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    Exam Review

    1. When assessing a lesion on the skin, which of the following findings are concerning? Select all that apply.
      (SATA)
      A)
      Asymmetry of the lesions
      B)
      Red and black coloration
      C)
      Flat
      D)
      8 mm in diameter
      E)
      Round edges
    2. A nurse is assessing a client who has ataxia. Which of the following actions should the nurse take to evaluate the client's ability to safely ambulate?
      A)
      Check the function of cranial nerve V.
      B)
      Observe for the presence of Kernig's sign.
      C)
      Inspect for the presence of clubbing.
      D)
      Perform a Romberg's test.
    3. A nurse reports an incident of suspected child abuse. One of the parents of the child becomes upset and demands to know the reason for the nurse's action. Which of the following responses by the nurse is appropriate?
      A)
      “As a nurse, I am required by law to report suspected child abuse.”
      B)
      "I reported the incident to my supervisor who decided to contact the authorities."
      C)
      "The provider will be coming to explain the situation."
      D)
      ”I am unable to discuss this, but I can contact my supervisor to speak with you."
    4. When performing a skin assessment, which areas of the skin are at the highest risk for skin breakdown? Select all that apply.
      (SATA)
      A)
      Groin
      B)
      Соссух
      C)
      Heels
      D)
      Scapula
      E)
      Under the breasts
    Page 1 of 9

    Exam Review

    1. A nurse is assessing a client who has a pressure ulcer. The nurse should recognize which of the following findings is a manifestation of a stage 3 pressure ulcer?
      A)
      Exposed bone
      B)
      Blood filled blisters
      C)
      Necrotic subcutaneous tissue
      D)
      Partial-thickness skin loss
    2. A nurse in a dermatologist's office is planning an educational session about skin cancer. Which of the following should the nurse include as risk factors for skin cancer? (Select all that apply.)
      (SATA)
      A)
      Genetic predisposition
      B)
      Dark skin
      C)
      Previous skin injury
      D)
      Under 40 years of age
      E)
      Overexposure to ultraviolet light
    3. When assessing a client's skin, the nurse finds clusters of lesions. How would the nurse document the lesions?
      A)
      Confluent
      B)
      Discrete
      C)
      Grouped
      D)
      Annular
    4. A nurse is caring for a client who has right-sided acoustic neuroma resulting in impairment of cranial nerves IX and X. Which of the following actions should the nurse take?
      A)
      Apply an eye patch to the client's right eye.
      B)
      Provide range-of-motion exercises to the client's neck and shoulders.
      C)
      Avoid the use of warm water to wash the client's face.
      D)
      Place suction equipment at the client's bedside.
    Page 2 of 9

    Exam Review

    1. What is stereognosis?
      A)
      The ability to hear each of the three words in the whisper test
      B)
      The ability to identify an object placed in the hand with eyes closed
      C)
      The ability to identify a letter or number drawn on the hand with eyes closed
      D)
      The ability to hear the tuning fork evenly in both ears during the Weber and Rinne tests
    2. A nurse is teaching a client who has diabetes mellitus about diabetic retinopathy. Which of the following statements should the nurse make to the client?
      A)
      “It is caused by an increase in intraocular pressure."
      B)
      "Clouding of the lens is a manifestation of diabetic retinopathy."
      C)
      "Seeing spots is a manifestation of diabetic retinopathy."
      D)
      "Have an eye exam every 2 years."
    3. When performing an otoscope examination for a 2-year-old child, which of the following techniques is correct?
      A)
      Tilting the patient's head forward before inserting the speculum
      B)
      Pulling the pinna up and back before inserting the speculum
      C)
      Once the speculum is in the ear, release the pinna
      D)
      Pulling the pinna down before inserting the speculum
    4. Using the Glasgow Coma Scale, which number indicates that the patient is in a comatose state?
      A)
      15
      B)
      12
      C)
      6
      D)
      8
    Page 3 of 9

