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Health Assessment for Nursing Practice 5th Edition, Wilson Test Bank

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Test Bank For Health Assessment for Nursing Practice 5th Edition, Wilson. Note: This is not a text book. Description: ISBN-13: 978-0323091510, ISBN-10: 0323091512.

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Test Bank Health Assessment Nursing Practice 5th Edition, Wilson

MULTIPLE CHOICE
Chapter 1: Importance of Health Assessment
1. A patient comes to the emergency department and tells the triage nurse that he is “having a heart attack.” What is the nurse’s top priority at this time?
a. Determine the patient’s personal data and insurance coverage.
b. Ask the patient to take a seat in the waiting room until his name is called.
c. Request that a nurse collect data for a comprehensive history.
d. Ask a nurse to start a focused assessment of this patient now.
2. Which situation illustrates a screening assessment?
a. A patient visits an obstetric clinic for the first time and the nurse conducts a detailed history and physical examination.
b. A hospital sponsors a health fair at a local mall and provides cholesterol and blood pressure checks to mall patrons.
c. The nurse in an urgent care center checks the vital signs of a patient who is complaining of leg pain.
d. A patient newly diagnosed with diabetes mellitus comes to test his fasting blood glucose level.
3. For which person is a screening assessment indicated?
a. The person who had abdominal surgery yesterday
b. The person who is unaware of his high serum glucose levels
c. The person who is being admitted to a long-term care facility
d. The person who is beginning rehabilitation after a knee replacement
4. For which person is a shift assessment indicated?
a. The person who had abdominal surgery yesterday
b. The person who is unaware of his high serum glucose levels.
c. The person who is being admitted to a long-term care facility.
d. The person who is beginning rehabilitation after a knee replacement.
5. For which person is a comprehensive assessment indicated?
a. The person who had abdominal surgery yesterday
b. The person who is unaware of his high serum glucose levels
c. The person who is being admitted to a long-term care facility
d. The person who is beginning rehabilitation after a knee replacement
6. For which person is an episodic or follow-up assessment indicated?
a. The person who had abdominal surgery yesterday
b. The person who is unaware of his high serum glucose levels
c. The person who is being admitted to a long-term care facility
d. The person who is beginning rehabilitation after a knee replacement
7. Which is an example of data a nurse collects during a physical examination?
a. The patient’s lack of hair and shiny skin over both shins
b. The patient’s stated concern about lack of money for prescriptions
c. The patient’s complaints of tingling sensations in the feet
d. The patient’s mother’s statements that the patient is very nervous lately
8. The nurse documents which information in the patient’s history?
a. The patient’s skin feels warm to the touch.
b. The patient is scratching his arm.
c. The patient’s temperature is 100° F.
d. The patient complains of itching.
9. Which patient information does the nurse document in the patient’s physical assessment?
a. Slurred speech
b. Immunizations
c. Smoking habit
d. Allergies
10. After collecting the data, the nurse begins data analysis with which action?
a. Clustering data
b. Documenting subjective data
c. Reporting information to other health team members
d. Documenting objective information
Chapter 2: Interviewing Patients to Obtain a Health History
1. Which statement or question does the nurse use during the introduction phase of the interview?
a. “I’m here to learn more about the pain you’re experiencing.”
b. “Can you describe the pain that you’re experiencing?”
c. “I heard you say that the pain is ‘all over’ your body.”
d. “What relieves the pain you are having?”
2. Which statement is appropriate to use when beginning an interview with a new patient?
a. “Have you ever been a patient in this clinic before?”
b. “What is your purpose for coming to the clinic today?”
c. “Tell me a little about yourself and your family.”
d. “Did you have any difficulty finding the clinic?”
3. Which statement by the nurse demonstrates a patient-centered interview?
a. “I need to complete this questionnaire about your medical and family history.”
b. “The hospital requires me to complete this assessment as soon as possible.”
c. “Tell me about the symptoms you’ve been having.”
d. “I’ve had the same symptoms that you’ve described.”
4. Which question is an example of an open-ended question?
a. “Have you experienced this pain before?”
b. “Do you have someone to help you at home?”
c. “How many times a day do you use your inhaler?”
d. “What were you doing when you felt the pain?”
5. A nurse suspects a female patient is a victim of physical abuse. Which response is most likely to encourage the patient to confide in the nurse?
a. “You’ve got a huge bruise on your face. Did your husband hit you?”
b. “That bruise looks tender. I don’t know how people can do that to one another.”
c. “If your boyfriend hit you, you can get a restraining order against him.”
d. “I’ve seen women who have been hurt by boyfriends or husbands. Does anyone hit you?”
6. Which technique used by the nurse encourages a patient to continue talking during an interview?
a. Laughing and smiling during conversation
b. Using phrases such as “Go on,” and “Then?”
c. Repeating what the patient said, but using different words
d. Asking the patient to clarify a point
7. During the history, the patient states that she does not use many drugs. What is the nurse’s appropriate response to this statement?
a. “Tell me about the drugs you are using currently.”
b. “To some people six or seven is not many.”
c. “Do you mean prescription drugs or illicit drugs?”
d. “How often are you using these drugs?”
8. A nurse is interviewing a patient who was diagnosed with type 2 diabetes mellitus 6 months ago. Since that time, the patient has gained weight and her blood glucose levels remain high. The nurse suspects that the patient is noncompliant with her diet. Which response by the nurse enhances data collection in this situation?
a. “Tell me about what foods you eat and the frequency of your meals”
b. “What symptoms do you notice when your blood sugar levels are high?”
c. “You need to follow what the doctor has prescribed to manage your disease”
d. “Tell me what you know about the cause of type 2 diabetes.”
9. A male patient tells the nurse that he rarely sleeps more than 4 hours a night and has not experienced any problems because of the lack of sleep. Which response by the nurse is most appropriate?
a. “That is interesting.”
b. “Only 4 hours of sleep? How do you stay awake during the day?”
c. “Really? Everyone needs more sleep than that.”
d. “Did I understand that you sleep 4 hours every night?”
10. Which technique should the nurse use to obtain more data about a patient’s vague or ambiguous statement?
a. Laughing and smiling during conversation
b. Using phrases such as “Go on,” and “Then?”
c. Repeating what the patient has said, but using different words
d. Asking the patient to explain a point
Chapter 3: Techniques and Equipment for Physical Assessment
1. What is the most important nursing action to reduce transmission of microorganisms during a physical assessment?
a. Clean the bell and diaphragm of the stethoscope between patients.
b. Perform hand hygiene.
c. Wear gloves when anticipating exposure to body fluids.
d. Wear eye protection when anticipating spatter of body fluids.
2. When examining a patient, the nurse remembers to follow which principle of Standard Precautions?
a. Wear gloves throughout the entire examination of the patient.
b. Wear gloves when in contact with the patient’s mucous membranes.
c. Wear gloves to reduce the need for handwashing.
d. Wear eye protection and a gown during the examination of the patient.
3. How do nurses prevent a latex allergy?
a. They use nonlatex gloves for all procedures.
b. They protect their hands using oil-based hand lotion applying latex gloves.
c. They use a powder-free, low-allergen latex gloves.
d. They wash their hands with mild soap and dry thoroughly before applying latex gloves.
4. Which explanation is most appropriate for a nurse preparing to palpate a patient’s neck?
a. “I need to feel for tumors in your neck.”
b. “I’m going to feel your neck for any abnormalities.”
c. “I need to press deeply on your neck so please hold still.”
d. “Is there any tenderness in your neck?”
5. Which nurse is performing the technique of light palpation appropriately?
a. Nurse A applies the bimanual technique to determine size and location of the patient’s heart.
b. Nurse B uses the fingertips to feel for temperature differences on the patient’s legs.
c. Nurse C places the ulnar surface of the hands on the patient’s thorax to detect vibrations.
d. Nurse D depresses the patient’s abdomen approximately 4 cm to assess pulsations.
