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The nurse is preparing to assess an older adult and discovers that the older adult is in
severe pain. Which statement about pain and the older adult is true?
a. Pain is inevitable with aging.
b. Older adults with cognitive impairments feel less pain.
c. Alleviating pain should be a priority over other aspects of the assessment.
d. The assessment should take priority so that care decisions can be made.
A woman has just learned that she is pregnant. What are some things the nurse should
teach her about her breasts?
a. She can expect her areolae to become larger and darker in color.
b. Breasts may begin secreting milk after the fourth month of pregnancy.
c. She should inspect her breasts for visible veins and immediately report these.
d. During pregnancy, breast changes are fairly uncommon; most of the changes occur
after the birth.
A 55-year-old postmenopausal woman is being seen in the clinic for her annual
examination. She is concerned about changes in her breasts that she has noticed over
the past 5 years. She states that her breasts have decreased in size and that the elasticity
has changed so that her breasts seem "flat and flabby." The nurse's best reply would be:
a. "This change occurs most often because of long-term use of bras that do not provide
enough support to the breast tissues."
b. "This is a normal change that occurs as women get older and is due to the increased
levels of progesterone during the aging process."
c. "Decreases in hormones after menopause causes atrophy of the glandular tissue in the
breast and is a normal process of aging."
d. "Postural changes in the spine make it appear that your breasts have changed in
shape. Exercises to strengthen the muscles of the upper back and chest wall will help
prevent the changes in elasticity and size."
During the cardiac auscultation, the nurse hears a sound immediately occurring after the
S2 at the second left intercostal space. To further assess this sound, what should the
nurse do?
a. Have the patient turn to the left side while the nurse listens with the bell of the
stethoscope.
b. Ask the patient to hold his or her breath while the nurse listens again.
c. No further assessment is needed because the nurse knows this sound is an S3.
d. Watch the patient's respirations while listening for the effect on the sound.
The nurse notices that a patient's submental lymph nodes are enlarged. In an effort to
identify the cause of the node enlargement, the nurse would assess the patient's:
a. Infraclavicular area.
b. Supraclavicular area.
c. Area distal to the enlarged node.
d. Area proximal to the enlarged node.
When the nurse performs the confrontation test, the nurse has assessed:
a. Extraocular eye muscles (EOMs).
b. Pupils (pupils equal, round, reactive to light, and accommodation [PERRLA]).
c. Near vision.
d. Visual fields.
A student is late for his appointment and has rushed across campus to the health clinic.
The nurse should:
a. Allow 5 minutes for him to relax and rest before checking his vital signs.
b. Check the blood pressure in both arms, expecting a difference in the readings because
of his recent exercise.
c. Immediately monitor his vital signs on his arrival at the clinic and then 5 minutes
later, recording any differences.
d. Check his blood pressure in the supine position, which will provide a more accurate
reading and will allow him to relax at the same time.
During the interview, a patient reveals that she has some vaginal discharge. She is
worried that it may be a sexually transmitted infection. The nurse's most appropriate
response to this would be:
a. "Oh, don"t worry. Some cyclic vaginal discharge is normal."
b. "Have you been engaging in unprotected sexual intercourse?"
c. "I"d like some information about the discharge. What color is it?"
d. "Have you had any urinary incontinence associated with the discharge?"
In a patient who has anisocoria, the nurse would expect to observe:
a. Dilated pupils.
b. Excessive tearing.
c. Pupils of unequal size.
d. Uneven curvature of the lens.
A 20-year-old construction worker has been brought into the emergency department
with heat stroke. He has delirium as a result of a fluid and electrolyte imbalance. For
the mental status examination, the nurse should first assess the patient's:
a. Affect and mood
b. Memory and affect
c. Language abilities
d. Level of consciousness and cognitive abilities
The nurse is reviewing concepts related to one's heritage and beliefs. The belief in
divine or superhuman power(s) to be obeyed and worshipped as the creator(s) and
ruler(s) of the universe is known as:
a. Culture.
b. Religion.
c. Ethnicity.
d. Spirituality.
A patient comes to the clinic complaining of a cough that is worse at night but not as
bad during the day. The nurse recognizes that this cough may indicate:
a. Pneumonia.
b. Postnasal drip or sinusitis.
c. Exposure to irritants at work.
d. Chronic bronchial irritation from smoking.
A patient's vision is recorded as 20/30 when the Snellen eye chart is used. The nurse
interprets these results to indicate that:
a. At 30 feet the patient can read the entire chart.
b. The patient can read at 20 feet what a person with normal vision can read at 30 feet.
c. The patient can read the chart from 20 feet in the left eye and 30 feet in the right eye.
d. The patient can read from 30 feet what a person with normal vision can read from 20
feet.
A patient is seen in the clinic for complaints of "fainting episodes that started last
week." How should the nurse proceed with the examination?
a. Blood pressure readings are taken in both the arms and the thighs.
b. The patient is assisted to a lying position, and his blood pressure is taken.
c. His blood pressure is recorded in the lying, sitting, and standing positions.
d. His blood pressure is recorded in the lying and sitting positions; these numbers are
then averaged to obtain a mean blood pressure.
A mother has noticed that her son, who has been to a new babysitter, has some blisters
and scabs on his face and buttocks. On examination, the nurse notices moist,
thin-roofed vesicles with a thin erythematous base and suspects:
a. Eczema.
b. Impetigo.
c. Herpes zoster.
d. Diaper dermatitis.
When performing the bimanual examination, the nurse notices that the cervix feels
smooth and firm, is round, and is fixed in place (does not move). When cervical
palpation is performed, the patient complains of some pain. The nurse's interpretation of
these results should be which of these?
a. These findings are all within normal limits.
b. Cervical consistency should be soft and velvetynot firm.
c. The cervix should move when palpated; an immobile cervix may indicate
malignancy.
d. Pain may occur during palpation of the cervix.
