final review

nurs 311

During an interview, the nurse states, "You mentioned

shortness of breath. Tell me more about that." Which
verbal skill is used with this statement?

A) Reflection
B) Facilitation
C) Direct question
D) Open-ended question

 D) Open-ended question
Page: 32 The open-ended question asks for
narrative information. It states the topic to be
discussed but only in general terms. The
nurse should use it to begin the interview, to
introduce a new section of questions, and
whenever the person introduces a new topic.

A nurse is taking complete health histories on all of the patients attending

a wellness workshop. On the history form, one of the written questions
asks, "You don't smoke, drink, or take drugs, do you?" This question is an
example of:

A) talking too much.

B) using confrontation.
C) using biased or leading questions.
D) using blunt language to deal with
distasteful topics.

 C) using biased or leading questions.

Page: 36 This is an example of using leading
or biased questions. Asking, "You don't
smoke, do you?" implies that one answer is
"better" than another. If the person wants to
please someone, he or she is either forced to
answer in a way corresponding to their
implied values or is made to feel guilty when
admitting the other answer.

The nurse is interviewing a patient who has a hearing impairment.

What techniques would be most beneficial in communicating with
this patient?

A) Determine the communication method he prefers.

B) Avoid using facial and hand gestures because most hearingimpaired people find this degrading.

C) Request a sign language interpreter before meeting with him

to help facilitate the communication.
D) Speak loudly and with exaggerated facial movement when
talking with him because this helps with lip reading.

 A) Determine the communication method he prefers.

Pages: 40-41 The nurse should ask the deaf person the
preferred way to communicateby signing, lip reading,
or writing. If the person prefers lip reading, then the nurse
should be sure to face him or her squarely and have
good lighting on the nurse's face. The nurse should not
exaggerate lip movements because this distorts words.
Similarly, shouting distorts the reception of a hearing aid
the person may wear. The nurse should speak slowly
and should supplement his or her voice with appropriate
hand gestures or pantomime.

The nurse is performing a health interview on a patient who has a

language barrier, and no interpreter is available. Which is the best example
of an appropriate question for the nurse to ask in this situation?

A) "Do you take medicine?"

B) "Do you sterilize the bottles?"
C) "Do you have nausea and vomiting?"
D) "You have been taking your medicine,
haven't you?"

 A) "Do you take medicine?"

Page: 46 In a situation where there is a
language barrier and no interpreter available,
use simple words avoiding medical jargon.
Avoid using contractions and pronouns. Use
nouns repeatedly and discuss one topic at a
time.

A female patient does not speak English well, and the nurse needs
to choose an interpreter. Which of the following would be the most
appropriate choice?

A) A trained interpreter
B) A male family member
C) A female family member
D) A volunteer college student from the
foreign language studies department

 A) A trained interpreter
Page: 46 whenever possible, the nurse
should use a trained interpreter, preferably
one who knows medical terminology. In
general, an older, more mature interpreter is
preferred to a younger, less experienced one,
and the same gender is preferred when
possible.

The nurse is conducting an interview. Which of these statements is

true regarding open-ended questions? Select all that apply.

A) They elicit cold facts.

B) They allow for self-expression.
C) They build and enhance rapport.
D) They leave interactions neutral.
E) They call for short one- to two-word
answers.
F) They are used when narrative
information is needed.

 B) They allow for self-expression.

C) They build and enhance rapport.
F) They are used when narrative information
Page: 32 Open-ended questions allow for selfexpression, build rapport, and obtain narrative
information. These features enhance
communication during an interview. The other
statements are appropriate for closed or direct
questions.

An elderly Mexican-American woman with traditional beliefs has

been admitted to an inpatient care unit. A culturally-sensitive nurse
would

A) contact the hospital administrator about the

best course of action.
B) automatically get a curandero for her because
it is not culturally appropriate for her to request
one.
C) further assess the patient's cultural beliefs and
offer the patient assistance in contacting a
curandero or priest if she desires.
D) ask the family what they would like to do
because Mexican-Americans traditionally give
control of decisions to their families.

 C) further assess the patient's cultural beliefs and

offer the patient assistance in contacting a
curandero or priest if she desires.
Pages: 22-23 In addition to seeking help from the
biomedical/scientific health care provider, patients
may also seek help from folk or religious healers.
Some people, such as those of Mexican-American
or American Indian origins, may believe that the
cure is incomplete unless the body, mind, and spirit
are also healed (although the division of the person
into parts is a Western concept).

The nurse is reviewing concepts of cultural aspects of pain. Which

statement is true regarding pain?

A) All patients will behave the same way when in

pain.
B) Just as patients vary in their perceptions of
pain, so will they vary in their expressions of
pain.
C) Cultural norms have very little to do with pain
tolerance, because pain tolerance is always
biologically determined.
D) A patient's expression of pain is largely
dependent on the amount of tissue injury
associated with the pain.

 B) Just as patients vary in their perceptions of pain,

so will they vary in their expressions of pain.
Page: 25 In addition to expecting variations in pain
perception and tolerance, the nurse should expect
variations in the expression of pain. It is well known
that individuals turn to their social environment for
validation and comparison. The other statements
are incorrect.

When the nurse is evaluating the reliability of a patient's responses,

which of these statements would be correct? The patient:

A. has a history of drug abuse and therefore

is not reliable.
B. provided consistent information and
therefore is reliable.
C. smiled throughout interview and therefore
is assumed reliable.
D. would not answer questions concerning
stress and therefore is not reliable.