6. How does the nurse perform the bimanual technique of palpation to assess organs?
a. Using the palmar surface of the dominant hand to press inward to a depth of about 1 cm
b. Holding a light source in one hand while stroking the skin lightly with the dominant hand
c. Using the ulnar surfaces of both hands to press inward 4 to 5 cm
d. Using both hands, one anterior and one posterior, to entrap an organ between the fingertips
7. While assessing a patient’s lower extremities, the nurse suspects the lower extremities feel cooler than the upper extremities. To confirm this suspicion, how does the nurse compare the temperatures of the lower extremities with the upper extremities?
a. Using the backs (dorsum) of the hands to detect differences
b. Using the ulnar surface of the hands to detect differences
c. Using the pads of the fingers to detect differences
d. Using the palmar surface (underside) of the hands to detect differences
8. How does a nurse assess for fluid in a patient’s abdomen?
a. Placing the nondominant hand (pleximeter) over the area to be percussed, and striking the index finger of the pleximeter with the pad of the middle finger of the dominant hand
b. Applying indirect percussion by tapping one finger lightly on the abdominal wall with the plexor
c. Placing the middle finger of the nondominant hand (pleximeter) over the area to be percussed, and striking that finger with the tip of the middle finger of the dominant hand
d. Using direct percussion by placing one hand over the abdomen and striking lightly with the other hand
9. What assessment data do nurses obtain through striking a hand directly against the flank or costovertebral angle of a patient’s body?
a. Fluid in the lungs
b. Tenderness over the kidneys
c. Air in the abdomen
d. Tenderness over the liver
10. A patient has been complaining of abdominal cramping and gas; the nurse notes that his abdomen is slightly distended. Which sound does the nurse expect to hear during percussion of this patient’s abdomen?
a. Flatness
b. Dullness
c. Resonance
d. Tympany
Chapter 4: General Inspection and Measurement of Vital Signs
1. Which body system does the nurse assess primarily by inspection?
a. Respiratory
b. Gastrointestinal
c. Skin
d. Cardiovascular
2. A patient is sitting slightly forward bracing his arms on his knees in a tripod position. This position is associated with which symptom?
a. Abdominal pain
b. Spinal deformity
c. Back pain
d. Breathing difficulty
3. The temperature of a patient is measured every 6 hours at 6 AM, 12 PM, 6 PM, and 12 AM. Which temperature reading is expected to be low due to a normal variation?
a. The measurement at 6 AM
b. The measurement at 12 PM
c. The measurement at 6 PM
d. The measurement at 12 AM
4. Which statement is correct regarding taking or interpreting axillary temperatures?
a. Axillary temperatures should not be used in patients less than 2 years of age.
b. Readings may be less accurate.
c. The thermometer is left in place for no more than 3 minutes.
d. The thermometer is placed in the axilla with the shoulder abducted.
5. A temperature of 99.8° F taken in the axilla is equivalent to which temperature value taken orally?
a. 100.8° F
b. 99.8° F
c. 98.8° F
d. 97.8° F
6. The nurse suspects an irregularity in the rhythm of the patient’s radial pulse. What is the most appropriate action for this nurse to take at this time?
a. Document this rhythm as normal for the patient.
b. Use a Doppler to check the brachial pulse.
c. Count the patient’s apical pulse for a full minute.
d. Count the radial pulse again for 15 seconds and multiply by 4.
7. The patient with a respiratory rate that is within normal limits is the _____ whose respiratory rate is _____ breaths/min.
a. 16-month-old; 36
b. 6-year-old; 20
c. 14-year-old;26
d. 40-year-old; 10
8. A nurse is taking vital signs of an adult patient whose oxygen saturation is 96%. The patient’s temperature is 102° F, blood pressure is 130/86, pulse is 100 beats/min, and respiratory rate is 26 breaths/min. Which factor may be contributing to the elevated respiratory rate?
a. The patient’s temperature
b. The patient’s oxygen saturation
c. The patient’s pulse rate
d. The patient’s blood pressure
9. Nurses understand that a patient’s diastolic pressure represents which physiologic function?
a. The pressure needed to open the aortic and pulmonic valves
b. The pressure in blood vessels when the ventricles contract
c. The pressure of the blood returning to the heart from the venous system
d. The pressure in blood vessels when the ventricles are relaxed
10. According to research findings, which site is preferred for measuring blood pressure when the nurse is unable to use the patient’s upper arms?
a. Ankle
b. Thigh
c. Calf
d. Wrist
Chapter 5: Ethnic, Cultural, and Spiritual Considerations
1. What are the characteristics of one’s culture?
a. Color of skin and hair
b. System of beliefs and practices
c. Food preferences
d. Language and religion
2. Which example below best characterizes a patient’s race?
a. The language spoken in the patient’s home is Tagalog.
b. The patient’s family follows a kosher diet.
c. The patient and his family have blonde hair and fair skin.
d. The patient’s grandparents came to the United States from Germany.
3. After the death of a Native American man, the nurse opened a window to allow spirits to leave. This action is an example of which attribute of the concept of cultural competence?
a. Adapting interventions based on cultural practices (Tailoring)
b. Gaining information about cultural differences (Knowledge)
c. Considering the effects of another’s values and experiences (Understanding)
d. Showing appreciation for cultural differences (Respect)
4. A Hispanic patient tells an African American nurse, “You are African American and can’t possibly understand how a person like me feels.” What is an appropriate response by the nurse at this time?
a. Find a nurse who is not African American to interview the patient.
b. Ask the patient, “Why do you think that, since we just met?”
c. Note that the patient is very defensive about being racially different.
d. Encourage the patient to describe what he means by his statement.
5. A male nurse is assigned to the care of a gay male with alcoholism. This sexual orientation is inconsistent with the beliefs of the nurse. What actions, if any, can the nurse take to provide patient-centered care to this patient?
a. No action is necessary at this time.
b. Examine his own feelings about alcoholism and homosexuality.
c. Determine the patient’s degree of risk for contracting the human immunodeficiency virus.
d. Discuss homosexuality and alcoholism with the patient.
6. Which nursing behaviors indicate culturally competent care?
a. Recognizing that there are different definitions of health and illness
b. Complying with the stated plan of treatment despite the patient’s differing opinion
c. Understanding that there is diversity even among people of the same cultural group
d. Helping patients of different cultures adopt the beliefs and behaviors of the dominant culture
7. A nurse is conducting an assessment of an American Indian woman who has come to the clinic complaining of persistent headaches. The patient tells the nurse that the medicines prescribed by the tribal healer have done “some good.” What is the appropriate response of the nurse at this time?
a. “I advise you to stop taking those medicines from the tribal healer.”
b. “Perhaps you should increase the frequency of the healer’s medicines.”
c. “Tell me about these medicines and how often you are using them.”
d. “Could your headaches be caused by the healer’s medicines?”
8. Which question is the most appropriate to learn about a patient’s religious practices?
a. “How often do you go to church?”
b. “Where is your church located?”
c. “Do you mind telling me about your religion?”
d. “Do you have any specific religious or spiritual practices or beliefs?”
9. A patient tells the nurse that her religion prohibits her from eating food prepared outside of a special kitchen. What is the nurse’s appropriate action to meet this patient’s needs?
a. Call the dietary department to cancel the patient’s meal tray.
b. Tell the patient that her diet must be carefully monitored and prepared at the hospital.
c. Tell the patient that because of her illness, a few changes to her religious requirements will be necessary.
d. Ask the patient to describe the requirements for the special kitchen.
10. Which question is most effective in assessing a patient’s personal beliefs about health and illness?
a. “What or who do you believe controls your health?”
b. “Do you see your health care provider annually?”
c. “Do you have specific beliefs about health and illness?”
d. “Who makes the health decisions in your family?”
Chapter 6: Pain Assessment
1. How do nurses assess a patient’s pain?
a. By assessing physiologic changes of the patient
b. By understanding the sensory experience related to the amount of tissue damage
c. By the patient’s medical diagnosis or surgical procedure
d. By asking the patient to rate the pain being experienced
2. The nurse notes in the patient’s history that the patient has persistent, malignant pain. What is the meaning of this type of pain?
a. The pain has been present for at least 2 weeks.
b. The pain began after recent surgery and is associated with healing incisions.
c. The pain has been present for 6 or more months.
d. The pain has been present since surgery to remove cancer.
3. A patient has had chronic back pain for several years. On assessment, the nurse notes that the patient sits quietly in a chair, reads a book, talks with a companion, and does not appear to be in pain. When questioned, the patient rates the pain as a 6 on a scale of 0 to 10. How does the nurse interpret these data?
a. Many patients cannot be believed when they complain of severe pain lasting many months.
b. Patients may not have the same objective responses to chronic pain because of compensation over time.
c. The patient probably has already taken a very effective pain medication.
d. This patient is probably not having as much pain as reported initially, and more assessment is required.
