Exam Review

findings align with the ABCDE rule and should be reported to the healthcare provider? Select all that apply.
(SATA)
A)
The mole has patches of black, brown, and red colors within it.
B)
The mole is 5mm in size.
C)
The mole is asymmetrical, with one half different in shape from the other.
D)
The mole has an irregular and notched border.
E)
The mole is uniform in color with a light brown shade throughout.
A nurse is reviewing the charts of four patients. Which patient requires the most immediate intervention related to skin changes?
A)
A patient with chronic venous insufficiency and brownish discoloration of the lower legs.
B)
A patient with a history of Raynaud's phenomenon and episodic cyanosis of the fingers.
C)
A patient with localized erythema around surgery site on the leg.
D)
A patient with new onset of cyanosis around the lips.
The nurse is percussing the patient's abdomen. Which percussion tone should be heard over the liver?
A)
Hyperresonance
B)
Borborygmus
C)
Dullness
D)
Tympany
The nurse assesses a patient's neurologic function. Which sign could indicate injury to the cerebellum? Select all that apply.
(SATA)
A)
Uncoordinated finger-nose-finger test
B)
Smooth, balanced gait
C)
Lost sense of smell
D)
Positive Romberg test
E)
Slow alternating movements

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Exam Review

The nurse is assessing a patient's active range of motion (ROM) and notices limited extension at the left elbow. What is the next step for the nurse to take?
A)
Document muscle testing as 4/5
B)
Attempt passive ROM to bend the left arm
C)
Recommend rest, ice, compression, elevation
D)
Attempt passive ROM to straighten the left arm
A patient reports severe abdominal pain around the umbilicus and right lower quadrant (RLQ) as well as nausea and vomiting for 2 days. Place these nursing assessment steps in the correct order.
(SATA)
A)
Notifying the health care provider
B)
Palpating for rebound tenderness
C)
Inspecting for position
D)
Handwashing
E)
Palpating lightly
F)
Auscultating for bowel sounds
The nurse is assessing a newborn with a scaphoid abdomen. Which condition is likely to cause the problem?
A)
Enlarged spleen
B)
Hepatitis
C)
Macrosomia
D)
Dehydration
Which of the following is common when a patient's nutritional reserves are depleted? Select all that apply.
(SATA)
A)
Lower resistance to infections
B)
Delayed wound healing
C)
Gallbladder disease
D)
Impaired growth & development
E)
Type II diabetes
F)
Auscultating for bowel sounds

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Exam Review

A nurse is caring for a newborn diagnosed with erythema toxicum neonatorum. Which nursing action is most appropriate?
A)
Bathe the newborn with hypoallergenic soap twice daily to reduce the rash.
B)
Apply a thin layer of antibiotic ointment to prevent secondary infection.
C)
Educate the parents that the condition is benign and requires no treatment.
D)
Isolate the newborn to prevent spread to other infants.
E)
Give antifungal treatments to the newborn.
What is a dermatome?
A)
A papule with irregular borders
B)
A hearing test that uses a tuning fork
C)
A large, leather-covered book
D)
An area of skin that is innervated by a particular spinal nerve
Which statement is NOT correct?
A)
"Sharing needles is a big risk factor for hepatitis."
B)
"Chronic hepatitis increases the risk for liver cancer."
C)
"Newborns should receive the Hepatitis B vaccine."
D)
"Health care workers should get a Hepatitis C vaccine."
A nurse is caring for a newborn diagnosed with erythema toxicum neonatorum. Which nursing action is most appropriate?
A)
Bathe the newborn with hypoallergenic soap twice daily to reduce the rash.
B)
Apply a thin layer of antibiotic ointment to prevent secondary infection.
C)
Educate the parents that the condition is benign and requires no treatment.
D)
Isolate the newborn to prevent spread to other infants.
E)
Give antifungal treatments to the newborn.

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Exam Review

The nurse is caring for an aging adult who reports constipation. Which intervention may provide relief for the patient? Select all that apply.
A)
Restrict fluid intake at night
B)
Ensure easy access to the toilet
C)
Eat raw fruits and vegetables
D)
Increase physical activity
The nurse is assessing the abdomen of a woman who is eight months pregnant. Which characteristic is the nurse likely to observe? Select all that apply.
A)
Fetal movement
B)
Linea nigra
C)
Striae
D)
Vernix caseosa
E)
Scaphoid profile
The patient is able to elevate his shoulders bilaterally until the nurse presses down on his shoulders. How should the nurse document his muscle strength?
A)
0/5
B)
1/5
C)
2/5
D)
3/5
E)
4/5
The school nurse is screening the kindergarten students. She notices many of the children are scratching their heads. Which is a common sign of head lice?
A)
White flakes that are easily removed from hair shaft
B)
Patchy bald spots over the scalp
C)
Light brown colored dots attached to hair at nape of neck
D)
Thick yellow crusts on the scalp

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Exam Review

Please read the following scenario, then select 1 "Potential Condition", 2 "Actions to Take", and 2 "Parameters to Monitor". Scenario: You witness your elderly neighbor fall on her driveway while raking leaves. She reports "feeling funny." She is oriented to person & place, but is unsure of the date or why she fell. Her speech is slurred. Her breathing appears normal, but her pulse is over 100 bpm and irregular. She tells you that her only medication is a "baby aspirin" that she takes every day as a blood thinner.
Which neurologic finding is most concerning?
A)
The aging adult who has fine tremors of the hand
B)
The patient with one pupil that is non-reactive to light
C)
The newborn who extends his arms when startled
D)
The patient who sways during the Romberg test
The nurse cares for a patient who is one day post-op surgery. The nurse checks the patient's oral temperature and notes that it is 38° Celsius. Which action by the nurse is appropriate? Select all that apply.
A)
Document the oral temperature in the health care record
B)
Offer a blanket to prevent patient shivering
C)
Inspect the surgical incision for redness, swelling, heat, & pain
D)
Administer acetaminophen as ordered pm to reduce fever
E)
Notify the Health Care Provider (HCP)
A 16-year-old patient who is six months post wrist fracture is in for a follow up visit. The nurse assesses the range of motion (ROM) of the affected arm and notes which bones are involved in pronation and supination of the forearm?
A)
Phalanges and clavicle
B)
Metacarpal and carpal
C)
Humerus and scapula
D)
Radius and ulna

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Exam Review

The school nurse is assessing a student for scoliosis. When comparing the right and left sides, which landmark, if uneven, could indicate a problem? Select all that apply.
A)
Iliac crest
B)
Temporomandibular joint
C)
Interphalangeal joint
D)
Scapula
E)
Acromion process
The nurse is educating the patient about synovial joints in the body. Which joint can be included in this teaching? Select all that apply.
A)
Shoulder
B)
Wrist
C)
Skull
D)
Spine
E)
Ankle
The emergency room nurse is caring for an adolescent who briefly lost consciousness following a collision with another player on the soccer field. Which sign is concerning? Select all that apply.
A)
Patient's pupillary reaction is sluggish
B)
Patient asks "Where am I?"
C)
Patient successfully performs the finger-nose-finger test
D)
Patient states "At least we won the game!"
E)
Patient has a positive Romberg test
The nurse is caring for a patient with an injury to the frontal lobe of the brain. Which sign or symptom would the nurse expect?
A)
Difficulty understanding speech
B)
Impaired ability to sense touch, vibration, positioning
C)
New onset vision changes
D)
Frequent emotional outbursts

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