 B. provided consistent information and

therefore is reliable.
Page: 50. A reliable person always gives the
same answers, even when questions are
rephrased or are repeated later in the
interview. The other statements are not
correct.

A 5-year-old boy is being admitted to the hospital to have his tonsils

removed. Which information should the nurse collect before this
procedure?

A. The child's birth weight

B. The age at which he crawled
C. Whether he has had the measles
D. Reactions to previous hospitalizations

 D. Reactions to previous hospitalizations

Assess how the child reacted to
hospitalization and any complications. If the
child reacted poorly, he or she may be afraid
now and will need special preparation for the
examination that is to follow. The other items
are not significant for the procedure.

The nurse is preparing to do a functional assessment. Which

statement best describes the purpose of a functional assessment?

A. It assesses how the individual is coping

with life at home.
B. It determines how children are meeting
developmental milestones.
C. It can identify any problems with memory
the individual may be experiencing.
D. It helps to determine how a person is
managing day-to-day activities.

 D. It helps to determine how a person is

managing day-to-day activities.
Page: 67. The functional assessment
measures how a person manages day-to-day
activities. The other answers do not reflect
the purpose of a functional assessment.

The nurse is performing a functional assessment on an 82-year-old

patient who recently had a stroke. Which of these questions would
be most important to ask?

A. "Do you wear glasses?"

B. "Are you able to dress yourself?"
C. "Do you have any thyroid problems?"
D. "How many times a day do you have a
bowel movement?"

 B. "Are you able to dress yourself?"

Page: 67. Functional assessment measures
how a person manages day-to-day activities.
For the older person, the meaning of health
becomes those activities that they can or
cannot do. The other responses do not relate
to functional assessment.

During an examination, the nurse can assess mental status by

which activity?

A) Examining the patient's

electroencephalogram
B) Observing the patient as he or she
performs an IQ test
C) Observing the patient and inferring health
or dysfunction
D) Examining the patient's response to a
specific set of questions

 C) Observing the patient and inferring health

or dysfunction
Page: 71. Mental status cannot be scrutinized
directly like the characteristics of skin or heart
sounds. Its functioning is inferred through
assessment of an individual's behaviors, such
as consciousness, language, mood and affect,
and other aspects.

The nurse is assessing a 75-year-old man. As the nurse begins the

mental status portion of the assessment, the nurse expects that
this patient:

A) will have no decrease in any of his abilities,

including response time.
B) will have difficulty on tests of remote memory
because this typically decreases with age.
C) may take a little longer to respond, but his
general knowledge and abilities should not have
declined.
D) will have had a decrease in his response time
because of language loss and a decrease in
general knowledge.

 C) may take a little longer to respond, but his

general knowledge and abilities should not have
declined.
Page: 72. The aging process leaves the parameters
of mental status mostly intact. There is no decrease
in general knowledge and little or no loss in
vocabulary. Response time is slower than in youth.
It takes a bit longer for the brain to process
information and to react to it. Recent memory,
which requires some processing is somewhat
decreased with aging, but remote memory is not
affected.

During a mental status examination, the nurse wants to assess a

patient's affect. The nurse should ask the patient which question?

A) "How do you feel today?"

B) "Would you please repeat the following
words?"
C) "Have these medications had any effect
on your pain?"
D) "Has this pain affected your ability to get
dressed by yourself?"

 A) "How do you feel today?"

Page: 74. Judge mood and affect by body
language and facial expression and by
asking directly, "How do you feel today?" or
"How do you usually feel?" The mood should
be appropriate to the person's place and
condition and should change appropriately
with topics.

The nurse is performing a mental status examination. Which

statement is true regarding the assessment of mental status?

A) Mental status assessment diagnoses

specific psychiatric disorders.
B) Mental disorders occur in response to
everyday life stressors.
C) Mental status functioning is inferred
through assessment of an individual's
behaviors.
D) Mental status can be assessed directly,
just like other systems of the body (e.g.,
cardiac and breath sounds).

 C) Mental status functioning is inferred

through assessment of an individual's
behaviors.
Page: 71. Mental status functioning is inferred
through assessment of an individual's
behaviors. It cannot be assessed directly like
characteristics of the skin or heart sounds.

When performing a physical assessment, the technique the nurse

will always use first is:

A) palpation.
B) inspection.
C) percussion.
D) auscultation.

 B) inspection.
Pages: 115-116. The skills requisite for the physical
examination are inspection, palpation, percussion,
and auscultation. The skills are performed one at a
time and in this order (with the exception of the
abdominal assessment, where auscultation takes
place before palpation and percussion). The
assessment of each body system begins with
inspection. A focused inspection takes time and
yields a surprising amount of information.

The nurse would use bimanual palpation technique in which

situation?

A) Palpating the thorax of an infant

B) Palpating the kidneys and uterus
C) Assessing pulsations and vibrations
D) Assessing the presence of tenderness
and pain

 B) Palpating the kidneys and uterus

Pages: 115-116. Bimanual palpation requires
the use of both hands to envelop or capture
certain body parts or organs such as the
kidneys, uterus, or adnexa. The other
situations are not appropriate for bimanual
palpation.

When performing a physical examination, safety must be considered to

protect the examiner and the patient against the spread of infection. Which of
these statements describes the most appropriate action the nurse should take
when performing a physical examination?

A) There is no need to wash one's hands after

removing gloves, as long as the gloves are still
intact.
B) Wash hands before and after every physical
patient encounter.
C) Wash hands between the examination of each
body system to prevent the spread of bacteria from
one part of the body to another.
D) Wear gloves throughout the entire examination
to demonstrate to the patient concern regarding the
spread of infectious diseases.