4. Which patient would be expected to experience acute pain?
a. A patient who had abdominal surgery 8 hours ago
b. A patient who has cancer and has been receiving treatment for 4 months
c. A patient who states that he or she has lived with severe pain for many years
d. A patient who has been treated unsuccessfully over the past year for back pain
5. Which patient has pain caused by abnormal processing of sensory input from the peripheral nervous system?
a. The patient who has aching pain from muscle strain
b. The patient who has burning pain along the sciatic nerve
c. The patient who has cramping pain from a tumor in the colon
d. The patient who has throbbing pain from arthritis
6. A patient reports “right shoulder pain that comes and goes” as the chief complaint. During the physical examination, the patient asks why the upper right abdomen is being examined for shoulder pain. What is the appropriate response from the nurse?
a. “A comprehensive examination is required to determine the cause of your pain.”
b. “There may be associated problems that have not produced any symptoms yet that we want to identify.”
c. “Yes, this can be confusing, but if you will be patient I’m sure we can find something to help you.”
d. “It does seem odd, but the gallbladder doesn’t have pain receptors of its own, so the pain shows up in the shoulder.”
7. A patient who had an amputation of his lower leg comes to the clinic with a complaint of pain. He asks, “How I can be feeling pain in my foot—my foot is gone!” What is the appropriate response from the nurse?
a. “After your amputation, pain perception increases.”
b. “Amputating your leg caused abnormal processing of sensory input by the peripheral nervous system.”
c. “Stimulation of nerves from your leg sends impulses to the brain so that you feel pain even though your leg is no longer there.”
d. “When sensory nerves enter the spinal cord, they stimulate nerves from unaffected organs in the same spinal cord segment as those neurons in areas where injury or disease is located.”
8. A patient who had extensive surgery asks the nurse for pain medication for a pain of 9 on a scale of 0 to 10. The nurse completes an assessment of this patient’s pain and agrees to give pain medication. When the nurse returns to the patient with the ordered intravenous pain medication, she notices the patient’s eyes are closed and he appears to be sleeping. What is the nurse’s appropriate action at this time?
a. Lock up the medication in a safe location until the patient awakens.
b. Arouse the patient to confirm he still wants the medication.
c. Give the medication as ordered and agreed to.
d. Consult a colleague about what action to take.
9. In the labor and delivery department, the nurse notices that two women who are in labor are responding differently to their contractions. The first woman, who is having her first baby, has rated her pain as a “7,” seems agitated, and has asked for pain medication. The second woman, who is having her third baby, has also rated her pain as a “7,” but is calmer and says she does not need anything for pain at this time. What explains the differences in the outward responses to pain between these women?
a. Pain tolerance
b. Pain threshold
c. Nociception
d. Physiologic stress
10. A patient admitted to the emergency department with “excruciating chest pain, above the rating of 10,” has a heart rate of 55, rapid, irregular respirations, complains of nausea, and is too weak to move to the stretcher without aid. The nurse recognizes that this response to severe pain is due to the response of the _____ nervous system.
a. Parasympathetic
b. Sympathetic
c. Central
d. Peripheral
Chapter 7: Mental Health and Abusive Behavior Assessment
1. What function do neurotransmitters have in mental health disorders?
a. Dopamine levels are increased in schizophrenia.
b. Increased levels of gamma aminobutyric acid (GABA) contribute to anxiety.
c. Serotonin is decreased in a state of anxiety.
d. Norepinephrine is increased in depression.
2. A male patient scores 125 on the Holmes Social Readjustment Scale. How does the nurse interpret this score?
a. He is experiencing a great deal of stress in his life and needs hospitalization.
b. At this time he has no stress in his life and is healthy both mentally and physically.
c. He has relatively low stress in his life and use of daily relaxation can be beneficial.
d. He has a moderate chance of developing a stress-related illness and can reduce this by practicing stress management.
3. A 24-year-old male patient tells the nurse he has had no energy for 2 weeks. He has no trouble falling asleep; in fact, he sleeps deeply about 12 hours every night. He states that he has gained 10 lb in the past 2 months and has no friends. The nurse associates these manifestations with which mental health disorder?
a. Depression
b. Schizophrenia
c. Bipolar disorder
d. Anxiety disorder
4. A female patient states that she has had problems with depression in the past and thinks she is depressed again. Which response by the nurse is most appropriate?
a. “What do you think is causing your depression this time?”
b. “What therapies have worked for you in the past?”
c. “Did you stop taking your medication?’”
d. “Do you think this is a situational depression?”
5. Which patient may be experiencing severe anxiety?
a. A woman who tells the nurse she is terrified of cats
b. A man who tells the nurse he feels worthless and is always tired
c. A woman who reports that she is sleeping very lightly each night because her child has an ear infection
d. A man who phones the nurse five times asking for instructions about how to take his new medication
6. While assessing a man during a physical examination for work, the nurse suspects alcohol use. Which assessment tool is appropriate in this situation?
a. AUDIT screening tool
b. Rapid eye test
c. Mental status examination
d. Holmes Social Readjustment Rating Scale
7. A nurse screens every adult and adolescent patient for alcohol consumption. Which patient drinks more than recommended?
a. The man who reports drinking 3 beers and one shot of whiskey each day
b. The woman who reports drinking 2 glasses of wine and 2 vodka martinis each day
c. The older adult man who reports drinking one glass of sherry before going to bed each night
d. The woman who reports drinking one glass of wine with lunch and dinner each day.
8. During a sports physical for a 16-year-old girl, the nurse asks which question to collect data about drug use?
a. “Many teenagers have tried street drugs. Have you tried these drugs? ”
b. “Tell me which street drugs your friends have offered to you?”
c. “Do most of your friends drink alcohol or do street drugs?”
d. “Your high school has a reputation for drug use. Do you use drugs?”
9. In contrasting the assessment of mental status from mental health, a nurse recognizes that data for the mental status examination are obtained using which techniques?
a. Asking them about their relatives who have mental health disorders
b. Having them demonstrate their ability to reason and calculate
c. Asking them to recall how they have coped with daily stress
d. Having them describe their mood and emotions
10. A nurse is admitting a new patient. Which statement by the patient suggests a bipolar disorder?
a. “The last time I had blood drawn at the office, I fainted dead away.”
b. “No matter how hard I try, I just can’t get into an elevator of any kind.”
c. “Everyone knows I can control the financial health of this town with a snap of my fingers.”
d. “I worked for Frank Sinatra’s band for several months when I lived in New Jersey years ago.”
Chapter 8: Nutritional Assessment
1. A patient with mild renal disease has been put on a 2200-calorie per day diet plan with the lowest recommended amount of protein. During discharge teaching, the nurse explains to this patient how to use nutrition labels to determine the amount of protein in the product. The nurse explains, however, that the label is based on 2000 calories. Which is the appropriate formula to teach this patient the least amount of protein he can eat on his prescribed diet?
a. 2200 calories ´ 0.15 = 330/9 calories/gram = 36.6 g
b. 2200 calories ´ 0.10 = 220/4 calories/gram = 55 g
c. 2200 calories ´ 0.20 = 440/9 calories/gram = 48.8 g
d. 2200 calories ´ 0.12 = 264/4 calories/gram = 66 g
2. A patient is put on an 1800-calorie a day diet plan. During discharge teaching, the nurse explains to this patient how to use nutrition labels to determine the amount of carbohydrates in the product. The nurse explains, however, that the label is based on 2000 calories. Which is the appropriate formula to teach this patient of the maximum grams of carbohydrates she can eat on her prescribed diet?
a. 1800 calories ´ 0.45 = 810/4 calories/gram = 202.5 g
b. 1800 calories ´ 0.60 = 1080/4 calories/gram = 270 g
c. 1800 calories ´ 0.55 = 990/9 calories/gram = 110 g
d. 1800 calories ´ 0.50 = 900/9 calories/gram = 100 g
3. A patient tells the nurse that she tries to keep her fat intake at less than 15% of her total caloric intake per day. What is the nurse’s most appropriate response to this patient’s comment?
a. “That is admirable; how do you accomplish fat intake that low on a daily basis?”
b. “Eating fat is essential for good health, and you should consume about 40% of your fats as monounsaturated fat.”
c. “Limiting fat prevents some diseases, but your fat intake is much lower than the 25% recommended.”
d. “If you want to bring your fat intake down further, you might want to eliminate eating fast foods.”
