In assessing a patient’s major risk factors for heart disease, which would the nurse want
to include when taking a history?
a. Family history, hypertension, stress, and age
b. Personality type, high cholesterol, diabetes, and smoking
c. Smoking, hypertension, obesity, diabetes, and high cholesterol
d. Alcohol consumption, obesity, diabetes, stress, and high cholesterol
Which of these statements is true regarding the use of Standard Precautions in the
health care setting?
a. Standard Precautions apply to all body fluids, including sweat.
b. Use alcohol-based hand rub if hands are visibly dirty.
c. Standard Precautions are intended for use with all patients, regardless of their risk or
presumed infection status.
d. Standard Precautions are to be used only when nonintact skin, excretions containing
visible blood, or expected contact with mucous membranes is present.
A 50-year-old woman is in the clinic for weakness in her left arm and leg that she has
noticed for the past week. The nurse should perform which type of neurologic
examination?
a. Glasgow Coma Scale
b. Neurologic recheck examination
c. Screening neurologic examination
d. Complete neurologic examination
The nurse is reviewing the structures of the ear. Which of these statements concerning
the eustachian tube is true?
a. The eustachian tube is responsible for the production of cerumen.
b. It remains open except when swallowing or yawning.
c. The eustachian tube allows passage of air between the middle and outer ear.
d. It helps equalize air pressure on both sides of the tympanic membrane.
A 45-year-old man is in the clinic for a routine physical examination. During the
recording of his health history, the patient states that he has been having difficulty
sleeping. “I”ll be sleeping great, and then I wake up and feel like I can”t get my breath.”
The nurse’s best response to this would be:
a. “When was your last electrocardiogram?”
b. “It’s probably because it’s been so hot at night.”
c. “Do you have any history of problems with your heart?”
d. “Have you had a recent sinus infection or upper respiratory infection?”
In examining a 70-year-old male patient, the nurse notices that he has bilateral
gynecomastia. Which of the following describes the nurse’s best course of action?
a. Recommend that he make an appointment with his physician for a mammogram.
b. Ignore it. Benign breast enlargement in men is not unusual.
c. Explain that this condition may be the result of hormonal changes, and recommend
that he see his physician.
d. Explain that gynecomastia in men is usually associated with prostate enlargement
and recommend that he be thoroughly screened.
During an interview, a woman has answered “yes” to two of the Abuse Assessment
Screen questions. What should the nurse say next?
a. “I need to report this abuse to the authorities.”
b. “Tell me about this abuse in your relationship.”
c. “So you were abused?”
d. “Do you know what caused this abuse?”
The nurse is preparing to conduct a mental status examination. Which statement is true
regarding the mental status examination?
a. A patient’s family is the best resource for information about the patient’s coping skills.
b. Gathering mental status information during the health history interview is usually
sufficient.
c. Integrating the mental status examination into the health history interview takes an
enormous amount of extra time.
d. To get a good idea of the patient’s level of functioning, performing a complete mental
status examination is usually necessary.
A 60-year-old man is at the clinic for an eye examination. The nurse suspects that he
has ptosis of one eye. How should the nurse check for this?
a. Perform the confrontation test.
b. Assess the individual’s near vision.
c. Observe the distance between the palpebral fissures.
d. Perform the corneal light test, and look for symmetry of the light reflex.
The nurse assesses the hearing of a 7-month-old by clapping hands. What is the
expected response? The infant:
a. Turns his or her head to localize the sound.
b. Shows no obvious response to the noise.
c. Shows a startle and acoustic blink reflex.
d. Stops any movement, and appears to listen for the sound.
The nurse is taking temperatures in a clinic with a TMT. Which statement is true
regarding use of the TMT?
a. A tympanic temperature is more time consuming than a rectal temperature.
b. The tympanic method is more invasive and uncomfortable than the oral method.
c. The risk of cross-contamination is reduced, compared with the rectal route.
d. The tympanic membrane most accurately reflects the temperature in the ophthalmic
artery.
During a routine office visit, a patient takes off his shoes and shows the nurse “this
awful sore that won”t heal.” On inspection, the nurse notes a 3-cm round ulcer on the
left great toe, with a pale ischemic base, well-defined edges, and no drainage. The nurse
should assess for other signs and symptoms of:
a. Varicosities.
b. Venous stasis ulcer.
c. Arterial ischemic ulcer.
d. Deep-vein thrombophlebitis.