 B) Wash hands before and after every physical

patient encounter.
Page: 120. The nurse should wash his or her hands
before and after every physical patient encounter;
after contact with blood, body fluids, secretions, and
excretions; after contact with any equipment
contaminated with body fluids; and after removing
gloves. Hands should be washed after gloves have
been removed, even if the gloves appear to be
intact. Gloves should be worn when there is
potential contact with any body fluids.

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 an abnormal finding and
refer the patient for additional treatment.

40

 A) consider this a normal finding.

Pages: 116-117. Percussion over relatively
dense organs, such as the liver or spleen, will
produce a dull sound. The other responses
are not correct.

41

The nurse is assessing an 80-year-old male patient. Which

assessment findings would be considered normal?

A) An increase in body weight from younger

years
B) Additional deposits of fat on the thighs and
lower legs
C) The presence of kyphosis and flexion in
the knees and hips
D) A change in overall body proportion, a
longer trunk, and shorter extremities

42

 C) The presence of kyphosis and flexion in the

knees and hips
Page: 149. Changes that occur in the aging person
include more prominent bony landmarks,
decreased body weight (especially in males), a
decrease in subcutaneous fat from the face and
periphery, and additional fat deposited on the
abdomen and hips. Postural changes of kyphosis
and slight flexion in the knees and hips also occur.
43

When assessing the force, or strength, of a

pulse, the nurse recalls that it:
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.

44

 C) is a reflection of the heart's stroke volume.

Page: 134. The heart pumps an amount of
blood (the stroke volume) into the aorta. The
force flares the arterial walls and generates a
pressure wave, which is felt in the periphery
as the pulse.

45

The nurse is performing a nutritional assessment on an 80-year-old

patient. The nurse knows that physiological changes that directly
affect the nutritional status of the elderly include:

A) slowed gastrointestinal motility.

B) hyperstimulation of the salivary glands.
C) an increased sensitivity to spicy and
aromatic foods.
D) decreased gastrointestinal absorption
causing esophageal reflux.

46

 A) slowed gastrointestinal motility.

Page: 176. Normal physiological changes in
aging adults that affect nutritional status
include slowed gastrointestinal motility,
decreased gastrointestinal absorption,
diminished olfactory and taste sensitivity,
decreased saliva production, decreased visual
acuity, and poor dentition.
47

The nurse keeps in mind that a thorough skin assessment is

very important because the skin holds information about a
person's:

A) support systems.
B) circulatory status.
C) socioeconomic status.
D) psychological wellness.

48

 B) circulatory status.
Page: 211. The skin holds information about
the body's circulation, nutritional status, and
signs of systemic diseases as well as topical
data on the integument itself.

49

A 65-year-old man with emphysema and bronchitis has come to the

clinic for a follow-up appointment. On assessment, the nurse might
expect to see which assessment finding?

A) Anasarca
B) Scleroderma
C) Pedal erythema
D) Clubbing of the nails

50

 D) Clubbing of the nails

Pages: 217-218. Clubbing of the nails occurs
with congenital cyanotic heart disease,
neoplastic, and pulmonary diseases. The
other responses are assessment findings not
associated with pulmonary diseases.

51

The nurse has discovered decreased skin turgor in a patient and

knows that this is an expected finding in which of these
conditions?

A) Severe obesity
B) Childhood growth spurts
C) Severe dehydration
D) Connective tissue disorders such as
scleroderma

52

 C) Severe dehydration
Page: 215. Decreased skin turgor is
associated with severe dehydration or
extreme weight loss.

53

The nurse is assessing for clubbing of the

fingernails and would expect to find:
A) a nail base that is firm and slightly tender.
B) curved nails with a convex profile and
ridges across the nail.
C) a nail base that feels spongy with an angle
of the nail base of 150 degrees.
D) an angle of the nail base of 180 degrees
or greater with a nail base that feels spongy.

54

 D) an angle of the nail base of 180 degrees

or greater with a nail base that feels spongy.
Pages: 217-218. The normal nail is firm at its
base and has an angle of 160 degrees. In
clubbing, the angle straightens to 180
degrees or greater and the nail base feels
spongy.

55

The nurse suspects that a patient has hyperthyroidism and laboratory data
indicate that the patient's thyroxine and tri-iodothyronine hormone levels are
elevated. Which of these findings would the nurse most likely find on
examination?

A) Tachycardia
B) Constipation
C) Rapid dyspnea
D) Atrophied nodular thyroid

56

 A) Tachycardia
Thyroxine and tri-iodothyronine are thyroid
hormones that stimulate the rate of cellular
metabolism, resulting in tachycardia. With an
enlarged thyroid as in hyperthyroidism, the nurse
might expect to find diffuse enlargement (goiter) or
a nodular lump, but not an atrophied gland.
Dyspnea and constipation are not findings
associated with hyperthyroidism.
57

A woman comes to the clinic and states, "I've been sick for so long! My eyes
have gotten so puffy, and my eyebrows and hair have become coarse and dry."
The nurse will assess for other signs and symptoms of:

A) Graves Disease.
B) Parkinson's syndrome.
C) myxedema.
D) scleroderma.

58

 C) myxedema.
Pages: 276-277. Myxedema (hypothyroidism)
is a deficiency of thyroid hormone that, when
severe, causes a nonpitting edema or
myxedema. The patient will have a puffy
edematous face especially around eyes
(periorbital edema), coarse facial features,
dry skin, and dry, coarse hair and eyebrows.
See Table 13-4, Abnormal Facial
Appearances with Chronic Illnesses, for
59

The physician reports that a patient with a neck tumor has a

tracheal shift. The nurse is aware that this means that the
patient's trachea is:

A) pulled to the affected side.