4. A patient who keeps his fat consumption at 10% of his total caloric intake is at risk for deficiency of which nutrient(s)?
a. Iron
b. Vitamins A, D, and K
c. Zinc
d. B and C vitamins
5. A nurse is asking questions about the present health status of a young woman who has lost weight recently. Which question is most appropriate when inquiring about present health status?
a. “What concerns have you had in the past regarding your weight?”
b. “Do you have anorexia?”
c. “Describe the recent changes in your weight.”
d. “Do you have a family history of eating disorders?”
6. While assessing a patient’s ability to consume food, the nurse recalls which types of foods are the easiest to chew and swallow?
a. Thin liquids
b. Soft foods
c. Dry foods
d. Chewy foods
7. Which tool is the best choice for a nurse to use as a quick screening tool to assess a patient’s dietary intake?
a. Food diary
b. Calorie count
c. Comprehensive diet history
d. 24-hour recall
8. A nurse calculates a patient’s body mass index (BMI) as 33. This measurement indicates which class of weight?
a. Overweight
b. Obesity class I
c. Obesity class II
d. Obesity class III
9. Nurses use which measurement as the most highly correlated with risk of morbidity and mortality?
a. Waist-to-hip ratio
b. Triceps skinfold measure
c. Desirable body weight
d. Body mass index (BMI)
10. What is the desired body weight for a male who is 7 feet tall?
a. 178 lb
b. 225 lb
c. 250 lb
d. 275 lb
Chapter 9: Skin, Hair, and Nails
1. A patient asks the nurse if it is possible to grow new skin. What is the nurse’s most appropriate response?
a. “Even if new skin growth is required, the melanocytes do not regenerate.”
b. “The avascular epidermis sheds slowly and is replaced completely every 4 weeks.”
c. “The outer layer of skin remains the same over the lifetime except for repairing injuries.”
d. “Epidermal regeneration is impossible because it is avascular.”
2. A nurse assessing a patient with liver disease expects to find which manifestation during the examination?
a. Yellowish color in the axilla and groin
b. Yellow pigmentation in the sclera
c. Very pale skin on the palms
d. Ashen-gray color in the oral mucous membranes
3. How does the nurse recognize jaundice in a dark-skinned patient?
a. Inspect the conjunctiva for ashen-gray color.
b. Inspect the nail beds for a deeper brown or purple skin tone.
c. Inspect the palms and soles for yellowish-green color.
d. Inspect the oral mucous membrane for yellow color.
4. What signs of cyanosis does a nurse inspect for in a dark-skinned patient?
a. Ashen-gray color of the oral mucous membranes
b. Blue color in the nail beds
c. Ashen-blue color in the palms and soles
d. Blue-gray color in the ear lobes and lips
5. When the patient’s chart includes a notation that petechiae are present, what finding does a nurse expect during inspection?
a. Purplish-red pinpoint lesions
b. Deep purplish or red patches of skin
c. Small raised fluid-filled pinkish nodules
d. Generalized reddish discoloration of an area of skin
6. When performing a skin assessment of an adult patient, the nurse expects what finding?
a. Reddened area does not blanch when gentle pressure is applied
b. Indentation of the finger remains in the skin after palpation
c. Flaking or scaling of the skin
d. Return of skin to its original position when pinched up slightly
7. A nurse notices a patient’s nails are thin and depressed with the edges turned up. What additional abnormal data should the nurse expect to find on this patient?
a. Pale conjunctiva
b. Jaundice
c. Ecchymosis
d. Rashes
8. A 45-year-old woman tells the nurse she is distressed by the presence of dark, coarse hair on her face that has recently developed. What is the nurse’s most appropriate response to this patient?
a. “This is simple vellus hair and it will decrease in amount over time.”
b. “Some women in your cultural group normally have dark hair on their faces.”
c. “This is unusual; female hair distribution should be limited to arms, legs, and pubis.”
d. “Coarse dark hair could result from hormonal changes such as from menopause.”
9. What findings does a nurse expect when inspecting and palpating a patient’s nails?
a. A nail base angle of not more than 90 degrees
b. Whitish to clear nails in darker-skinned patients
c. Nail surface is smooth and rounded
d. Transverse depression running across the nails
10. A nurse notices that the angle of the patient’s proximal nail fold and the nail plate are almost a flat line; about 160 degrees. How does the nurse interpret this finding?
a. This patient has chronic pulmonary disease.
b. This is an expected finding.
c. This is due to stress to the nails.
d. This is associated with anemia.
Chapter 10: Head, Eyes, Ears, Nose, and Throat
1. A patient is admitted with edema of the occipital lobe following a head injury. The nurse correlates which finding with damage to this area?
a. Ipsilateral ptosis
b. Impaired vision
c. Pupillary constriction
d. Increased intraocular pressure
2. The nurse is taking a health history on a patient who reports frequent stabbing headaches occurring once a day lasting about an hour. Which statement by the patient is most indicative of cluster headaches?
a. “I usually have nausea and vomiting with my headaches.”
b. “My whole head is constantly throbbing.”
c. “It feels like my head is in a vice.”
d. “The pain is on the left side over my eye, forehead, and cheek.”
3. A patient reports having migraine headaches on one side of the head that often start with an aura and last 1 to 3 days. As a part of the symptom analysis, the patient reports which associated symptoms of migraine headaches?
a. Nausea, vomiting, or visual disturbances
b. Nasal stuffiness or discharge
c. Ringing in the ears or dizziness
d. Red, watery eyes or drooping eyelids
4. The nurse is taking a health history on a patient who reports frequent headaches with pain in the front of the head, but sometimes felt in the back of the head. Which statement by the patient is most indicative of tension headaches?
a. “I usually have nausea and vomiting with my headaches.”
b. “My whole head is constantly throbbing.”
c. “It feels like my head is in a vice.”
d. “The pain is on the left side over my eye, forehead, and cheek.”
5. During symptom analysis, the nurse helps the patient distinguish between dizziness and vertigo. Which description by the patient indicates vertigo?
a. “I felt faint, like I was going to pass out.”
b. “I just could not keep my balance when I sat up.”
c. “It seemed that the room was spinning around.”
d. “I was afraid that I was going to lose consciousness.”
6. During symptom analysis, the nurse helps the patient distinguish between dizziness and vertigo. Which description by the patient indicates dizziness?
a. “I felt faint, like I was going to pass out.”
b. “It felt like I was on a merry-go-round.”
c. “The room seemed to be spinning around.”
d. “My body felt like it was revolving and could not stop.”
7. Which patient in the eye clinic should the nurse assess first?
a. The patient who reports a gradual clouding of vision
b. The patient who complains of sudden loss of vision
c. The patient who complains of double vision
d. The patient who complains of poor night vision
8. A patient complains of right ear pain. What findings does the nurse anticipate on inspecting the patient’s ears?
a. Redness and edema of the pinna of the right ear
b. Report of pain when the nurse manipulates the right ear
c. Bulging and red tympanic membrane in the right ear
d. Increased cerumen in the right ear canal
9. During the history, a patient reports watery nasal drainage from allergies. Based on this information, what does the nurse expect to find on inspection of the nares?
a. Enlarged and pale turbinates
b. Polyps within the nares
c. High vascularity of the turbinates
d. Dry and dull turbinates
10. A patient complains of nasal drainage and sinus headache. The nurse suspects a nasal infection and anticipates observing which finding during examination?
a. Foul-smelling drainage
b. Purulent green-yellow drainage
c. Bloody drainage
d. Watery drainage
Chapter 11: Lungs and Respiratory System
1. A patient tells the nurse that she has smoked two packs of cigarettes a day for 20 years. The nurse records this as how many pack-years?
a. 10
b. 20
c. 40
d. 60
2. After taking a brief health history, a nurse needs to complete a focused assessment on which patient?
a. A male who works as a painter
b. A male who plays basketball and hockey
c. A female who recently moved into a college dormitory
d. A female who has a history of gout
3. During a symptom analysis, a patient describes his productive cough and states his sputum is thick and yellow. Based on these data, the nurse suspects which factor as the cause of these symptoms?
a. Virus
b. Allergy
c. Fungus
d. Bacteria
4. During the problem-based history, a patient reports coughing up sputum when lying on the right side, but not when lying on the back or left side. The nurse suspects this patient may have a lung abscess. What additional question does the nurse ask to gather more data?
a. “Does the sputum have an odor?”
b. “Do you have chest pain when you take a deep breath?”
c. “Have you also experienced tightness in your chest?”
d. “Have you coughed up any blood?”