A 32-year-old woman tells the nurse that she has noticed “very sudden, jerky
movements” mainly in her hands and arms. She says, “They seem to come and go,
primarily when I am trying to do something. I haven”t noticed them when I”m
sleeping.” This description suggests:
a. Tics.
b. Athetosis.
c. Myoclonus.
d. Chorea.
The nurse is preparing to auscultate for heart sounds. Which technique is correct?
a. Listening to the sounds at the aortic, tricuspid, pulmonic, and mitral areas
b. Listening by inching the stethoscope in a rough Z pattern, from the base of the heart
across and down, then over to the apex
c. Listening to the sounds only at the site where the apical pulse is felt to be the
strongest
d. Listening for all possible sounds at a time at each specified area
The nurse is watching a new graduate nurse perform auscultation of a patient’s
abdomen. Which statement by the new graduate shows a correct understanding of the
reason auscultation precedes percussion and palpation of the abdomen?
a. “We need to determine the areas of tenderness before using percussion and
palpation.”
b. “Auscultation prevents distortion of bowel sounds that might occur after percussion
and palpation.”
c. “Auscultation allows the patient more time to relax and therefore be more
comfortable with the physical examination.”
d. “Auscultation prevents distortion of vascular sounds, such as bruits and hums, that
might occur after percussion and palpation.”
The nurse knows that determining whether a person is oriented to his or her
surroundings will test the functioning of which structure(s)?
a. Cerebrum
b. Cerebellum
c. CNs
d. Medulla oblongata
While gathering equipment after an injection, a nurse accidentally received a prick from
an improperly capped needle. To interpret this sensation, which of these areas must be
intact?
a. Corticospinal tract, medulla, and basal ganglia
b. Pyramidal tract, hypothalamus, and sensory cortex
c. Lateral spinothalamic tract, thalamus, and sensory cortex
d. Anterior spinothalamic tract, basal ganglia, and sensory cortex
When listening to heart sounds, the nurse knows that the S1:
a. Is louder than the S2 at the base of the heart.
b. Indicates the beginning of diastole.
c. Coincides with the carotid artery pulse.
d. Is caused by the closure of the semilunar valves.
A pregnant woman states, “I just know labor will be so painful that I won”t be able to
stand it. I know it sounds awful, but I really dread going into labor.” The nurse responds
by stating, “Oh, don”t worry about labor so much. I have been through it, and although
it is painful, many good medications are available to decrease the pain.” Which
statement is true regarding this response? The nurse’s reply was a:
a. Therapeutic response. By sharing something personal, the nurse gives hope to this
woman.
b. Nontherapeutic response. By providing false reassurance, the nurse actually cut off
further discussion of the woman’s fears.
c. Therapeutic response. By providing information about the medications available, the
nurse is giving information to the woman.
d. Nontherapeutic response. The nurse is essentially giving the message to the woman
that labor cannot be tolerated without medication.
During an assessment of a 20-year-old Asian patient, the nurse notices that he has dry,
flaky cerumen in his canal. What is the significance of this finding? This finding:
a. Is probably the result of lesions from eczema in his ear.
b. Represents poor hygiene.
c. Is a normal finding, and no further follow-up is necessary.
d. Could be indicative of change in cilia; the nurse should assess for hearing loss.
The nurse knows that normal splitting of the S2 is associated with:
a. Expiration.
b. Inspiration.
c. Exercise state.
d. Low resting heart rate.
A patient’s laboratory data reveal an elevated thyroxine (T4) level. The nurse would
proceed with an examination of the _____ gland.
a. Thyroid
b. Parotid
c. Adrenal
d. Parathyroid
During the assessment of a woman in her 22ndweek of pregnancy, the nurse is unable to
hear fetal heart tones with the fetoscope. The nurse should:
a. Immediately notify the physician, then wait 10 minutes and try again.
b. Ask the woman if she has felt the baby move today.
c. Wait 10 minutes, and try again.
d. Use ultrasound to verify cardiac activity.
