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An older man is concerned about his sexual performance. The nurse knows that in the
absence of disease, a withdrawal from sexual activity later in life may be attributable to:
a. Side effects of medications.
b. Decreased libido with aging.
c. Decreased sperm production.
d. Decreased pleasure from sexual intercourse.
When assessing the pulse of a 6-year-old boy, the nurse notices that his heart rate varies
with his respiratory cycle, speeding up at the peak of inspiration and slowing to normal
with expiration. The nurse's next action would be to:
a. Immediately notify the physician.
b. Consider this finding normal in children and young adults.
c. Check the child's blood pressure, and note any variation with respiration.
d. Document that this child has bradycardia, and continue with the assessment.
A visiting nurse is making an initial home visit for a patient who has many chronic
medical problems. Which type of data base is most appropriate to collect in this setting?
a. A follow-up data base to evaluate changes at appropriate intervals
b. An episodic data base because of the continuing, complex medical problems of this
patient
c. A complete health data base because of the nurse's primary responsibility for
monitoring the patient's health
d. An emergency data base because of the need to collect information and make
accurate diagnoses rapidly
A woman in her 26th week of pregnancy states that she is "not really short of breath"
but feels that she is aware of her breathing and the need to breathe. What is the nurse's
best reply?
a. "The diaphragm becomes fixed during pregnancy, making it difficult to take in a deep
breath."
b. "The increase in estrogen levels during pregnancy often causes a decrease in the
diameter of the rib cage and makes it difficult to breathe."
c. "What you are experiencing is normal. Some women may interpret this as shortness
of breath, but it is a normal finding and nothing is wrong."
d. "This increased awareness of the need to breathe is normal as the fetus grows
because of the increased oxygen demand on the mother's body, which results in an
increased respiratory rate."
During an assessment, a patient tells the nurse that her fingers often change color when
she goes out in cold weather. She describes these episodes as her fingers first turning
white, then blue, then red with a burning, throbbing pain. The nurse suspects that she is
experiencing:
a. Lymphedema.
b. Raynaud disease.
c. Deep-vein thrombosis.
d. Chronic arterial insufficiency.
During an assessment, the nurse knows that expected assessment findings in the normal
adult lung include the presence of:
a. Adventitious sounds and limited chest expansion.
b. Increased tactile fremitus and dull percussion tones.
c. Muffled voice sounds and symmetric tactile fremitus.
d. Absent voice sounds and hyperresonant percussion tones.
Which statement concerning the areas of the brain is true?
a. The cerebellum is the center for speech and emotions.
b. The hypothalamus controls body temperature and regulates sleep.
c. The basal ganglia are responsible for controlling voluntary movements.
d. Motor pathways of the spinal cord and brainstem synapse in the thalamus.
The nurse suspects that a patient has carpal tunnel syndrome and wants to perform the
Phalen test. To perform this test, the nurse should instruct the patient to:
a. Dorsiflex the foot.
b. Plantarflex the foot.
c. Hold both hands back to back while flexing the wrists 90 degrees for 60 seconds.
d. Hyperextend the wrists with the palmar surface of both hands touching, and wait for
60 seconds.
The nurse suspects that a patient has appendicitis. Which of these procedures are
appropriate for use when assessing for appendicitis or a perforated appendix? Select all
that apply.
a. Test for the Murphy sign
b. Test for the Blumberg sign
c. Test for shifting dullness
d. Perform the iliopsoas muscle test
e. Test for fluid wave
The nurse is preparing to measure fat and lean body mass and bone mineral density.
Which tool is appropriate?
a. Measuring tape
b. Skinfold calipers
c. Bioelectrical impedance analysis (BIA)
d. Dual-energy x-ray absorptiometry (DEXA)
During the interview portion of data collection, the nurse collects __________ data.
a. Physical
b. Historical
c. Objective
d. Subjective
A 1-month-old infant has a head measurement of 34 cm and has a chest circumference
of 32 cm. Based on the interpretation of these findings, the nurse would:
a. Refer the infant to a physician for further evaluation.
b. Consider these findings normal for a 1-month-old infant.
c. Expect the chest circumference to be greater than the head circumference.
d. Ask the parent to return in 2 weeks to re-evaluate the head and chest circumferences.
A patient has finished giving the nurse information about the reason he is seeking care.
When reviewing the data, the nurse finds that some information about past
hospitalizations is missing. At this point, which statement by the nurse would be most
appropriate to gather these data?
a. "Mr. Y., at your age, surely you have been hospitalized before!"
b. "Mr. Y., I just need permission to get your medical records from County Medical."
c. "Mr. Y., you mentioned that you have been hospitalized on several occasions. Would
you tell me more about that?"
d. "Mr. Y., I just need to get some additional information about your past
hospitalizations. When was the last time you were admitted for chest pain?"
As part of the health history of a 6-year-old boy at a clinic for a sports physical
examination, the nurse reviews his immunization record and notes that his last
measles-mumps-rubella (MMR) vaccination was at 15 months of age. What
recommendation should the nurse make?
a. No further MMR immunizations are needed.
b. MMR vaccination needs to be repeated at 4 to 6 years of age.
c. MMR immunization needs to be repeated every 4 years until age 21 years.
d. A recommendation cannot be made until the physician is consulted.
A patient has a severed spinal nerve as a result of trauma. Which statement is true in
this situation?
a. Because there are 31 pairs of spinal nerves, no effect results if only one nerve is
severed.
b. The dermatome served by this nerve will no longer experience any sensation.
c. The adjacent spinal nerves will continue to carry sensations for the dermatome served
by the severed nerve.
d. A severed spinal nerve will only affect motor function of the patient because spinal
nerves have no sensory component.
