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The nurse is performing an assessment on an adult. The adult's vital signs are normal,
and capillary refill time is 5 seconds. What should the nurse do next?
a. Ask the patient about a history of frostbite.
b. Suspect that the patient has venous insufficiency.
c. Consider this a delayed capillary refill time, and investigate further.
d. Consider this a normal capillary refill time that requires no further assessment.
A patient states, "I can hear a crunching or grating sound when I kneel." She also states
that "it is very difficult to get out of bed in the morning because of stiffness and pain in
my joints." The nurse should assess for signs of what problem?
a. Crepitation
b. Bone spur
c. Loose tendon
d. Fluid in the knee joint
During an abdominal assessment, the nurse is unable to hear bowel sounds in a patient's
abdomen. Before reporting this finding as silent bowel sounds, the nurse should listen
for at least:
a. 1 minute.
b. 5 minutes.
c. 10 minutes.
d. 2 minutes in each quadrant.
During a class on the aspects of culture, the nurse shares that culture has four basic
characteristics. Which statement correctly reflects one of these characteristics?
a. Cultures are static and unchanging, despite changes around them.
b. Cultures are never specific, which makes them hard to identify.
c. Culture is most clearly reflected in a person's language and behavior.
d. Culture adapts to specific environmental factors and available natural resources.
During an examination, the nurse observes a female patient's vestibule and expects to
see the:
a. Urethral meatus and vaginal orifice.
b. Vaginal orifice and vestibular (Bartholin) glands.
c. Urethral meatus and paraurethral (Skene) glands.
d. Paraurethral (Skene) and vestibular (Bartholin) glands.
Put the following patient situations in order according to the level of priority.
a. A patient newly diagnosed with type 2 diabetes mellitus does not know how to check
his own blood glucose levels with a glucometer.
b. A teenager who was stung by a bee during a soccer match is having trouble
breathing.
c. An older adult with a urinary tract infection is also showing signs of confusion and
agitation.
1) a = First-level priority problem
2) b = Second-level priority problem
3) c = Third-level priority problem
The nurse is performing a digital examination of a patient's prostate gland and notices
that a normal prostate gland includes which of the following characteristics? Select all
that apply.
a. 1 cm protrusion into the rectum
b. Heart-shaped with a palpable central groove
c. Flat shape with no palpable groove
d. Boggy with a soft consistency
e. Smooth surface, elastic, and rubbery consistency
f. Fixed mobility
A 60-year-old woman has developed reflexive sympathetic dystrophy after arthroscopic
repair of her shoulder. A key feature of this condition is that the:
a. Affected extremity will eventually regain its function.
b. Pain is felt at one site but originates from another location.
c. Patient's pain will be associated with nausea, pallor, and diaphoresis.
d. Slightest touch, such as a sleeve brushing against her arm, causes severe and intense
pain.
A 69-year-old patient has been admitted to an adult psychiatric unit because his wife
thinks he is getting more and more confused. He laughs when he is found to be
forgetful, saying "I"m just getting old!" After the nurse completes a thorough
neurologic assessment, which findings would be indicative of Alzheimer disease?
Select all that apply.
a. Occasionally forgetting names or appointments
b. Difficulty performing familiar tasks, such as placing a telephone call
c. Misplacing items, such as putting dish soap in the refrigerator
d. Sometimes having trouble finding the right word
e. Rapid mood swings, from calm to tears, for no apparent reason
f. Getting lost in one's own neighborhood
During an assessment of an older adult, the nurse should expect to notice which finding
as a normal physiologic change associated with the aging process?
a. Hormonal changes causing vasodilation and a resulting drop in blood pressure
b. Progressive atrophy of the intramuscular calf veins, causing venous insufficiency
c. Peripheral blood vessels growing more rigid with age, producing a rise in systolic
blood pressure
d. Narrowing of the inferior vena cava, causing low blood flow and increases in venous
pressure resulting in varicosities
During a cardiovascular assessment, the nurse knows that an S4 heart sound is:
a. Heard at the onset of atrial diastole.
b. Usually a normal finding in the older adult.
c. Heard at the end of ventricular diastole.
d. Heard best over the second left intercostal space with the individual sitting upright.
During a bimanual examination, the nurse detects a solid tumor on the ovary that is
heavy and fixed, with a poorly defined mass. This finding is suggestive of:
a. Ovarian cyst.
b. Endometriosis.
c. Ovarian cancer.
d. Ectopic pregnancy.
During an examination, the nurse would expect the cervical os of a woman who has
never had children to appear:
a. Stellate.
b. Small and round.
c. As a horizontal irregular slit.
d. Everted.
An older adult patient in a nursing home has been receiving tube feedings for several
months. During an oral examination, the nurse notes that patient's gums are swollen,
ulcerated, and bleeding in some areas. The nurse suspects that the patient has what
condition?
a. Rickets
b. Vitamin A deficiency
c. Linoleic-acid deficiency
d. Vitamin C deficiency
While auscultating heart sounds, the nurse hears a murmur. Which of these instruments
should be used to assess this murmur?
a. Electrocardiogram
b. Bell of the stethoscope
c. Diaphragm of the stethoscope
d. Palpation with the nurse's palm of the hand
A patient's pregnancy test is positive, and she wants to know when the baby is due. The
first day of her last menstrual period was June 14, and that period ended June 20. Using
the Ngele rule, what is her expected date of delivery?
a. March 7
b. March 14
c. March 21
d. March 27
During a follow-up visit, the nurse discovers that a patient has not been taking his
insulin on a regular basis. The nurse asks, "Why haven"t you taken your insulin?"