A mother asks when her newborn infant's eyesight will be developed. The nurse should
reply:
a. "Vision is not totally developed until 2 years of age."
b. "Infants develop the ability to focus on an object at approximately 8 months of age."
c. "By approximately 3 months of age, infants develop more coordinated eye
movements and can fixate on an object."
d. "Most infants have uncoordinated eye movements for the first year of life."
When examining a patient's eyes, the nurse recalls that stimulation of the sympathetic
branch of the autonomic nervous system:
a. Causes pupillary constriction.
b. Adjusts the eye for near vision.
c. Elevates the eyelid and dilates the pupil.
d. Causes contraction of the ciliary body.
The wife of a 65-year-old man tells the nurse that she is concerned because she has
noticed a change in her husband's personality and ability to understand. He also cries
very easily and becomes angry. The nurse recalls that the cerebral lobe responsible for
these behaviors is the __________ lobe.
a. Frontal
b. Parietal
c. Occipital
d. Temporal
The nurse notices a colleague is preparing to check the blood pressure of a patient who
is obese by using a standard-sized blood pressure cuff. The nurse should expect the
reading to:
a. Yield a falsely low blood pressure.
b. Yield a falsely high blood pressure.
c. Be the same, regardless of cuff size.
d. Vary as a result of the technique of the person performing the assessment.
When documenting IPV and elder abuse, the nurse should include:
a. Photographic documentation of the injuries.
b. Summary of the abused patient's statements.
c. Verbatim documentation of every statement made.
d. General description of injuries in the progress notes.
The mother of a 10-month-old infant tells the nurse that she has noticed that her son
becomes blue when he is crying and that the frequency of this is increasing. He is also
not crawling yet. During the examination the nurse palpates a thrill at the left lower
sternal border and auscultates a loud systolic murmur in the same area. What would be
the most likely cause of these findings?
a. Tetralogy of Fallot
b. Atrial septal defect
c. Patent ductus arteriosus
d. Ventricular septal defect
The nurse has discovered decreased skin turgor in a patient and knows that this finding
is expected in which condition?
a. Severe obesity
b. Childhood growth spurts
c. Severe dehydration
d. Connective tissue disorders such as scleroderma
For the first time, the nurse is seeing a patient who has no history of nutrition-related
problems. The initial nutritional screening should include which activity?
a. Calorie count of nutrients
b. Anthropometric measures
c. Complete physical examination
d. Measurement of weight and weight history
A patient is visiting the clinic for an evaluation of a swollen, painful knuckle. The nurse
notices that the knuckle above his ring on the left hand is swollen and that he is unable
to remove his wedding ring. This joint is called the _________ joint.
a. Interphalangeal
b. Tarsometatarsal
c. Metacarpophalangeal
d. Tibiotalar
A 13-year-old girl is visiting the clinic for a sports physical examination. The nurse
should remember to include which of these tests in the examination?
a. Testing for occult blood
b. Valsalva maneuver
c. Internal palpation of the anus
d. Inspection of the perianal area
During a health history, a 22-year old woman asks, "Can I get that vaccine for human
papilloma virus (HPV)? I have genital warts and I"d like them to go away!" What is the
nurse's best response?
a. "The HPV vaccine is for girls and women ages 9 to 26 years, so we can start that
today."
b. "This vaccine is only for girls who have not yet started to become sexually active."
c. "Let's check with the physician to see if you are a candidate for this vaccine."
d. "The vaccine cannot protect you if you already have an HPV infection."
A patient tells the nurse that he has noticed that one of his moles has started to burn and
bleed. When assessing his skin, the nurse pays special attention to the danger signs for
pigmented lesions and is concerned with which additional finding?
a. Color variation
b. Border regularity
c. Symmetry of lesions
d. Diameter of less than 6 mm
The nurse is performing an assessment on a 21-year-old patient and notices that his
nasal mucosa appears pale, gray, and swollen. What would be the most appropriate
question to ask the patient?
a. "Are you aware of having any allergies?"
b. "Do you have an elevated temperature?"
c. "Have you had any symptoms of a cold?"
d. "Have you been having frequent nosebleeds?"
The nurse is examining the lymphatic system of a healthy 3-year-old child. Which
finding should the nurse expect?
a. Excessive swelling of the lymph nodes
b. Presence of palpable lymph nodes
c. No palpable nodes because of the immature immune system of a child
d. Fewer numbers and a smaller size of lymph nodes compared with those of an adult
The nurse is testing the function of CN XI. Which statement best describes the response
the nurse should expect if this nerve is intact? The patient:
a. Demonstrates the ability to hear normal conversation.
b. Sticks out the tongue midline without tremors or deviation.
c. Follows an object with his or her eyes without nystagmus or strabismus.
d. Moves the head and shoulders against resistance with equal strength.
The nurse suspects that a patient has a distended bladder. How should the nurse assess
for this condition?
a. Percuss and palpate in the lumbar region.
b. Inspect and palpate in the epigastric region.
c. Auscultate and percuss in the inguinal region.
d. Percuss and palpate the midline area above the suprapubic bone.
In the health promotion model, the focus of the health professional includes:
a. Changing the patient's perceptions of disease.
b. Identifying biomedical model interventions.
c. Identifying negative health acts of the consumer.
d. Helping the consumer choose a healthier lifestyle.
When the nurse is interviewing a preadolescent girl, which opening question would be
least threatening?
a. "Do you have any questions about growing up?"
b. "What has your mother told you about growing up?"
c. "When did you notice that your body was changing?"
d. "I remember being very scared when I got my period. How do you think you"ll feel?"