B) pushed to the unaffected side.
C) pulled downward.
D) pulled downward in a rhythmic pattern.

60

 B) pushed to the unaffected side.

Pages: 262-263. The trachea is pushed to the
unaffected side with an aortic aneurysm, a tumor,
unilateral thyroid lobe enlargement, and
pneumothorax. The trachea is pulled to the affected
side with large atelectasis, pleural adhesions, or
fibrosis. Tracheal tug is a rhythmic downward pull
that is synchronous with systole and occurs with
aortic arch aneurysm
61

During an assessment of an infant, the nurse notes that the

fontanels are depressed and sunken. The nurse suspects which
condition?

A) Rickets
B) Dehydration
C) Mental retardation
D) Increased intracranial pressure

62

 B) Dehydration
Pages: 265-266. Depressed and sunken
fontanels occur with dehydration or malnutrition.
Mental retardation and rickets have no effect on
fontanels. Increased intracranial pressure would
cause tense or bulging, and possibly pulsating
fontanels.

63

The nurse is performing an eye assessment on an 80-year-old

patient. Which of these findings is considered abnormal?

A) A decrease in tear production

B) Unequal pupillary constriction in response
to light
C) The presence of arcus senilis seen around
the cornea
D) Loss of the outer hair on the eyebrows
due to a decrease in hair follicles

64

 B) Unequal pupillary constriction in response

to light
Pages: 305-308. Pupils are small in old age,
and the pupillary light reflex may be slowed,
but pupillary constriction should be
symmetric. The assessment findings in the
other responses are considered normal in
older persons
65

During an examination, the patient states he is hearing a

buzzing sound and says that it is "driving me crazy!" The nurse
recognizes that this symptom indicates:

A) vertigo.
B) pruritus.
C) tinnitus.
D) cholesteatoma.

66

 C) tinnitus.
Pages: 328-329. Tinnitus is a sound that
comes from within a person; it can be a
ringing, crackling, or buzzing sound. It
accompanies some hearing or ear disorders

67

When assessing a patient's lungs, the

nurse recalls that the left lung:
A) consists of two lobes.
B) is divided by the horizontal fissure.
C) consists primarily of an upper lobe on the
posterior chest.
D) is shorter than the right lung because of
the underlying stomach.

68

 A) consists of two lobes.

Pages: 413-414. The left lung has two lobes,
and the right lung has three lobes. The right
lung is shorter than the left lung because of
the underlying liver. The left lung is narrower
than the right lung because the heart bulges
to the left. The posterior chest is almost all
lower lobe
69

During an assessment, the nurse knows that expected

assessment findings in the normal adult lung include the
presence of:

A) adventitious sounds and limited chest

expansion.
B) increased tactile fremitus and dull
percussion tones.
C) muffled voice sounds and symmetrical
tactile fremitus.
D) absent voice sounds and hyperresonant
percussion tones.

70

 C) muffled voice sounds and symmetrical

tactile fremitus.
Pages: 429-430. Normal lung findings include
symmetric chest expansion, resonant
percussion tones, vesicular breath sounds
over the peripheral lung fields, muffled voice
sounds, and no adventitious sounds

71

A 65-year-old patient with a history of heart failure comes to the clinic with
complaints of "being awakened from sleep with shortness of breath." Which
action by the nurse is most appropriate?

A) Obtain a detailed history of the patient's

allergies and history of asthma.
B) Tell the patient to sleep on his or her right
side to facilitate ease of respirations.
C) Assess for other signs and symptoms of
paroxysmal nocturnal dyspnea.
D) Assure the patient that this is normal and
will probably resolve within the next week.

72

 C) Assess for other signs and symptoms of

paroxysmal nocturnal dyspnea.
Pages: 419-420. The patient is experiencing
paroxysmal nocturnal dyspnea: being
awakened from sleep with shortness of
breath and the need to be upright to achieve
comfort

73

When auscultating the lungs of an adult patient, the nurse notes that over the
posterior lower lobes low-pitched, soft breath sounds are heard, with inspiration
being longer than expiration. The nurse interprets that these are:

A) sounds normally auscultated over the

trachea.
B) bronchial breath sounds and are normal in
that location.
C) vesicular breath sounds and are normal in
that location.
D) bronchovesicular breath sounds and are
normal in that location.

74

 C) vesicular breath sounds and are normal in

that location.
Pages: 428-429. Vesicular breath sounds are
low-pitched, soft sounds with inspiration
being longer than expiration. These breath
sounds are expected over peripheral lung
fields where air flows through smaller
bronchioles and alveoli.
75

The nurse is percussing over the lungs of a patient with

pneumonia. The nurse knows that percussion over an area of
atelectasis in the lungs would reveal:

A) dullness.
B) tympany.
C) resonance.
D) hyperresonance.

76

 A) dullness.
Pages: 424-425. A dull percussion note
signals an abnormal density in the lungs, as
with pneumonia, pleural effusion, atelectasis,
or tumor

77

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

78

 A) Wheezes
Page: 445. Wheezes are caused by air
squeezed or compressed through
passageways narrowed almost to closure by
collapsing, swelling, secretions, or tumors,
such as with acute asthma or chronic
emphysema.

79

During auscultation of breath sounds, the nurse should use the

stethoscope correctly, in which of the following ways?

