Turbinates.
d. Kiesselbach plexus.
Which of these statements is true regarding the vertebra prominens? The vertebra
prominens is:
a. The spinous process of C7.
b. Usually nonpalpable in most individuals.
c. Opposite the interior border of the scapula.
d. Located next to the manubrium of the sternum.
A woman who is in the second trimester of pregnancy mentions that she has had “more
nosebleeds than ever” since she became pregnant. The nurse recognizes that this is a
result of:
a. A problem with the patient’s coagulation system.
b. Increased vascularity in the upper respiratory tract as a result of the pregnancy.
c. Increased susceptibility to colds and nasal irritation.
d. Inappropriate use of nasal sprays.
The nurse is examining an infant and prepares to elicit the Moro reflex at which time
during the examination?
a. When the infant is sleeping
b. At the end of the examination
c. Before auscultation of the thorax
d. Halfway through the examination
The nurse is preparing to perform an otoscopic examination of a newborn infant. Which
statement is true regarding this examination?
a. Immobility of the drum is a normal finding.
b. An injected membrane would indicate an infection.
c. The normal membrane may appear thick and opaque.
d. The appearance of the membrane is identical to that of an adult.
During an examination of a patient in her third trimester of pregnancy, the nurse notices
that the patient’s thyroid gland is slightly enlarged. No enlargement had been previously
noticed. The nurse suspects that the patient:
a. Has an iodine deficiency.
b. Is exhibiting early signs of goiter.
c. Is exhibiting a normal enlargement of the thyroid gland during pregnancy.
d. Needs further testing for possible thyroid cancer.
When assessing the neonate, the nurse should test for hip stability with which method?
a. Eliciting the Moro reflex
b. Performing the Romberg test
c. Checking for the Ortolani sign
d. Assessing the stepping reflex
When assessing a patient, the nurse notes that the left femoral pulse as diminished,
1+/4+. What should the nurse do next?
a. Document the finding.
b. Auscultate the site for a bruit.
c. Check for calf pain.
d. Check capillary refill in the toes.
During an examination, the nurse finds that a patient has excessive dryness of the skin.
The best term to describe this condition is:
a. Xerosis.
b. Pruritus.
c. Alopecia.
d. Seborrhea.
The nurse is auscultating the lungs of a patient who had been sleeping and notices short,
popping, crackling sounds that stop after a few breaths. The nurse recognizes that these
breath sounds are:
a. Atelectatic crackles that do not have a pathologic cause.
b. Fine crackles and may be a sign of pneumonia.
c. Vesicular breath sounds.
d. Fine wheezes.
A patient has been diagnosed with strep throat. The nurse is aware that without
treatment, which complication may occur?
a. Rubella
b. Leukoplakia
c. Rheumatic fever
d. Scarlet fever
The ability that humans have to perform very skilled movements such as writing is
controlled by the:
a. Basal ganglia.
b. Corticospinal tract.
c. Spinothalamic tract.
d. Extrapyramidal tract.
An examiner is using an ophthalmoscope to examine a patient’s eyes. The patient has
astigmatism and is nearsighted. The use of which of these techniques would indicate
that the examination is being correctly performed?
a. Using the large full circle of light when assessing pupils that are not dilated
b. Rotating the lens selector dial to the black numbers to compensate for astigmatism
c. Using the grid on the lens aperture dial to visualize the external structures of the eye
d. Rotating the lens selector dial to bring the object into focus
While performing an assessment of a 65-year-old man with a history of hypertension
and coronary artery disease, the nurse notices the presence of bilateral pitting edema in
the lower legs. The skin is puffy and tight but normal in color. No increased redness or
tenderness is observed over his lower legs, and the peripheral pulses are equal and
strong. In this situation, the nurse suspects that the likely cause of the edema is which
condition?
a. Heart failure
b. Venous thrombosis
c. Local inflammation
d. Blockage of lymphatic drainage