5. Which question will give the nurse additional information about the nature of a patient’s dyspnea?
a. “How often do you see the physician?”
b. “How has this condition affected your day-to-day activities?”
c. “Do you have a cough that occurs with the dyspnea?”
d. “Does your heart rate increase when you are short of breath?”
6. A patient complains of shortness of breath and having to sleep on three pillows to breathe comfortably at night. During the nurse’s examination, what findings will suggest that the cause of this patient’s dyspnea is due to heart disease rather than respiratory disease?
a. Increased anteroposterior diameter
b. Clubbing of the fingers
c. Bilateral peripheral edema
d. Increased tactile fremitus
7. During a history, a nurse notices a patient is short of breath, is using pursed-lip breathing, and maintains a tripod position. Based on these data, what abnormal finding should the nurse expect to find during the examination?
a. Increased tactile fremitus
b. Inspiratory and expiratory wheezing
c. Tracheal deviation
d. An increased anteroposterior diameter
8. A nurse notices a patient’s chest wall moving in during inspiration and out during expiration. What additional assessment must the nurse perform immediately?
a. Palpate for tracheal deviation.
b. Auscultate for bronchovesicular breath sounds in the lung periphery.
c. Palpate posterior thoracic muscles for tenderness.
d. Auscultate for absence of breath sounds in the lung periphery.
9. A nurse inspects a patient’s hands and notices clubbing of the fingers. The nurse correlates this finding with what condition?
a. Pulmonary infection
b. Trauma to the thorax
c. Chronic hypoxemia
d. Allergic reaction
10. A nurse is assessing a patient who was diagnosed with emphysema and chronic bronchitis 5 years ago. During the assessment of this patient’s integumentary system, what finding should the nurse correlate to this respiratory disease?
a. Dry, flaky skin
b. Clubbing of the fingers
c. Hypertrophy of the nails
d. Hair loss from the scalp
Chapter 12: Heart and Peripheral Vascular System
1. A nurse informs a patient that her blood pressure is 128/78. The patient asks what the number 128 means. What is the nurse’s appropriate response? The 128 represents the pressure in your blood vessels when:
a. “The ventricles relax and the aortic and pulmonic valves open.”
b. “The ventricles contract and the mitral and tricuspid valves close.”
c. “The ventricles contract and the mitral and tricuspid valves open.”
d. “The ventricles relax and the aortic and pulmonic valves close.”
2. A nurse determines that a patient has a heart rate of 42 beats per minute. What might be a cause of this heart rate?
a. Sinoatrial (SA) node failure
b. Atrial bradycardia
c. A well-conditioned heart muscle
d. Left ventricular hypertrophy
3. While taking a history, a nurse learns that a patient had rheumatic heart disease as a child. Based on this information, what abnormal data might this nurse expect to find during an examination?
a. An extra beat just before the S2 heart sound heard during auscultation
b. A raspy machine-like or blowing sound heard during auscultation
c. A prominent thrust of the heart against the chest wall felt on palpation
d. A visible indentation of pericardial tissue noted during inspection
4. A nurse is completing a symptom analysis with a patient complaining of chest pain. When asked what makes the chest pain worse, the patient reports that coughing and sneezing increase the chest pain. Based on these data, what does the nurse suspect as the cause of this patient’s chest pain?
a. Stable angina
b. Esophageal reflux disease
c. Mitral valve prolapse
d. Costochondritis
5. The patient describes her chest pain as “squeezing, crushing, and 12 on a scale of 10.” This pain started more than an hour ago while she was resting, and she also feels nauseous. Based on these findings, the nurse should assess for which associated symptoms?
a. Tachycardia, tachypnea, and hypertension
b. Dyspnea, diaphoresis, and palpitations
c. Hyperventilation, fatigue, anorexia, and emotional strain
d. Fever, dyspnea, orthopnea, and friction rub
6. When auscultating the heart of a patient with pericarditis, the nurse expects to hear which sound?
a. A systolic murmur
b. An S3 heart sound
c. A friction rub
d. An S4 heart sound
7. Which patient’s statement helps a nurse distinguish between chest pain originating from pericarditis rather than from angina?
a. “No, I have not done anything to strain chest muscles.”
b. “If I take a deep breath, the pain gets much worse.”
c. “This pain feels like there’s an elephant sitting on my chest.”
d. “Whenever this pain happens, it goes right away if I lie down.”
8. While taking a history, a nurse learns that this patient experiences shortness of breath (dyspnea). If the cause of the dyspnea is a cardiovascular problem, the nurse expects which abnormal finding on examination?
a. Flat jugular neck veins
b. Red, shiny skin on the legs
c. Weak, thready peripheral pulses
d. Edema of the feet and ankles
9. A nurse is assessing a patient’s peripheral circulation. Which finding indicates venous insufficiency of this patient’s legs?
a. Paresthesias and weak, thin peripheral pulses
b. Leg pain that can be relieved by walking
c. Edema that is worse at the end of the day
d. Leg pain that increases when the legs are lowered
10. A patient reports having leg pain while walking that is relieved with rest. Based on these data, the nurse expects which finding on inspection and palpation of this patient?
a. 1+ edema of the feet and ankles bilaterally
b. The circumference of the right leg is larger than the left leg
c. Patchy petechiae and purpura of the lower extremities
d. Cool feet with capillary refill of toes greater than 3 seconds
Chapter 13: Abdomen and Gastrointestinal System
1. A patient tells the nurse, “I’ve been having pain in my belly for several days that gets worse after eating.” Which datum from the symptom analysis is consistent with the nurse’s suspicion of peptic ulcer disease?
a. Gnawing epigastric pain radiates to the back or shoulder that worsens after eating.
b. Sharp midepigastric pain radiates to the jaw.
c. Intermittent cramping pain in the left lower quadrant is relieved by defecation.
d. Colicky pain is felt near the umbilicus with vomiting and constipation.
2. During an assessment for abdominal pain, a patient reports a colicky abdominal pain and pain in the right shoulder that gets worse after eating fried foods. What question does the nurse ask to confirm the suspicion of cholelithiasis?
a. “Have you noticed any swelling in your ankles or feet at the end of the day?”
b. “Have you noticed a change in the color of your urine or stools?”
c. “Have you vomited up any blood in the last 24 hours?”
d. “Have you experienced fever, chills, or sweating?”
3. A patient reports having frequent heartburn. Which question does the nurse ask in response to this information?
a. “Has your abdomen been distended when you feel the heartburn?”
b. “What have you eaten in the last 24 hours?”
c. “Is there a history of heart disease in your family?”
d. “How long after eating do you have heartburn?”
4. A patient reports having abdominal distention. The nurse notices that the patient’s sclerae are yellow. What question is appropriate for the nurse to ask in response to this information?
a. “Has there been a change in your usual pattern of urination?”
b. “Have you had any nausea or vomiting?”
c. “Has there been a change in your bowel habits?”
d. “Have you had indigestion or heartburn?”
5. A patient reports having abdominal distention and having vomited several times yesterday and today. What question is appropriate for the nurse to ask in response to this information?
a. “Has there been a change in your usual pattern of urination?”
b. “Did you have heartburn before the vomiting?”
c. “What did the vomitus look like?”
d. “Have you noticed a change in the color of your urine or stools?”
6. A patient reports a change in the usual pattern of urination. What question does the nurse ask to determine if incontinence is the reason for these symptoms?
a. “Do you have the feeling that you cannot wait to urinate?”
b. “Are you urinating a large amount each time you go to the bathroom?”
c. “Has the color of your urine changed lately?”
d. “Have you noticed any swelling in your ankles at the end of the day?”
