Exam Review
- A nurse is obtaining a history from a 30-year-old female client. Which of the following questions would you ask to assess health promotion act?A)"Do you have annual breast examinations?"B)"Do you have a history of breast cancer?""C)"Do you have breast implants?"D)"Have you had any problems with nipple discharge?"
- Which of the following statements is true regarding the function of the brain?A)Basal ganglia are responsible for controlling voluntary movementsB)Hypothalamus controls temperature and regulates sleepC)Temporal lobe controls sensations and visual receptionD)Cerebellum is the center for speech and emotions
- During an assessment of the neurological system, a nurse places a key in the hand of a client, and he identifies it as a key. The nurse would describe this finding asA)ExtinctionB)Tactile discriminationC)Stereognosis.D)Graphesthesia
- The nurse is reviewing concepts of cultural aspects of pain. Which statement is true regarding pain?A)A patient's expression of pain is largely dependent on the amount of tissue injury associated with the pain.B)All patients will behave in the same way when in pain.C)Just as patients vary in their perceptions of pain, so will they vary in their expressions of pain.D)Cultural norms have very little to do with pain tolerance because pain tolerance is always biologically determined.
Exam Review
- The nurse is assessing voice sounds during a respiratory assessment. Which of these findings indicates a normal assessment? (Select All that Apply)(SATA)A)As the patient says a long "ee-ee ee" sound, the examiner hears a long "aaaaaa" sound.B)When the patient speaks in a normal voice, the examiner can hear a sound but cannot exactly distinguish what is being saidC)As the patient says a long "ee-ee-ee sound, the examiner also hears a long "ee-ee-ee" sound.D)As the patient repeatedly says "ninety-nine," the examiner clearly hears the words "ninetynine."E)Voice sounds are faint, muffled, and almost inaudible when the patient whispers "one, two, three" in a very soft voice
- During an examination, the nurse asks a patient to bend forward from the waist and notices that the patient has lateral tilting. When his leg is raised straight up, the patient complains of a pain going down his buttock into his leg. The nurse suspects:A)Herniated nucleus pulposus.B)Meniscus tear.C)ScoliosisD)Spasm of paravertebral muscles
- The nurse is assessing the neurologic status of a patient who has a late-stage brain tumor. With the reflex hammer, the nurse draws a light stroke up the lateral side of the sole of the foot and inward, across the ball of the foot. In response, the patient's toes fan out, and the big toe shows dorsiflexion. The nurse interprets this result as:A)Achilles reflex, which is an expected response.B)Negative Babinski sign, which is normal for adults.C)Positive Babinski sign, which is abnormal for adults.D)Clonus, which is a hyperactive response
- The nurse is performing a physical assessment on a newly admitted patient. Select subjective or objective for the findings below.
Subjective Objective Pulse 68 bpm ✓ 7 x 4 cm scar on the left lower abdomen. ✓ Blood pressure 148/92 ✓ History of allergies ✓ Last menstrual period ✓ Shortness of breath ✓ Pain 8/10 ✓ Brawny edema in lower extremities. ✓ Temperature 101 SF ✓ Use of medications at home ✓
Exam Review
- While conducting a cultural health assessment a nurse should include which of the following?A)Health-related beliefsB)Chief complaintC)Medical historyD)Family history
- The nurse is reviewing a patient's medical record and notes that he is in a coma. Using the Glasgow Coma Scale, which number indicates that the patient is in a coma?A)24B)12C)15D)6
- A patient states, "I can hear a crunching or grating sound when I kneel." She also states that "it is very difficult to get out of bed in the morning because of stiffness and pain in my joints." The nurse should assess for signs of what problem?A)Bone spurB)CrepitationC)Loose tendonD)Fluid in the knee joint
- To enhance muscle relaxation prior to an abdominal examination the nurse wouldA)Place a small pillow under the knees.B)Ensure adequate lighting.C)Expose the chest and abdomen for examination.D)Place the patient on their left side.
Exam Review
- The nurse is describing how to perform a testicular self-examination to a patient. Which statement is most appropriateA)"A good time to examine your testicles is just before you take a shower"B)"The testicle is egg shaped and movable. It feels firm and has a lumpy consistency."C)"If you notice an enlarged testicle or a painless lump, call your health care providerD)“Perform a testicular examination at least once a week to detect the early stages of testicular cancer."
- The wife of a 65-year-old man tells the nurse that she is concerned because she has noticed a change in her husband's personality and ability to understand. He also cries very easily and becomes angry. The nurse recalls that the cerebral lobe responsible for these behaviors is the……..lobe.A)FrontalB)OccipitalC)TemporalD)Parietal
- During an examination, the nurse notices severe nystagmus in both eyes of a patient. Which conclusion by the nurse is correct? Severe nystagmus in both eyes:A)May indicate disease of the cerebellum or brainstem.B)is a sign that the patient is nervous about the examinationC)Indicates a visual problem, and a referral to an ophthalmologist is indicated.D)is a normal occurrence
- A 92-year-old patient has had a stroke. The right side of his face is drooping. The nurse might also suspect which of these assessment findings?A)XerostomiaB)RhinorrheaC)DysphagiaD)Epistaxis
Exam Review
- Which assessment finding(s) for a client with hypothyroidism should the nurse document as abnormal? Select all that apply.A)Poor dentitionB)Skin is pink, dry and warmC)Client states, "I can't seem to get warm lately"D)Weight gain of five pounds in two monthsE)Periorbital non-pitting edema
- A young swimmer comes to the sports clinic complaining of a very sore shoulder. He was running at the pool, slipped on some wet concrete, and tried to catch himself with his outstretched hand. He landed on his outstretched hand and has not been able to move his shoulder since. The nurses notices a length discrepancy between his two arms. The nurse suspects:A)Tear of rotator cuff.B)Adhesive capsulitis.C)Joint effusion.D)Dislocated shoulder
- During an assessment of a 62-year-old man, the nurse notices the patient has a stooped posture, shuffling walk with short steps, flat facial expression, and pill-rolling finger movements. These findings would be consistent with:A)Cerebral palsy.B)Cerebellar ataxia.C)Muscular dystrophyD)Parkinsonism.
- When performing a physical assessment of a client's maxillary the nurse should.A)Press above and below the cheek bones.B)Apply pressure anteriorly to the tragus.C)Ask if the client has a history of headaches.D)Ask if the client has a history of sinus infections.
Exam Review
- In assessing a patient's major risk factors for heart disease, which would the nurse want to include when taking a history?A)Alcohol consumption, obesity, diabetes, stress, and high cholesterolB)Personality type, high cholesterol, diabetes, and smokingC)Smoking hypertension, obesity, diabetes, and high cholesterolD)Family history, hypertension, stress, and age
- While assessing the client's gait during, which of the following would indicate a need for further evaluation?A)Feet stay parallel when moving forward.B)Heels strike the ground before the toes.C)Reses each foot off the floor with each step.D)Right arm and leg move forward together
- A client arrives in the Emergency Department via ambulance with the following signs: central cyanosis, HR 42, BP 80/50. What priority level should the nurse identify for this client?A)Third level priorityB)First level priorityC)RoutineD)Second level priority
- When the nurse asks a 68-year-old patient to stand with his 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)Positive Romberg sign.B)Ataxia.C)Lack of coordination.D)Negative Homans sign.