Which statement is an appropriate evaluation of this question?
a. This question may place the patient on the defensive.
b. This question is an innocent search for information.
c. Discussing his behavior with his wife would have been better.
d. A direct question is the best way to discover the reasons for his behavior.
The nurse is performing a general survey of a patient. Which finding is considered
normal?
a. When standing, the patient's base is narrow.
b. The patient appears older than his stated age.
c. Arm span (fingertip to fingertip) is greater than the height.
d. Arm span (fingertip to fingertip) equals the patient's height.
A 45-year-old mother of two children is seen at the clinic for complaints of "losing my
urine when I sneeze." The nurse documents that she is experiencing:
a. Urinary frequency.
b. Enuresis.
c. Stress incontinence.
d. Urge incontinence.
The nurse keeps in mind that a thorough skin assessment is extremely important
because the skin holds information about a person's:
a. Support systems.
b. Circulatory status.
c. Socioeconomic status.
d. Psychological wellness.
In the assessment of a 1-month-old infant, the nurse notices a lack of response to noise
or stimulation. The mother reports that in the last week he has been sleeping all of the
time, and when he is awake all he does is cry. The nurse hears that the infant's cries are
very high pitched and shrill. What should be the nurse's appropriate response to these
findings?
a. Refer the infant for further testing.
b. Talk with the mother about eating habits.
c. Do nothing; these are expected findings for an infant this age.
d. Tell the mother to bring the baby back in 1 week for a recheck.
A 2-week-old infant can fixate on an object but cannot follow a light or bright toy. The
nurse would:
a. Consider this a normal finding.
b. Assess the pupillary light reflex for possible blindness.
c. Continue with the examination, and assess visual fields.
d. Expect that a 2-week-old infant should be able to fixate and follow an object.
When reviewing the use of alcohol by older adults, the nurse notes that older adults
have several characteristics that can increase the risk of alcohol use. Which would
increase the bioavailability of alcohol in the blood for longer periods in the older adult?
a. Increased muscle mass
b. Decreased liver and kidney functioning
c. Decreased blood pressure
d. Increased cardiac output
The nurse is reviewing information about evidence-based practice (EBP). Which
statement best reflects EBP?
a. EBP relies on tradition for support of best practices.
b. EBP is simply the use of best practice techniques for the treatment of patients.
c. EBP emphasizes the use of best evidence with the clinician's experience.
d. The patient's own preferences are not important with EBP.
The nurse is testing the hearing of a 78-year-old man and is reminded of the changes in
hearing that occur with aging that include which of the following? Select all that apply.
a. Hearing loss related to aging begins in the mid 40s.
b. Progression of hearing loss is slow.
c. The aging person has low-frequency tone loss.
d. The aging person may find it harder to hear consonants than vowels.
e. Sounds may be garbled and difficult to localize.
f. Hearing loss reflects nerve degeneration of the middle ear.
The nurse is asking questions about a patient's health beliefs. Which questions are
appropriate? Select all that apply.
a. "What is your definition of health?"
b. "Does your family have a history of cancer?"
c. "How do you describe illness?"
d. "What did your mother do to keep you from getting sick?"
e. "Have you ever had any surgeries?"
f. "How do you keep yourself healthy?"
Many Asians believe in the yin/yang theory, which is rooted in the ancient Chinese
philosophy of Tao. Which statement most accurately reflects "health" in an Asian with
this belief?
a. A person is able to work and produce.
b. A person is happy, stable, and feels good.
c. All aspects of the person are in perfect balance.
d. A person is able to care for others and function socially.
The nurse is assessing the body weight as a percentage of ideal body weight on an
adolescent patient who was admitted for suspected anorexia nervosa. The patient's usual
weight was 125 pounds, but today she weighs 98 pounds. The nurse calculates the
patient's ideal body weight and concludes that the patient is:
a. Experiencing mild malnutrition.
b. Experiencing moderate malnutrition.
c. Experiencing severe malnutrition.
d. Still within expected parameters with her current weight.
When the nurse is conducting sexual history from a male adolescent, which statement
would be most appropriate to use at the beginning of the interview?
a. "Do you use condoms?"
b. "You don"t masturbate, do you?"
c. "Have you had sex in the last 6 months?"
d. "Often adolescents your age have questions about sexual activity."
The nurse is performing a cardiac assessment on a 65-year-old patient 3 days after her
myocardial infarction (MI). Heart sounds are normal when she is supine, but when she
is sitting and leaning forward, the nurse hears a high-pitched, scratchy sound with the
diaphragm of the stethoscope at the apex. It disappears on inspiration. The nurse
suspects:
a. Increased cardiac output.
b. Another MI.
c. Inflammation of the precordium.
d. Ventricular hypertrophy resulting from muscle damage.
When performing a physical assessment, the first technique the nurse will always use
is:
a. Palpation.
b. Inspection.
c. Percussion.
d. Auscultation.
The nurse is conducting a class for new graduate nurses. During the teaching session,
the nurse should keep in mind that novice nurses, without a background of skills and
experience from which to draw, are more likely to make their decisions using:
a. Intuition.
b. A set of rules.
c. Articles in journals.
d. Advice from supervisors.
During a seminar on cultural aspects of nursing, the nurse recognizes that the definition
stating "the specific and distinct knowledge, beliefs, skills, and customs acquired by
members of a society" reflects which term?
a. Mores
b. Norms
c. Culture
d. Social learning