The nurse is examining a patient who has possible cardiac enlargement. Which
statement about percussion of the heart is true?
a. Percussion is a useful tool for outlining the heart’s borders.
b. Percussion is easier in patients who are obese.
c. Studies show that percussed cardiac borders do not correlate well with the true
cardiac border.
d. Only expert health care providers should attempt percussion of the heart.
The nurse is testing superficial reflexes on an adult patient. When stroking up the lateral
side of the sole and across the ball of the foot, the nurse notices the plantar flexion of
the toes. How should the nurse document this finding?
a. Positive Babinski sign
b. Plantar reflex abnormal
c. Plantar reflex present
d. Plantar reflex 2+ on a scale from “0 to 4+”
A pregnant woman is interested in breastfeeding her baby and asks several questions
about the topic. Which information is appropriate for the nurse to share with her?
a. Breastfeeding is best when also supplemented with bottle feedings.
b. Babies who are breastfed often require supplemental vitamins.
c. Breastfeeding is recommended for infants for the first 2 years of life.
d. Breast milk provides the nutrients necessary for growth, as well as natural immunity.
During a skin assessment, the nurse notices that a Mexican-American patient has skin
that is yellowish-brown; however, the skin on the hard and soft palate is pink and the
patient’s scleras are not yellow. From this finding, the nurse could probably rule out:
a. Pallor
b. Jaundice
c. Cyanosis
d. Iron deficiency
The nurse is taking an initial blood pressure reading on a 72-year-old patient with
documented hypertension. How should the nurse proceed?
a. Cuff should be placed on the patient’s arm and inflated 30 mm Hg above the patient’s
pulse rate.
b. Cuff should be inflated to 200 mm Hg in an attempt to obtain the most accurate
systolic reading.
c. Cuff should be inflated 30 mm Hg above the point at which the palpated pulse
disappears.
d. After confirming the patient’s previous blood pressure readings, the cuff should be
inflated 30 mm Hg above the highest systolic reading recorded.
The nurse is attempting to assess the femoral pulse in a patient who is obese. Which of
these actions would be most appropriate?
a. The patient is asked to assume a prone position.
b. The patient is asked to bend his or her knees to the side in a froglike position.
c. The nurse firmly presses against the bone with the patient in a semi-Fowler position.
d. The nurse listens with a stethoscope for pulsations; palpating the pulse in an obese
person is extremely difficult.
A mother brings in her newborn infant for an assessment and tells the nurse that she has
noticed that whenever her newborn’s head is turned to the right side, she straightens out
the arm and leg on the same side and flexes the opposite arm and leg. After observing
this on examination, the nurse tells her that this reflex is:
a. Abnormal and is called the atonic neck reflex.
b. Normal and should disappear by the first year of life.
c. Normal and is called the tonic neck reflex, which should disappear between 3 and 4
months of age.
d. Abnormal. The baby should be flexing the arm and leg on the right side of his body
when the head is turned to the right.
A 17-year-old single mother is describing how difficult it is to raise a 3-year-old child
by herself. During the course of the interview she states, “I can”t believe my boyfriend
left me to do this by myself! What a terrible thing to do to me!” Which of these
responses by the nurse uses empathy?
a. “You feel alone.”
b. “You can”t believe he left you alone?”
c. “It must be so hard to face this all alone.”
d. “I would be angry, too; raising a child alone is no picnic.”
The nurse is obtaining a health history on a 3-month-old infant. During the interview,
the mother states, “I think she is getting her first tooth because she has started drooling
a lot.” The nurse’s best response would be:
a. “You”re right, drooling is usually a sign of the first tooth.”
b. “It would be unusual for a 3 month old to be getting her first tooth.”
c. “This could be the sign of a problem with the salivary glands.”
d. “She is just starting to salivate and hasn”t learned to swallow the saliva.”
During an examination of a female patient, the nurse notes lymphadenopathy and
suspects an acute infection. Acutely infected lymph nodes would be:
a. Clumped.
b. Unilateral.
c. Firm but freely movable.
d. Firm and nontender.
Receiving is a part of the communication process. Which receiver is most likely to
misinterpret a message sent by a health care professional?
a. Well-adjusted adolescent who came in for a sports physical
b. Recovering alcoholic who came in for a basic physical examination
c. Man whose wife has just been diagnosed with lung cancer
d. Man with a hearing impairment who uses sign language to communicate and who has
an interpreter with him