A 22-year-old woman has been considering using oral contraceptives. As a part of her
health history, the nurse should ask:
a. “Do you have a history of heart murmurs?”
b. “Will you be in a monogamous relationship?”
c. “Have you carefully thought this choice through?”
d. “If you smoke, how many cigarettes do you smoke per day?”
The nurse is performing an assessment on a 7-year-old child who has symptoms of
chronic watery eyes, sneezing, and clear nasal drainage. The nurse notices the presence
of a transverse line across the bridge of the nose, dark blue shadows below the eyes,
and a double crease on the lower eyelids. These findings are characteristic of:
a. Allergies.
b. Sinus infection.
c. Nasal congestion.
d. Upper respiratory infection.
A 75-year-old man with a history of hypertension was recently changed to a new
antihypertensive drug. He reports feeling dizzy at times. How should the nurse evaluate
his blood pressure?
a. Blood pressure and pulse should be recorded in the supine, sitting, and standing
positions.
b. The patient should be directed to walk around the room and his blood pressure
assessed after this activity.
c. Blood pressure and pulse are assessed at the beginning and at the end of the
examination.
d. Blood pressure is taken on the right arm and then 5 minutes later on the left arm.
The nurse is reviewing the risk factors for venous disease. Which of these situations
best describes a person at highest risk for the development of venous disease?
a. Woman in her second month of pregnancy
b. Person who has been on bed rest for 4 days
c. Person with a 30-year, 1 pack per day smoking habit
d. Older adult taking anticoagulant medication
The nurse is counting an infant’s respirations. Which technique is correct?
a. Watching the chest rise and fall
b. Watching the abdomen for movement
c. Placing a hand across the infant’s chest
d. Using a stethoscope to listen to the breath sounds
Which of these statements is most appropriate when the nurse is obtaining a
genitourinary history from an older man?
a. “Do you need to get up at night to urinate?”
b. “Do you experience nocturnal emissions, or “wet dreams’?”
c. “Do you know how to perform a testicular self-examination?”
d. “Has anyone ever touched your genitals when you did not want them to?”
When assessing the force, or strength, of a pulse, the nurse recalls that the pulse:
a. Is usually recorded on a 0- to 2-point scale.
b. Demonstrates elasticity of the vessel wall.
c. Is a reflection of the heart’s stroke volume.
d. Reflects the blood volume in the arteries during diastole.
The nurse notices that a patient has had a pale, yellow, greasy stool, or steatorrhea, and
recalls that this is caused by:
a. Occult bleeding.
b. Absent bile pigment.
c. Increased fat content.
d. Ingestion of bismuth preparations.
The nurse is assessing an older adult’s functional ability. Which definition correctly
describes one’s functional ability? Functional ability:
a. Is the measure of the expected changes of aging that one is experiencing.
b. Refers to the individual’s motivation to live independently.
c. Refers to the level of cognition present in an older person.
d. Refers to one’s ability to perform activities necessary to live in modern society.
The nurse is reviewing an assessment of a patient’s peripheral pulses and notices that
the documentation states that the radial pulses are “2+.” The nurse recognizes that this
reading indicates what type of pulse?
a. Bounding
b. Normal
c. Weak
d. Absent
The nurse is assessing the apical pulse of a 3-month-old infant and finds that the heart
rate is 135 beats per minute. The nurse interprets this result as:
a. Normal for this age.
b. Lower than expected.
c. Higher than expected, probably as a result of crying.
d. Higher than expected, reflecting persistent tachycardia.
The nurse is assessing a 16-year-old patient who has suffered head injuries from a
recent motor vehicle accident. Which of these statements indicates the most important
reason for assessing for any drainage from the ear canal?
a. If the drum has ruptured, then purulent drainage will result.
b. Bloody or clear watery drainage can indicate a basal skull fracture.
c. The auditory canal many be occluded from increased cerumen.
d. Foreign bodies from the accident may cause occlusion of the canal.
When assessing a patient’s pain, the nurse knows that an example of visceral pain would
be:
a. Hip fracture.
b. Cholecystitis.
c. Second-degree burns.
d. Pain after a leg amputation.
The nurse is preparing to perform a physical assessment. Which statement is true about
the physical assessment? The inspection phase:
a. Usually yields little information.
b. Takes time and reveals a surprising amount of information.
c. May be somewhat uncomfortable for the expert practitioner.
d. Requires a quick glance at the patient’s body systems before proceeding with
palpation.
The nurse is listening to the breath sounds of a patient with severe asthma. Air passing
through narrowed bronchioles would produce which of these adventitious sounds?
a. Wheezes
b. Bronchial sounds
c. Bronchophony
d. Whispered pectoriloquy
When percussing over the liver of a patient, the nurse notices a dull sound. The nurse
should:
a. Consider this a normal finding.
b. Palpate this area for an underlying mass.
c. Reposition the hands, and attempt to percuss in this area again.
d. Consider this finding as abnormal, and refer the patient for additional treatment.
During the precordial assessment on an patient who is 8 months pregnant, the nurse
palpates the apical impulse at the fourth left intercostal space lateral to the
midclavicular line. This finding would indicate:
a. Right ventricular hypertrophy.
b. Increased volume and size of the heart as a result of pregnancy.
c. Displacement of the heart from elevation of the diaphragm.
d. Increased blood flow through the internal mammary artery.
During a class on religion and spirituality, the nurse is asked to define spirituality.