The nurse is performing an external eye examination. Which statement regarding the
outer layer of the eye is true?
a. The outer layer of the eye is very sensitive to touch.
b. The outer layer of the eye is darkly pigmented to prevent light from reflecting
internally.
c. The trigeminal nerve (CN V) and the trochlear nerve (CN IV) are stimulated when
the outer surface of the eye is stimulated.
d. The visual receptive layer of the eye in which light waves are changed into nerve
impulses is located in the outer layer of the eye.
The nurse is reviewing concepts of cultural aspects of pain. Which statement is true
regarding pain?
a. All patients will behave the same way when in pain.
b. Just as patients vary in their perceptions of pain, so will they vary in their expressions
of pain.
c. Cultural norms have very little to do with pain tolerance, because pain tolerance is
always biologically determined.
d. A patient's expression of pain is largely dependent on the amount of tissue injury
associated with the pain.
The nurse is preparing for an internal genitalia examination of a woman. Which order
of the examination is correct?
a. Bimanual, speculum, and rectovaginal
b. Speculum, rectovaginal, and bimanual
c. Speculum, bimanual, and rectovaginal
d. Rectovaginal, bimanual, and speculum
A 54-year-old woman who has just completed menopause is in the clinic today for a
yearly physical examination. Which of these statements should the nurse include in
patient education? "A postmenopausal woman:
a. Is not at any greater risk for heart disease than a younger woman."
b. Should be aware that she is at increased risk for dyspareunia because of decreased
vaginal secretions."
c. Has only stopped menstruating; there really are no other significant changes with
which she should be concerned."
d. Is likely to have difficulty with sexual pleasure as a result of drastic changes in the
female sexual response cycle."
During a physical examination, the nurse finds that a male patient's foreskin is fixed and
tight and will not retract over the glans. The nurse recognizes that this condition is:
a. Phimosis.
b. Epispadias.
c. Urethral stricture.
d. Peyronie disease.
During an assessment of a 32-year-old patient with a recent head injury, the nurse
notices that the patient responds to pain by extending, adducting, and internally rotating
his arms. His palms pronate, and his lower extremities extend with plantar flexion.
Which statement concerning these findings is most accurate? This patient's response:
a. Indicates a lesion of the cerebral cortex.
b. Indicates a completely nonfunctional brainstem.
c. Is normal and will go away in 24 to 48 hours.
d. Is a very ominous sign and may indicate brainstem injury.
The nurse is examining a 6-month-old infant and places the infant's feet flat on the table
and flexes his knees up. The nurse notes that the right knee is significantly lower than
the left. Which of these statements is true of this finding?
a. This finding is a positive Allis sign and suggests hip dislocation.
b. The infant probably has a dislocated patella on the right knee.
c. This finding is a negative Allis sign and normal for an infant of this age.
d. The infant should return to the clinic in 2 weeks to see if his condition has changed.
When taking the health history on a patient with a seizure disorder, the nurse assesses
whether the patient has an aura. Which of these would be the best question for obtaining
this information?
a. "Does your muscle tone seem tense or limp?"
b. "After the seizure, do you spend a lot of time sleeping?"
c. "Do you have any warning sign before your seizure starts?"
d. "Do you experience any color change or incontinence during the seizure?"
When assessing a patient's pulse, the nurse should also notice which of these
characteristics?
a. Force
b. Pallor
c. Capillary refill time
d. Timing in the cardiac cycle
A patient complains of leg pain that wakes him at night. He states that he "has been
having problems" with his legs. He has pain in his legs when they are elevated that
disappears when he dangles them. He recently noticed "a sore" on the inner aspect of
the right ankle. On the basis of this health history information, the nurse interprets that
the patient is most likely experiencing:
a. Pain related to lymphatic abnormalities.
b. Problems related to arterial insufficiency.
c. Problems related to venous insufficiency.
d. Pain related to musculoskeletal abnormalities.
A patient comes in for a physical examination and complains of "freezing to death"
while waiting for her examination. The nurse notes that her skin is pale and cool and
attributes this finding to:
a. Venous pooling.
b. Peripheral vasodilation.
c. Peripheral vasoconstriction.
d. Decreased arterial perfusion.
A father brings in his 2-month-old infant to the clinic because the infant has had
diarrhea for the last 24 hours. He says his baby has not been able to keep any formula
down and that the diarrhea has been at least every 2 hours. The nurse suspects
dehydration. The nurse should test skin mobility and turgor over the infant's:
a. Sternum.
b. Forehead.
c. Forearms.
d. Abdomen.
When evaluating the temperature of older adults, the nurse should remember which
aspect about an older adult's body temperature?
a. The body temperature of the older adult is lower than that of a younger adult.
b. An older adult's body temperature is approximately the same as that of a young child.
c. Body temperature depends on the type of thermometer used.
d. In the older adult, the body temperature varies widely because of less effective heat
control mechanisms.
A woman who is 8 months pregnant comments that she has noticed a change in her
posture and is having lower back pain. The nurse tells her that during pregnancy,
women have a posture shift to compensate for the enlarging fetus. This shift in posture
is known as:
a. Lordosis.
b. Scoliosis.
c. Ankylosis.
d. Kyphosis.
A patient comes to the emergency department after a boxing match, and his left eye is
swollen almost shut. He has bruises on his face and neck. He says he is worried because
he "can"t see well" from his left eye. The physician suspects retinal damage. The nurse
recognizes that signs of retinal detachment include:
a. Loss of central vision.
b. Shadow or diminished vision in one quadrant or one half of the visual field.
c. Loss of peripheral vision.
d. Sudden loss of pupillary constriction and accommodation.