7. In assessing a patient with renal disease, the nurse palpates edema in both ankles and feet. Based on this finding, what question does the nurse ask the patient?
a. “Have you had any pain in your abdomen?”
b. “Have you had an unexpected weight gain?”
c. “Have you noticed a change in the color of your skin?”
d. “Have you had any nausea or vomiting?”
8. A patient reports having abdominal distention. The nurse observes that the patient’s sclerae are yellow. Which abnormal finding does the nurse anticipate on examination of this patient’s abdomen?
a. Decreased bowel sounds in all quadrants
b. Glistening or taut skin of the abdomen
c. Bulge in the abdomen when coughing
d. Bruit around the umbilicus
9. When inspecting a patient’s abdomen, which finding does the nurse note as normal?
a. Engorgement of veins around the umbilicus
b. Sudden bulge at the umbilicus when coughing
c. Visible peristalsis in all quadrants
d. Silver-white striae extending from the umbilicus
10. When inspecting a patient’s abdomen, the nurse notes which finding as abnormal?
a. Protruding abdomen with skin that is lighter in color than the arms and legs
b. Marked rhythmic pulsation to the left of the midline
c. Faint, fine vascular network
d. Small shadows created by changes in contour
Chapter 14: Musculoskeletal System
1. Which description of pain from the patient makes a nurse suspect the patient’s pain is originating from a muscle?
a. “Crampy”
b. “Dull and deep”
c. “Boring and intense”
d. “Sharp upon movement”
2. A nurse asks a patient to describe his new onset of leg pain. He slept well through the night, but this morning he suddenly developed pain in his left lower leg that is red and too painful to touch. Nothing relieves the pain. Based on these data, the nurse suspects which disorder is causing this pain?
a. Rheumatoid arthritis
b. Osteoarthritis
c. Gout
d. Tendonitis
3. During a history, the patient reports having gout. Based on this information, what findings does the nurse anticipate during a focused assessment?
a. Warm, tender, and deformed wrists and peripheral interphalangeal (PIP) joints bilaterally
b. Edema, warmth, and redness of one great toe and pea-like nodules in the ear lobes
c. Enlarged and tender PIP or distal interphalangeal (DIP) joints on one or several fingers
d. Tenderness with pronation and supination of the elbow and point tenderness on the lateral epicondyle
4. A patient reports joint pain interfering with sleep and morning joint stiffness for the first hour after getting out of bed. Considering this report, what abnormal findings does the nurse anticipate during the examination?
a. Abrupt onset of local tenderness, edema, and decreased range of motion of the shoulder and hip bilaterally
b. Decreased range of motion of one hip and knee with pain on flexion and crepitus during movement of these joints
c. Erythema in one great toe, ankle, and lower leg that is painful to the touch
d. Hot, painful, deformed, and edematous wrists and peripheral interphalangeal joints bilaterally
5. In assessing a patient with a history of poliomyelitis, the nurse suspects the right leg muscles are smaller than the left leg. What is the best approach for the nurse to confirm or reject this suspicion?
a. Palpating both legs using the pads of the thumb and index fingers and comparing one side with another
b. Using a tape to measure each leg’s circumference at the same location, above or below the nearest joint
c. Using a goniometer to measure the upper and lower legs with the patient in supine and standing positions
d. Palpating the legs using the tips of the thumb and index fingers, and comparing the findings with the Lovett scale
6. In assessing the joint range of motion of a patient’s knees, the nurse notices the flexion is less than expected in both knees. What is the next appropriate action for the nurse?
a. Documenting this finding as expected for this patient because it occurs in both knees
b. Palpating the suprapatellar pouch on each side of the quadriceps for contour, tenderness, and edema
c. Using a goniometer to measure the flexion in both knees and comparing the results with expected flexion
d. Applying opposing force to the lower leg while the patient tries to maintain flexion and extension
7. The nurse asks the patient to hold the arms straight out, perpendicular to the floor, and the nurse tries to push the patient’s arms down. This procedure tests the strength of which muscles?
a. Triceps
b. Biceps
c. Trapezius
d. Deltoid
8. To assess the triceps and biceps muscle strength, the nurse applies resistance to the patient’s arm. What should be done to ensure the appropriate muscle is being assessed?
a. The patient pushes up against the nurse’s hand to abduct the triceps muscle and pushes down against the nurse’s hand to adduct the biceps muscle.
b. The patient pushes forward against the nurse’s hand to extend the triceps muscle and pulls backward against the nurse’s hand to flex the biceps muscle.
c. The patient pulls backward against the nurse’s hand to flex the triceps muscle and pushes forward against the nurse’s hand to extend the biceps muscle.
d. The patient pushes up against the nurse’s hand to abduct the biceps muscle and pushes down against the nurse’s hand to adduct the triceps muscle.
9. The nurse notes that there is an audible clicking sound when the patient opens and closes the mouth. What is the appropriate response of the nurse at this time?
a. Recording this as an abnormal finding, requiring additional assessment
b. Measuring the distance between each side of the mandible and the eyes
c. Applying resistance to the maxilla and asking the patient to repeat the motion
d. Documenting this finding as expected if no other signs or symptoms are found
10. A nurse palpates the patient’s jaw movement by placing two fingers in front of each ear and asking the patient to slowly open and close the mouth. What movement does the nurse ask the patient to do next?
a. Move the jaw side to side.
b. Swallow.
c. Smile.
d. Clench the teeth together.
Chapter 15: Neurologic System
1. A nurse assesses a patient with a head injury who has slowing intellectual functioning, personality changes, and emotional lability. The nurse correlates these findings with which area of the brain?
a. Frontal lobe
b. Parietal lobe
c. Thalamus
d. Temporal lobe
2. In assessing a patient with damage to the occipital lobe, the nurse correlates which clinical manifestation to this injury?
a. Intentional tremors
b. Visual changes
c. Decreased hearing
d. Inability to formulate words
3. While obtaining a symptom analysis from a patient who has an inner ear infection, the nurse helps the patient distinguish between dizziness and vertigo. Which description by the patient indicates vertigo?
a. “I felt lightheaded when I stood up.”
b. “I just could not keep my balance when I sat up.”
c. “It seemed that the room was spinning around.”
d. “I was afraid that I was going to lose consciousness.”
4. While obtaining a symptom analysis from a patient who had a transient ischemic attack, the nurse helps the patient distinguish between dizziness and vertigo. Which description by the patient indicates dizziness?
a. “I felt lightheaded when I stood up.”
b. “It felt like I was on a merry-go-round.”
c. “The room seemed to be spinning around.”
d. “My body felt like it was revolving and could not stop.”
5. Which patient behavior indicates to the nurse that the patient’s facial cranial nerve (CN VII) is intact?
a. The patient’s eyes move to the left, right, up, down, and obliquely.
b. The patient moistens the lips with the tongue.
c. The sides of the mouth are symmetric when the patient smiles.
d. The patient’s eyelids blink periodically.
6. A nurse assessing a patient who had a cerebrovascular accident involving the Broca area suspects expressive or nonfluent aphasia. What communication abilities does the nurse anticipate from this patient?
a. The patient understands speech but is unable to translate ideas into meaningful speech.
b. The patient is unable to comprehend speech and thus does not respond verbally.
c. The patient is able to understand speech but has difficulty forming words, creating muffled speech.
d. The patient is unable to comprehend speech and responds inappropriately to conversation.
7. The nurse hears in a report that a patient has receptive or fluent aphasia. What communication abilities does the nurse anticipate from this patient?
a. The patient understands speech but is unable to translate ideas into meaningful speech.
b. The patient is able to understand speech but has difficulty forming words creating muffled speech.
c. The patient is unable to comprehend speech and thus does not respond verbally.
d. The patient is emotionally liable and cries easily, which interferes with the ability to communicate.
8. What is the earliest and most sensitive indication of altered cerebral function?
a. Unequal pupils
b. Loss of deep tendon reflexes
c. Paralysis on one side of the body
d. Change in level of consciousness
9. A patient reports having difficulty swallowing. Based on this information, how does the nurse assess the cranial nerve related to swallowing?
a. Ask the patient about feeling the blunt end of a paper clip along the jaw line.
b. Observe the rising of the soft palate when the patient says “Ahh.”
c. Observe the symmetry of the face when the patient talks.
d. Assess taste on the anterior part of the tongue.