Which answer is correct? “Spirituality:
a. Is a personal search to discover a supreme being.”
b. Is an organized system of beliefs concerning the cause, nature, and purpose of the
universe.”
c. Is a belief that each person exists forever in some form, such as a belief in
reincarnation or the afterlife.”
d. Arises out of each person’s unique life experience and his or her personal effort to
find purpose in life.”
When assessing a patient’s nutritional status, the nurse recalls that the best definition of
optimal nutritional status is sufficient nutrients that:
a. Are in excess of daily body requirements.
b. Provide for the minimum body needs.
c. Provide for daily body requirements but do not support increased metabolic demands.
d. Provide for daily body requirements and support increased metabolic demands.
A married couple has come to the clinic seeking advice on pregnancy. They have been
trying to conceive for 4 months and have not been successful. What should the nurse do
first?
a. Ascertain whether either of them has been using broad-spectrum antibiotics.
b. Explain that couples are considered infertile after 1 year of unprotected intercourse.
c. Immediately refer the woman to an expert in pelvic inflammatory diseasethe most
common cause of infertility.
d. Explain that couples are considered infertile after 3 months of engaging in
unprotected intercourse and that they will need a referral to a fertility expert.
The nurse is reviewing the function of the cranial nerves (CNs). Which CN is
responsible for conducting nerve impulses to the brain from the organ of Corti?
a. I
b. III
c. VIII
d. XI
The nurse is assessing a patient in the hospital who has received numerous antibiotics
and notices that his tongue appears to be black and hairy. In response to his concern,
what would the nurse say?
a. “We will need to get a biopsy to determine the cause.”
b. “This is an overgrowth of hair and will go away in a few days.”
c. “Black, hairy tongue is a fungal infection caused by all the antibiotics you have
received.”
d. “This is probably caused by the same bacteria you had in your lungs.”
A 65-year-old woman is in the office for routine gynecologic care. She had a complete
hysterectomy 3 months ago after cervical cancer was detected. Which statement does
the nurse know to be true regarding this visit?
a. Her cervical mucosa will be red and dry looking.
b. She will not need to have a Pap smear performed.
c. The nurse can expect to find that her uterus will be somewhat enlarged and her
ovaries small and hard.
d. The nurse should plan to lubricate the instruments and the examining hand
adequately to avoid a painful examination.
The mother of a 10-year-old boy asks the nurse to discuss the recognition of puberty.
The nurse should reply by saying:
a. “Puberty usually begins around 15 years of age.”
b. “The first sign of puberty is an enlargement of the testes.”
c. “The penis size does not increase until about 16 years of age.”
d. “The development of pubic hair precedes testicular or penis enlargement.”
The nurse should use which location for eliciting deep tendon reflexes?
a. Achilles
b. Femoral
c. Scapular
d. Abdominal
The nurse is preparing to do an otoscopic examination on a 2-year-old child. Which one
of these reflects the correct procedure?
a. Pulling the pinna down
b. Pulling the pinna up and back
c. Slightly tilting the child’s head toward the examiner
d. Instructing the child to touch his chin to his chest
Which of these statements about the peripheral nervous system is correct?
a. The CNs enter the brain through the spinal cord.
b. Efferent fibers carry sensory input to the central nervous system through the spinal
cord.
c. The peripheral nerves are inside the central nervous system and carry impulses
through their motor fibers.
d. The peripheral nerves carry input to the central nervous system by afferent fibers and
away from the central nervous system by efferent fibers.
The mother of a 2-year-old is concerned because her son has had three ear infections in
the past year. What would be an appropriate response by the nurse?
a. “It is unusual for a small child to have frequent ear infections unless something else is
wrong.”
b. “We need to check the immune system of your son to determine why he is having so
many ear infections.”
c. “Ear infections are not uncommon in infants and toddlers because they tend to have
more cerumen in the external ear.”
d. “Your son’s eustachian tube is shorter and wider than yours because of his age, which
allows for infections to develop more easily.”
The nurse is palpating the fundus of a pregnant woman. Which statement about
palpation of the fundus is true?
a. The fundus should be hard and slightly tender to palpation during the first trimester.
b. Fetal movement may not be felt by the examiner until the end of the second trimester.
c. After 20 weeks’ gestation, the number of centimeters should approximate the number
of weeks’ gestation.
d. Fundal height is usually less than the number of weeks’ gestation, unless an abnormal
condition such as excessive amniotic fluid is present.
The nurse is planning to assess new memory with a patient. The best way for the nurse
to do this would be to:
a. Administer the FACT test.
b. Ask him to describe his first job.
c. Give him the Four Unrelated Words Test.
d. Ask him to describe what television show he was watching before coming to the
clinic.
A 40-year-old man states that his physician told him that he has a hernia. He asks the
nurse to explain what a hernia is. Which response by the nurse is appropriate?
a. “No need to worry. Most men your age develop hernias.”
b. “A hernia is a loop of bowel protruding through a weak spot in the abdominal
muscles.”
c. “A hernia is the result of prenatal growth abnormalities that are just now causing
problems.”
d. “I”ll have to have your physician explain this to you.”
During an otoscopic examination, the nurse notices an area of black and white dots on
the tympanic membrane and the ear canal wall. What does this finding suggest?
a. Malignancy
b. Viral infection
c. Blood in the middle ear
d. Yeast or fungal infection
A 52-year-old patient states that when she sneezes or coughs she “wets herself a little.”
She is very concerned that something may be wrong with her. The nurse suspects that
the problem is:
a. Dysuria.
b. Stress incontinence.
c. Hematuria.
d. Urge incontinence.