A) Listen to at least one full respiration in each

location.
B) Listen as the patient inhales and then go to
the next site during exhalation.
C) Have the patient breathe in and out rapidly
while the nurse listens to the breath sounds.
D) If the patient is modest, listen to sounds
over his or her clothing or hospital gown.

80

 A) Listen to at least one full respiration in

each location.
Pages: 426-427. During auscultation of
breath sounds with a stethoscope, it is
important to listen to one full respiration in
each location. During the examination, the
nurse should monitor the breathing and offer
times for the person to breathe normally to
prevent possible dizziness
81

During palpation of the anterior chest wall, the nurse notices a

coarse, crackling sensation over the skin surface. On the basis of
these findings, the nurse suspects:

A) tactile fremitus.
B) crepitus.
C) friction rub.
D) adventitious sounds.

82

 B) crepitus.
Page: 424. Crepitus is a coarse, crackling
sensation palpable over the skin surface. It
occurs in subcutaneous emphysema when
air escapes from the lung and enters the
subcutaneous tissue, as after open thoracic
injury or surgery

83

During an assessment of a 68-year-old man with a recent onset of right-sided

weakness, the nurse hears a blowing, swishing sound with the bell of the
stethoscope over the left carotid artery. This finding would indicate:

A) a valvular disorder.
B) blood flow turbulence.
C) fluid volume overload.
D) ventricular hypertrophy

84

 B) blood flow turbulence.

Page: 471. A bruit is a blowing, swishing
sound indicating blood flow turbulence;
normally none is present

85

During an assessment of a healthy adult, where would the

nurse expect to palpate the apical impulse?

A) Third left intercostal space at the

midclavicular line
B) Fourth left intercostal space at the sternal
border
C) Fourth left intercostal space at the anterior
axillary line
D) Fifth left intercostal space at the
midclavicular line

86

 D) Fifth left intercostal space at the

midclavicular line
Pages: 473-474. The apical impulse should
occupy only one intercostal space, the fourth
or fifth, and it should be at or medial to the
midclavicular line

87

The nurse is preparing to auscultate for heart

sounds. Which technique is correct?
A) Listen to the sounds at the aortic, tricuspid,
pulmonic, and mitral areas.
B) Listen by inching the stethoscope in a rough
Z pattern, from the base of the heart across and
down, then over to the apex.
C) Listen to the sounds only at the site where
the apical pulse is felt to be the strongest.
D) Listen for all possible sounds at a time at
each specified area.

88

 B) Listen by inching the stethoscope in a rough Z pattern,

from the base of the heart across and down, then over to
the apex.
Pages: 475-476. Do not limit auscultation of breath
sounds to only four locations. Sounds produced by the
valves may be heard all over the precordium. Inch the
stethoscope in a rough Z pattern from the base of the
heart across and down, then over to the apex. Or, start at
the apex and work your way up. See Figure 19-22. Listen
selectively to one sound at a time

89

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

90

 B) Normal
Pages: 506-507. When documenting the
force, or amplitude, of pulses, 3+ indicates an
increased, full, or bounding pulse, 2+
indicates a normal pulse, 1+ indicates a weak
pulse, and 0 indicates an absent pulse

91

The nurse suspects that a patient has a distended bladder. How

should the nurse assess for this condition?

A) Percuss and palpate in the lumbar region.

B) Inspect and palpate in the epigastric
region.
C) Auscultate and percuss in the inguinal
region.
D) Percuss and palpate the midline area
above the suprapubic bone.

92

 D) Percuss and palpate the midline area

above the suprapubic bone.
Pages: 539-540. Dull percussion sounds
would be elicited over a distended bladder,
and the hypogastric area would seem firm to
palpation

93

While examining a patient, the nurse observes abdominal

pulsations between the xiphoid and umbilicus. The nurse would
suspect that these are:

A) pulsations of the renal arteries.

B) pulsations of the inferior vena cava.
C) normal abdominal aortic pulsations.
D) increased peristalsis from a bowel
obstruction.

94

 C) normal abdominal aortic pulsations.

Pages: 538-539. Normally, one may see the
pulsations from the aorta beneath the skin in
the epigastric area, particularly in thin
persons with good muscle wall relaxation

95

During an abdominal assessment, the nurse would

consider which of these findings as normal?

A) The presence of a bruit in the femoral area

B) A tympanic percussion note in the
umbilical region
C) A palpable spleen between the ninth and
eleventh ribs in the left midaxillary line
D) A dull percussion note in the left upper
quadrant at the midclavicular line

96

 B) A tympanic percussion note in the umbilical region

Pages: 539-540. Tympany should predominate in all
four quadrants of the abdomen because air in the
intestines rises to the surface when the person is
supine. Vascular bruits are not usually present.
Normally the spleen is not palpable. Dullness would
not be found in the area of lung resonance (left upper
quadrant at the midclavicular line)

97

A patient is suspected of having inflammation of the gallbladder,

or cholecystitis. The nurse should conduct which of these
techniques to assess for this condition?

A) Obturator test
B) Test for Murphy's sign
C) Assess for rebound tenderness
D) Iliopsoas muscle test

98

 B) Test for Murphy's sign

Page: 551. Normally, palpating the liver causes
no pain. In a person with inflammation of the
gallbladder, or cholecystitis, pain occurs as the
descending liver pushes the inflamed gallbladder
onto the examining hand during inspiration
(Murphy's test). The person feels sharp pain and
abruptly stops inspiration midway.