10. A patient reports having difficulty swallowing. Based on this information, how does the nurse assess the appropriate cranial nerve?
a. Ask the patient to stick out the tongue and move it in all directions.
b. Ask the patient to move the head to the right and left.
c. Observe the symmetry of the face when the patient talks.
d. Assess for taste on the anterior part of the tongue.
Chapter 16: Breasts and Axillae
1. In teaching a patient about breast self-examination, why does the nurse emphasize palpation of the axillary areas?
a. Because deep muscles in that area can mask changes
b. Because some patients avoid this area because of tenderness
c. Because most lymph draining from the breast flows through this area
d. Because supporting ligaments in this area may present as tissue changes
2. In reviewing the charts of several patients in the clinic, a nurse recognizes which patient as being at highest risk of breast cancer?
a. A woman who had her first child at age 26
b. A woman who reached menopause at age 58
c. A woman who breastfed all four of her children
d. A woman who states that she reached menarche at age 14
3. While giving a presentation about breast health, a nurse informs patients about which recommendation?
a. Women in their 30s should have annual clinical breast examinations.
b. Women at high risk of breast cancer should have semiannual mammograms.
c. Women who are postmenopausal require clinical breast examination every 5 years.
d. A screening mammogram is recommended for all women beginning at age 50 years.
4. Based on the history, a nurse determines that the patient with which finding requires further assessment?
a. Occasional discharge from nipples
b. Supernumerary nipples along the milk line
c. Rash in the axillae associated with change in deodorant
d. Mild breast swelling that fluctuates with the menstrual cycle
5. During a breast examination of a healthy female, the nurse recognizes which finding as normal?
a. Asymmetrical venous pattern
b. Unequal nipple size
c. Supernumerary nipples along the milk line
d. Pink discharge from one nipple when manipulated
6. A patient comes to the clinic complaining of a new onset of nipple discharge. After inspection of the breast and discharge, what action of the nurse has the highest priority?
a. Palpating both breasts comparing amount of discharge
b. Asking the patient about breast pain
c. Asking the patient to raise her arms and comparing the movement of the breasts
d. Obtaining a specimen of the discharge for cytology
7. What is the purpose of asking a female to lean forward during the breast examination?
a. To accentuate the Montgomery glands
b. To observe for symmetry of the suspensory ligaments
c. To compare nipple symmetry
d. To identify any breast masses in the subcutaneous tissues
8. Which technique does a nurse use to palpate the patient’s axillary lymph nodes?
a. With the patient sitting, the nurse places fingers of both hands deep into the axilla, one hand on either side, and firmly pushes the axillary tissue toward the center to feel for enlarged nodes.
b. With the patient lying supine with arms at the sides, the nurse uses the tips of the fingers of one hand to palpate the axilla moving from the posterior to the anterior aspect of the axilla to feel for enlarged nodes.
c. With the patient lying supine with the hand behind the head of the side being assessed, the nurse uses the pads of fingers of one hand to systematically palpate the axilla using small circular motions to feel for enlarged nodes.
d. With the patient sitting, the nurse places fingers of one hand deep into the axilla and firmly slides the fingers along the patient’s middle, anterior, and posterior of the axilla to feel for enlarged nodes.
9. When examining the lymph nodes of an adult female patient, the nurse recognizes which finding as normal?
a. Visible superficial nodes
b. Palpable supraclavicular nodes
c. Nonpalpable lymph nodes in the axilla
d. Enlarged, fixed nodes in the neck
10. A nurse performing a breast examination on a female patient places the patient in a supine position, places a pillow under the right shoulder, and asks the patient to place her right lower arm above her head. What is the reason for this position?
a. Flatten the breast tissue evenly over the chest wall.
b. Help the patient to relax and feel more comfortable.
c. Reveal lumps deep in the breast more easily.
d. Expose any drainage from the nipples.
Chapter 17: Reproductive System and the Perineum
1. During the initial inspection of the female genitalia, the nurse recognizes which finding as normal?
a. The labia minora are hair-covered and lying within the labia majora.
b. The cervical os in the multiparous woman has the shape of a small circle.
c. The vaginal vestibule lies between the labia minora and contains the urinary meatus.
d. The openings of Skene and Bartholin glands are visible posteriorly.
2. The pregnant patient tells the nurse that she has had three pregnancies and two live births to date. How does the nurse record this in the patient’s history?
a. Gravida 3, para 3
b. Gravida 3, para 2
c. Gravida 2, para 3
d. Gravida 2, para 2
3. A mother asks a nurse when her daughter should get immunized again for human papilloma virus (HPV). What is the nurse’s most appropriate response to this question?
a. “Your daughter does not need this immunization until she becomes sexually active.”
b. “The recommended age for this immunization is between ages 25 and 30 years of age.”
c. “Between the ages of 11 and 26 years is the recommended time for this immunization.”
d. “When she begins having menstrual periods is the best time for this immunization.”
4. A patient asks when she should make an appointment for her first Pap (Papanicolaou) test to screen for cervical cancer. What is the nurse’s most appropriate response?
a. “There is no need for Pap tests until after you have become pregnant.”
b. “All women should have the first Pap test after reaching menarche.”
c. “All women should have the first Pap test after they are 19 years of age.”
d. “All women should have the first Pap test when they become sexually active or at age 21.”
5. A patient asks when she can stop having Pap (Papanicolaou) tests. What is the nurse’s most appropriate response?
a. “Until you are no longer sexually active.”
b. “Through age 65.”
c. “Until you begin menopause.”
d. “Through the end of menopause.”
6. When performing a well woman examination, the nurse expects what findings?
a. The inner surface of the vestibule is deep pink and moist with a smooth texture.
b. The inguinal skin appears wrinkled and moist with sparse hair distribution.
c. The labia minora is deeply pigmented, and the tissue is ragged and asymmetrical.
d. Pubic hair is distributed evenly over the mons and shaped as a triangle with the apex over the mons.
7. The nurse documents which finding as expected on inspection of the anus?
a. Skin tone darker and coarser than that of the surrounding skin
b. Sphincter lightly closed when the patient is relaxed
c. Large amount of stiff, curling hair surrounding the anus
d. Slight protrusion under the skin when the patient strains or bears down
8. On inspection of the internal structure of the vagina, the nurse notes a rounded protrusion on the posterior wall of the vagina. How does the nurse document this finding?
a. Rectocele
b. Cystocele
c. Bartholin cyst
d. Nabothian cyst
9. During the examination of the internal genitalia with the speculum, the nurse records which finding as normal?
a. A healed laceration of the cervix in a nulliparous patient
b. A large amount of thick white drainage from the cervical os
c. Deviation of the cervix toward the posterior vaginal wall
d. Pink cervix with a small ring of reddened tissue near the os
10. The nurse recognizes that a Papanicolaou (Pap) test is indicated for which patient?
a. A 12-year-old who has not yet reached menarche.
b. A 30-year-old who had a normal Pap test 12 months ago.
c. A 45-year-old who had a total hysterectomy for cervical cancer.
d. A 55-year-old who had a total hysterectomy to treat endometriosis.
Chapter 18: Developmental Assessment Throughout the Life Span
1. Which statement best illustrates Erikson’s theory of development?
a. The main goal is to establish equilibrium between self and environment.
b. One progresses through stages that involve specific psychosocial tasks.
c. There are four distinct, sequential levels of cognitive development.
d. Cognitive development occurs from birth to around age 15.
2. A nurse asks a 15-year-old boy to think of an explanation for a simple puzzle. When he is unable to come up with any answer at all, the nurse recognizes that he may not yet have successfully mastered which of Piaget’s levels of cognitive development?
a. Sensorimotor
b. Preoperational
c. Concrete operations
d. Formal operations
3. When performing a physical assessment on a 7-month-old infant, the nurse notes that the child is able to smile responsively and unable to roll from the prone to the supine position. What is the most appropriate action for this nurse?
a. Reassure the parents that the infant is “performing like an 8-month-old.”
b. Document the infant’s growth and development as “within normal limits.”
c. Continue to assess the infant for other signs of developmental delay.
d. Give the caretaker specific directions for specialized exercises.
