The nurse is giving report to the next shift and is using the situation, background,
assessment, recommendation (SBAR) framework for communication. Which of these
statements reflects the Background portion of the report?
a. “I”m worried that his gastrointestinal bleeding is getting worse.”
b. “We need an order for oxygen.”
c. “My name is Ms. Smith, and I”m giving the report on Mrs. X in room 1104.”
d. “He is 4 days postoperative, and his incision is open to air.”
A patient is unable to shrug her shoulders against the nurse’s resistant hands. What
cranial nerve is involved with successful shoulder shrugging?
a. VII
b. IX
c. XI
d. XII
Which characteristic of the prostate gland would the nurse recognize as an abnormal
finding while palpating the prostate gland through the rectum?
a. Palpable central groove
b. Tenderness to palpation
c. Heart shaped
d. Elastic and rubbery consistency
A woman who has just discovered that she is pregnant is in the clinic for her first
obstetric visit. She asks the nurse, “How many drinks a day is safe for my baby?” The
nurse’s best response is:
a. “You should limit your drinking to once or twice a week.”
b. “It’s okay to have up to two glasses of wine a day.”
c. “As long as you avoid getting drunk, you should be safe.”
d. “No amount of alcohol has been determined to be safe during pregnancy.”
Which of these conditions is due to an inadequate intake of both protein and calories?
a. Obesity
b. Bulimia
c. Marasmus
d. Kwashiorkor
The nurse is examining a 3-month-old infant. While the nurse holds his or her thumbs
on the infant’s inner mid thighs and the fingers on the outside of the infant’s hips,
touching the greater trochanter, the nurse adducts the legs until the his or her thumbs
touch and then abducts the legs until the infant’s knees touch the table. The nurse does
not notice any “clunking” sounds and is confident to record a:
a. Positive Allis test.
b. Negative Allis test.
c. Positive Ortolani sign.
d. Negative Ortolani sign.
A patient states, “I feel so sad all of the time. I can”t feel happy even doing things I used
to like to do.” He also states that he is tired, sleeps poorly, and has no energy. To
differentiate between a dysthymic disorder and a major depressive disorder, the nurse
should ask which question?
a. “Have you had any weight changes?”
b. “Are you having any thoughts of suicide?”
c. “How long have you been feeling this way?”
d. “Are you having feelings of worthlessness?”
The nurse is performing a middle ear assessment on a 15-year-old patient who has had a
history of chronic ear infections. When examining the right tympanic membrane, the
nurse sees the presence of dense white patches. The tympanic membrane is otherwise
unremarkable. It is pearly, with the light reflex at 5 o”clock and landmarks visible. The
nurse should:
a. Refer the patient for the possibility of a fungal infection.
b. Know that these are scars caused from frequent ear infections.
c. Consider that these findings may represent the presence of blood in the middle ear.
d. Be concerned about the ability to hear because of this abnormality on the tympanic
membrane.
A 31-year-old patient tells the nurse that he has noticed a progressive loss in his
hearing. He says that it does seem to help when people speak louder or if he turns up
the volume of a television or radio. The most likely cause of his hearing loss is:
a. Otosclerosis.
b. Presbycusis.
c. Trauma to the bones.
d. Frequent ear infections.