99

When assessing muscle strength, the nurse observes that a patient has
complete range of motion against gravity with full resistance. What Grade
should the nurse record using a 0 to 5 point scale?

A) 2
B) 3
C) 4
D) 5

100

 D) 5
Pages: 578-579. Complete range of motion
against gravity is normal muscle strength and
is recorded as Grade 5 muscle strength

101

When the nurse asks a 68-year-old patient to stand with feet together and arms
at his side with his eyes closed, he starts to sway and moves his feet farther
apart. The nurse would document this finding as a(n):

A) ataxia.
B) lack of coordination.
C) negative Homans' sign.
D) positive Romberg sign

102

 D) positive Romberg sign.

Page: 638. Abnormal findings for Romberg
test include swaying, falling, and widening
base of feet to avoid falling. Positive
Romberg sign is loss of balance that is
increased by closing of the eyes. Ataxia is
uncoordinated or unsteady gait. Homans'
sign is used to test the legs for deep vein
thrombosis.
103

The nurse is caring for a patient who has just had neurosurgery. To
assess for increased intracranial pressure, what would the nurse
include in the assessment?

A) Cranial nerves, motor function, and

sensory function
B) Deep tendon reflexes, vital signs, and
coordinated movements
C) Level of consciousness, motor function,
pupillary response, and vital signs
D) Mental status, deep tendon reflexes,
sensory function, and pupillary response

104

 C) Level of consciousness, motor function, pupillary

response, and vital signs
Pages: 660-661. Some hospitalized persons have head
trauma or a neurologic deficit from a systemic disease
process. These people must be monitored closely for any
improvement or deterioration in neurologic status and for
any indication of increasing intracranial pressure. The
nurse should use an abbreviation of the neurologic
examination in the following sequence: level of
consciousness, motor function, pupillary response, and
vital signs
105

During an assessment of a 22-year-old woman who has a head injury from a car
accident 4 hours ago, the nurse notices the following change: pupils were equal, but
now the right pupil is fully dilated and nonreactive, left pupil is 4 mm and reacts to
light. What does finding this suggest?

A) Injury to the right eye

B) Increased intracranial pressure
C) Test was not performed accurately
D) Normal response after a head injury

106

 B) Increased intracranial pressure

Pages: 662-663. In a brain-injured person, a
sudden, unilateral, dilated, and nonreactive pupil
is ominous. Cranial nerve III runs parallel to the
brainstem. When increasing intracranial
pressure pushes the brainstem down (uncal
herniation), it puts pressure on cranial nerve III,
causing pupil dilation. The other responses are
incorrec
107

During assessment of a 20 yr old pt w/ 3-day history of N/V, nurse

notes dry mucosa, deep fissures on tongue. Reflective of:

A. Graves disease
B. OA
C. Dehydration
D. hypoxia

108

 C. Dehydration

109

When listening to heart sounds, the nurse knows that the valve
closures that can be heard best at the base of the heart are:

A. aortic & mitral

B. mitral & pulmonic
C. pulmonic & tricuspid
D. aortic & pulmonic

110

D. aortic & pulmonic

111

The nurse is examining a patient who is complaining of "feeling

cold." Which is a mechanism of heat loss in the body?

A. Radiation
B. Exercise
C. Food digestion
D. Metabolism

112

A. Radiation

113

A patient states that the pain medication is "not working" and rates his
postoperative pain at a 10 on a 1 to 10 scale. Which of these assessment
findings indicates an acute pain response to poorly controlled pain?

A. Increased blood pressure and pulse

B. Confusion
C. Hyperventilation
D. Depression

114

A. Increased blood pressure and pulse

115

The nurse is testing a patient's visual

accommodation, which refers to which action?

A. Involuntary blinking in the presence of

bright light
B. Changes in peripheral vision in response
to light
C. Pupillary dilation when looking at a far
object
D. Pupillary constriction when looking at a
near object

116

D. Pupillary constriction when looking at

a near object

117

The nurse needs to pull the portion of the ear that consists of
movable cartilage and skin down and back when administering
eardrops. This portion of the ear is called the:

A. outer meatus.
B. auricle.
C. concha.
D. mastoid process.

118

B. auricle

119

Which of the following statements is true regarding the

internal structures of the breast? The breast is:

A. composed mostly of milk ducts, known as

lactiferous ducts.
B. composed of glandular tissue, which
supports the breast by attaching to the chest
wall.
C. mainly muscle, with very little fibrous
tissue.
D. composed of fibrous, glandular, and
adipose tissue
120

D. composed of fibrous, glandular, and

adipose tissue

121

In performing a breast examination, the nurse knows that it is especially

important to examine the upper outer quadrant of the breast. The reason
for this is that the upper outer quadrant is:

A. the largest quadrant of the breast.

B. where most of the suspensory ligaments
attach.
C. more prone to injury and calcifications
than other locations in the breast.
D. the location of most breast tumors

122

D. the location of most breast tumors

123

The nurse is reviewing statistics regarding breast cancer. Which

woman, aged 40 years in the United States, has the highest risk
for development of breast cancer?

A. African-American
B. Asian
C. White
D. American Indian

124

A. African-American

125

Mrs. Jones is a 65-year-old patient who presents with complaints of skin spots
during a dermatology follow-up. As the health care provider, you note some
hyperpigmentation in this aging adult. On examination, you would expect to see:

A. caf au lait spots and hemangioma.

B. keratosis and lentigines.
C. linea nigra and chloasma.
D. None of the above.

126

B. keratosis and lentigines

127

An example of a primary lesion is a(n):

A. erosion.
B. ulcer.
C. urticaria.
D. port-wine stain.

128

C. urticaria.

129

The term used to describe the shape of a

lesion as being circular is:
A. scaphoid.
B. annular.
C. confluent.
D. zosteriform.