4. A 7-month-old infant weighs 11.6 lb compared with a birth weight of 7.1 lb and has a head circumference of 19 inches. What does the nurse document about this infant?
a. Underweight and normal head circumference
b. Underweight and larger-than-normal head circumference
c. Overweight and smaller-than-normal head circumference
d. Normal weight and larger-than-normal head circumference
5. A nurse notices that an infant tries to reach for a toy that the mother has hidden in her hand. This illustrates that the child has developed an understanding of which concept?
a. Object permanence
b. Trust versus mistrust
c. Autonomy
d. Parallel play
6. The parents of a toddler express concern that the child is not progressing the same way as their other children did at that age. What is the most appropriate suggestion the nurse can give the parents about monitoring the progress of the toddler?
a. Advising the parents to take the toddler to the clinic every 2 months for reevaluation
b. Teaching the parents how to use the Denver II test to assess for gross motor movement, language, fine motor movement, and personal-social skills
c. Suggesting that the child needs more time to reach the milestones and that additional monitoring is not necessary
d. Informing the parents about the ages and stages questionnaire (ASQ), which identifies developmental delays in children from 4 to 60 months
7. Which characteristics are expected during an assessment of a normal toddler?
a. Half of adult height achieved by age two, potbelly, and sway back.
b. Thirty-two erupted teeth by age 2, tripled birth weight by age 30 months.
c. Desire for autonomy coupled with sufficient judgment to ensure safety.
d. Head circumference greater than chest circumference, high frustration tolerance.
8. A nurse makes observations about a toddler’s motor development. Which behavior is an example of fine motor behavior?
a. Sitting up in a chair
b. Walking while holding on to the edge of a table
c. Creeping up the stairs
d. Stacking blocks to make a tower
9. A nurse is assessing a preschooler who is able to draw a three-part human figure, hop on one foot, and recognize three colors. The nurse recognizes these characteristics as consistent for what age?
a. 3 years old
b. 4 years old
c. 5 years old
d. 6 years old
10. A parent tells the nurse about having difficulty disciplining a 5-year-old child. What characteristic does the nurse teach this parent to improve the discipline of this child?
a. Children at this age are incapable of delaying gratification.
b. At age 5 years, children are not interested in attaining rights and privileges of individuality.
c. Five-year-olds should demonstrate basic social skills and respond to others’ expectations.
d. At age 5 years, children use highly inappropriate methods of expressing frustration.
Chapter 19: Assessment of the Infant, Child, and Adolescent
1. An adolescent patient appears reluctant to discuss sensitive issues with her parents present. What is the nurse’s most appropriate intervention?
a. Tell the patient that it is very important to be honest and specific.
b. Provide time when the adolescent is alone with the nurse.
c. Reassure the patient that anything said in the interview is considered confidential.
d. Ask the parents to answer the questions if the patient is not willing to answer.
2. What does the nurse teach to parents to prevent sudden infant death syndrome (SIDS)?
a. Place the baby on back to sleep.
b. Place the baby on side to sleep.
c. Not to feed the baby for 3 hours before sleep.
d. Place the baby on her stomach to sleep.
3. In taking a history from an adolescent girl about diet and nutrition, a nurse specifically asks which question?
a. “How frequently do you eat fast food or junk food?”
b. “Which carbonated drinks do you drink most often?”
c. “Do you have any food restrictions or diet routines?”
d. “What are your favorite fruits and vegetables?”
4. A nurse is assessing a child who is able to dress herself, jump rope, identify colors, and follow rules when playing games. These are expected developmental achievements of a child of what age?
a. 3 years old
b. 4 years old
c. 5 years old
d. 6 years old
5. A 4-year-old child has had a tonsillectomy and the nurse is preparing to ask him about his pain. Which technique is the most appropriate method for pain assessment for this patient?
a. Asking him if the pain hurts “a little or a lot”
b. Asking him to rate the pain on a scale of 0 to 10
c. Using the visual analog scale to rate the pain
d. Using the Wong/Baker FACES rating scale
6. Which assessment technique is appropriate to measure the 8-month-old’s vital signs during a well-baby check?
a. Assess temperature using a rectal thermometer.
b. Observe the infant’s abdomen when counting respirations.
c. Take the infant from the parent’s arms to assess pulse.
d. Measure blood pressure in the leg.
7. An American Indian mother expresses concern about an irregularly shaped, dark area over her neonate’s sacrum and buttocks. What is the nurse’s most appropriate response to this mother?
a. “This area will continue to grow until the infant is 10 to 15 months old.”
b. “This is a birth mark, which usually disappears by age 5 years.”
c. “This skin abnormality will require follow-up care.”
d. “This is a birth mark and they usually disappear by age 1 or 2 years.”
8. How does a nurse document a large, flat bluish capillary area on a neonate’s cheek?
a. Mongolian spot
b. Stork bite (telangiectasis)
c. Port-wine stain (nevus flammeus)
d. Strawberry hemangioma
9. How does a nurse collect baseline measurements of a 6-month-old infant?
a. Measure the chest circumference around the lower ribs.
b. Ask the parent how much the infant’s weight has changed since birth.
c. Measure the head just above the ears and eyebrows.
d. Ask the parent to hold the infant while the nurse measures the length.
10. How does a nurse assess the head circumference of an infant?
a. Places a ruler behind the infant’s head, noting the head width.
b. Uses a plastic headband placed around the infant’s head from crown to chin.
c. Places a measuring tape around the head above the eyebrows and occipital prominence.
d. Uses a measuring tape to find the distance between the ears and eyes and between the eyes and occiput.
Chapter 20: Assessment of the Pregnant Patient
1. A patient who is 30 weeks pregnant tells the nurse, “I have had low blood pressure all my life, and now it is 136/74. What’s wrong with me?” What is the most appropriate response by this nurse?
a. “A woman’s blood pressure usually drops several points during pregnancy, but yours hasn’t.”
b. “The blood pressure increases because your blood volume increases to supply you and the baby with enough blood.”
c. “Yes, this is a significant change from your baseline, and I advise you to see your obstetrician at your earliest convenience.”
d. “If you spend more time lying down, I think your blood pressure should return to normal in a few days.”
2. A nurse instructs the patient about which expected skin changes during pregnancy?
a. Nipples becoming thicker
b. Hands and feet becoming pale and cool
c. Blotchy, brown pigmentation of the abdomen
d. Stretch marks on the expanding abdomen
3. How does a nurse determine the Goodell sign?
a. Assesses the softening of the lower uterine segment
b. Palpates for softening of the cervix
c. Assesses the breasts for fullness and tenderness
d. Inspects the cervix for a bluish coloration
4. The nurse recognizes which clinical manifestation as a positive sign of pregnancy?
a. Cessation of menstruation
b. Visualization of the fetus by ultrasound
c. Nausea and increased abdominal girth
d. Positive pregnancy test (hCG)
5. Using Nägele’s rule, what is the estimated delivery date of a patient whose last menstrual period started on December 1?
a. August 1
b. August 10
c. September 4
d. September 8
6. What is the meaning of “G5, T1, P0, A3, L1” found in a patient’s history?
a. One birth at term
b. Three living children
c. Five grown children
d. One delivery not at term
7. A pregnant woman who drinks alcoholic beverages while pregnant increases the risk for which disorder?
a. Low infant birth weight
b. Birth defects
c. Abruptio placentae
d. Gestational diabetes mellitus
8. A nurse refers which pregnant patient for additional assessment?
a. A woman at 36 weeks of gestation who has 30% effacement of the cervix
b. A woman at 19 weeks of gestation who has noticed fetal movement every day this week
c. A woman at 20 weeks of gestation who has gained 4 lb in the last 2 weeks
d. A woman at 28 weeks of gestation who has a systolic blood pressure of 40 mg Hg over baseline
9. A patient’s prepregnant weight was 131 lb, within the desirable range for her height. What is the expected weight for this pregnant patient?
a. 131 lb at 1 week postpartum
b. 140 lb at the end of the first trimester
c. 145 lb at the end of the second trimester
d. 176 lb at the beginning of the third trimester
10. A pregnant patient presents to the clinic with a 3 lb/wk weight gain for 2 successive weeks. The nurse is most concerned that this patient is demonstrating signs of which condition?
a. Gestational diabetes mellitus
b. Preeclampsia
c. Placenta enlargement
d. Multiple gestations

AND MUCH MORE