130

B. annular

131

The sloughing of necrotic inflammatory tissue that causes a

deep depression in the skin that extends into the dermis is
called:

A. gangrene.
B. dermanecrosis.
C. ulceration.
D. maceration.

132

C. ulceration.

133

Mr. Verdana is a 41-year-old gentleman who presents with a complaint of skin

problems. On examination you note single-chambered, superficial lesions
containing free fluid > 1 cm in diameter, which are called:

A. furuncles.
B. vesicles.
C. wheals.
D. bullae.

134

D. bullae.

135

Elevated skin lesions that are greater

than 1 cm in diameter are called:
A. bullae.
B. papules.
C. nodules.
D. furuncles

136

C. nodules

137

A solid, circumscribed palpable skin lesion,

which is less than 1 cm in diameter, is a:

A. nodule.
B. bulla.
C. papule.
D. vesicle.

138

C. papule.

139

Mr. Shea is a 51-year-old patient who presents with complaints of a skin lesion.
On examination, you note a linear skin lesion that runs along a nerve route.
Which of the following terms best describes this lesion?

A. Zosteriform
B. Annular
C. Dermatome
D. Shingles

140

A. Zosteriform

141

Borborygmi is/are:
A. a midline longitudinal ridge in the
abdomen.
B. normal hyperperistaltic bowel sounds.
C. an inflammation of the peritoneum.
D. obesity.

142

B. normal hyperperistaltic bowel sound

143

Bowel sounds are:

A. high pitched.
B. air and fluid moving through the small
intestine.
C. irregular.
D. All of the above.

144

D. All of the above

145

The spinous processes that are prominent

at the base of the neck are:
A. T7 and T8.
B. C7 and T1.
C. T12 and L1.
D. L3 and L4.

146

B. C7 and T1.

147

Heberden's and Bouchard's nodes are hard

and nontender and are associated with:
A. osteoarthritis.
B. rheumatoid arthritis.
C. Dupuytren's contracture.
D. metacarpophalangeal bursitis.

148

A. osteoarthritis

149

Having the individual place the backs of the hands together

while flexing the wrist 90 degrees assesses for the presence of:

A. Dupuytren's contracture.
B. wrist ganglion.
C. carpal tunnel syndrome.
D. Tinel's sign.

150

C. carpal tunnel syndrome

151

Mrs. Kinder brings her infant son in for a health assessment. On

examination, you note polydactyly. An infant with polydactyly would be
expected to manifest which of the following?

A. Digits that are webbed together

B. Digits that are nonfunctional
C. Extra digits
D. Digits with extra joints

152

C. Extra digits

153

Cryptorchidism is:
A. an advanced and fixed foreskin too tight to
retract over the glans.
B. a circumscribed collection of serous fluid
in the tunica vaginalis surrounding the testes.
C. undescended testes.
D. hard, subcutaneous plaques associated
with painful bending of the erect penis.

154

C. undescended testes

155

Which of the following conditions would best utilize the

assessment technique of transilluminatation?

A. Palpating for inguinal hernia

B. Observing for hydrocele
C. Observing for phimosis
D. Palpating for tender testes

156

B. Observing for hydrocele

157

A red, round, superficial ulcer with serous discharge, which

is a possible sign of syphilis, is called:

A. cystitis.
B. a chancre.
C. hypospadias.
D. phimosis.

158

B. a chancre.

159

Mrs. Baker comes to your office with her 2-year-old son. On examination you
note that the urinary meatus appears on the upper surface of the penis. Which of
the following conditions best describes these clinical findings?

A. Varicocele
B. Epispadias
C. Hydrocele
D. Balanitis

160

B. Epispadias

161

Mr. Peyser is a 38-year-old patient who presents to your office for a yearly
physical examination. On exam you note that the foreskin of the penis is very
tight, preventing it from retracting over the glans. Which of the following
conditions best describes this clinical finding?

A. Phimosis
B. Paraphimosis
C. Spermatocele
D. Epispadias

162

A. Phimosis

163

Mr. Liggett is a 42-year-old patient who presents with a painful left testicle. On
examination you note abnormal dilation and tortuosity of the veins along the
spermatic cord. Which of the following conditions best describes this clinical
finding?

A. Varicocele
B. Priapism
C. Hypospadias
D. Epididymitis

164

D. Epididymitis

165

Amenorrhea is the term used for:

A. painful intercourse.
B. the dislodging of the cervical mucous plug.
C. the bluish discoloration of the cervix.
D. the absence of menstruation

166

D. the absence of menstruation

167

Dysmenorrhea is a synonym for:

A. painful intercourse.
B. bowel spasms with defecation.
C. cramping with urination.
D. abdominal cramping and pain associated
with menstruation.

168

D. abdominal cramping and pain

associated with menstruation

169

Mrs. Hoist is a 26-year-old patient who reports to the health

clinic with complaints of painful intercourse. A synonym for
painful intercourse is:

A. dysmenorrhea.
B. dyspareunia.
C. dysuria.
D. None of the above

170

B. dyspareunia.

171

A 40-year-old woman reports a change in mole size, accompanied by color

changes, itching, burning, and bleeding over the past month. She has a dark
complexion and has no family history of skin cancer, but she has had many
blistering sunburns in the past. The nurse would:

A) tell the patient to watch the lesion and report

back in 2 months.
B) refer the patient because of the suspicion of
melanoma on the basis of her symptoms.
C) ask additional questions regarding
environmental irritants that may have caused this
condition.
D) suspect that this is a compound nevus, which
is very common in young to middle-aged adults

172

B) refer the patient because of the suspicion of

melanoma on the basis of her symptoms.

173

When auscultating the heart, which of the following guidelines

may be used to identify S2?

A. S1 is longer than S2
B. S2 coincides with the R wave on the ECG
C. S2 is louder at the base than S1
D. S2 is louder at the apex

174

C. S2 is louder at the base than S1

175

A bruit heard while auscultating the carotid artery of a 65-year-old female is

caused by which of the following?

A. Turbulent blood flow

B.Turbulent blood flow through the carotid
artery
C. Carothritis
D. Arthritis

176

B.Turbulent blood flow through the carotid artery

177

The cardiac output is defined as the:

A.amount of blood pumped by the heart in 1

min.
B.amount of blood pumped by the heart in 30
sec.
C.amount of wbc pumped
D.amount of hemoglobin

178

A.amount of blood pumped by the heart in 1 min.

179

A heave or lift that is visible on the anterior precordium occurs in the presence of:

A. atrial hypertrophy
B.dorsal hypertrophy
C.ventricular hypertrophy
D. pulmonary hypertrophy

180

C.ventricular hypertrophy

181

When palpating the chest wall of a 24-year-old male with well-developed chest
muscles, which of the following would you expect to find?

A.Palpable base pulse

B.Nonpalpable apex pulse
C.Palpable apex pulse
D.Nonpalpable base pulse

182

B.Nonpalpable apex pulse

183

A split S2 heart sound is generally best heard:

A.at the beginning of inhalation

B.at the end of inhalation
C.end of expiration
D.beginning of expiration

184

B.at the end of inhalation

It is caused when the closure of the aortic
valve (A2) and the closure of the pulmonary
valve (P2) are not synchronized.

185

During ventricular diastole, which of the following activities takes place?

A.Blood pours rapidly into the atrium

B.Blood repulse
C.Blood pours rapidly into the ventricles.
D.Blood travel to the mainstream

186

C.Blood pours rapidly into the ventricles.

Diastole=Dilating
Systole=Squeezing

187

The first heart sound is caused by closure of the:

A.AV valves
B.semilunar valves
C.atrium valves
D.ventricular valves

188

A.AV valves

189

Axillary nodes drain the:

A.hand and lower arm.

B.breast and upper arm.
C.anterior abdominal wall
D.lower extremities

190

B.breast and upper arm.

191

When caring for a patient who has intermittent claudication, a

cardiac/vascular nurse advises the patient to:

A. apply graduated compression stockings

before getting out of bed.
B. elevate the legs when sitting.
C. refrain from exercise.
D. walk as tolerated.

192

D. walk as tolerated.
clinical diagnosis given for muscle pain
(ache, cramp, numbness or sense of fatigue),
classically in the calf muscle, which occurs
during exercise, such as walking, and is
relieved by a short period of rest
5 Ps

193

Prior to the client having a gynecological examination, the client says, How can
you see my uterus this way? An appropriate response for the nurse to make
would be:

A. This exam is to check your vagina and

cervix.
B. Its to check your bladder muscle wall.
C. The uterus can be seen this way.
D. The fallopian tubes attach here.

194

A. This exam is to check your vagina and cervix.

195

A 65-year-old female client asks the nurse, When can I stop having these Pap
smears? An appropriate response for the nurse to make to this client would be:

A. At least once per year.

B. After age 70 if youve had three years of
normal results.
C.Never. They are needed annually.
D. At least once every three years.

196

B. After age 70 if youve had three years of normal results.

197

During the physical examination of a male clients scrotum, the nurse palpates a
mass. What should the nurse do next with this information?

A. Nothing. This is a normal finding.

B. Document mass palpated, left testicle.
C. Perform transillumination to further assess
the finding.
D. Ask the client how long hes had a tumor
in his testicle.

198

C. Perform transillumination to further assess the finding.

Rationale: If a mass is detected during the

assessment of the scrotum, perform
transillumination.

199

Most blood enters the ventricle during ________.

A. atrial systole
B. atrial diastole
C. ventricular systole
D. isovolumic contraction

200

B. atrial diastole

201

Ventricular relaxation immediately follows ________.

A. atrial depolarization
B. ventricular repolarization
C. ventricular depolarization
D. atrial repolarization

202

B. ventricular repolarization
http://cnx.org/content/m47786/latest/
Great & clear website for cardiac cycle & info
about the heart

203

The nurse is preparing to assess the abdomen of a hospitilized client 2 days

after abdominal surgery. The nurse should first

A. palpate the incision site

B. auscultate for bowel sounds
C. percuss for tympany
D. inspect the abdominal area

204

D. inspect the abdominal area

205

An example of subjective data is:

A) decreased range of motion.
B) crepitation in the left knee joint.
C) left knee has been swollen and hot for the
past 3 days.
D) arthritis.

206

C) left knee has been swollen and hot for

the past 3 days.
Subjective data is what the person says
about himself or herself during history taking.

207

The nurse puts elastic stockings on a client following major

abdominal surgery. The nurse teaches the client that the
stockings are used after a surgical procedure to:

A. Prevent varicose veins

B. Prevent muscular atrophy
C. Ensure joint mobility and prevent
contractures
D. Facilitate the return of venous blood to the
heart

208

D. Facilitate the return of venous blood

to the heart

209