    Exam Review

    1. A home health nurse is assessing an older adult client in the home who has decreased vision due to a history of glaucoma. Which of the following findings should the nurse identify as a safety risk?
      A)
      Electrical cords are placed along the walls.
      B)
      Scatter rugs are present in the kitchen.
      C)
      Handrails are present in the bathroom.
      D)
      Uses a microwave for cooking.
    2. A nurse is performing an admission assessment on a client. Which of the following findings should the nurse identify as an indication that the client is dehydrated?
      A)
      Skin tenting present
      B)
      Low body temperature
      C)
      Blood pressure 178/90 mm Hg
      D)
      Jugular vein distention
    3. When assessing a client's skin, the nurse finds acne. How would the nurse document the lesions?
      A)
      Scale
      B)
      Pustule
      C)
      Macule
      D)
      Papule
    4. A home health nurse is assessing an older adult client in the home who has decreased vision due to a history of glaucoma. Which of the following findings should the nurse identify as a safety risk?
      A)
      Electrical cords are placed along the walls.
      B)
      Scatter rugs are present in the kitchen.
      C)
      Handrails are present in the bathroom.
      D)
      Uses a microwave for cooking.
    Page 4 of 9

    Exam Review

    1. A nurse is teaching a client about risk factors for skin cancer. Which of the following statements by the client indicates an understanding of the teaching?
      A)
      “I should apply sunscreen prior to going outside, even in the winter months."
      B)
      I used to lie in the sun all the time, but now I know the tanning bed is a better option."
      C)
      "Because I'm dark-complexed. I won't have to worry about skin cancer."
      D)
      "My father was treated for melanoma, but skin cancer isn't related to genetics."
    2. A nurse is caring for a client who has reported experiencing abuse at home. Which of the following actions should be a priority for the nurse?
      A)
      Assess risk for immediate harm.
      B)
      instruct the client on how to leave the relationship.
      C)
      Implement a safety plan.
      D)
      Refer the client to a community support group.
    3. A nurse is preparing to perform a cranial nerve examination for a client. Which of the following actions should the nurse take to check cranial nerve XI?
      A)
      Have the client identify specific smells.
      B)
      Check the client's visual acuity using a Snellen chart.
      C)
      Observe for the ability of the client to turn their head side to sidê.
      D)
      Whisper in one of the client's ears while occluding the other.
    4. A nurse is assessing for cyanosis in a client who has dark skin. Which of the following sites should the nurse examine to identify cyanosis in this client?
      A)
      Pinnae of the ears
      B)
      Dorsal surface of the hand
      C)
      Dorsal surface of the foot
      D)
      Conjunctivae
    Page 5 of 9

    Exam Review

    1. The nurse is performing a neurologic assessment of a 41-year-old patient the patient is able to open eyes to pain, uses inappropriate words, and has flexion withdrawal from pain. What is their GCS score?
      A)
      9
      B)
      7
      C)
      5
      D)
      12
    2. The nurse is examining a patient's ears, which of the following findings is considered the expected findings?
      A)
      The cone of light at 7 o'clock in the right ear and 5 o'clock in the left ear with a pink and moist tympanic membrane.
      B)
      The cone of light at 7 o'clock in the right ear and 5 o'clock in the left ear with a pearly gray tympanic membrane.
      C)
      The cone of light at 5 o'clock in the right ear and 7 o'clock in the left ear with a pink and moist tympanic membrane.
      D)
      The cone of light at 5 o'clock in the right ear and 7 o'clock in the left ear with a pearly gray tympanic membrane.
    3. When assessing lymph nodes on the face and neck, which of the following findings are concerning? Select all that apply.
      A)
      Tender to the touch
      B)
      Hard nodule
      C)
      Measuring at 4 mm
      D)
      Immovable
      E)
      Non-palpable
    4. A nurse is caring for a client. Exhibits
      A)
      Potassium level
      B)
      Prealbumin/ level
      C)
      History of diabetes mellitus
      D)
      History of hyperlipidemia
      E)
      wound infection
      F)
      Decreased pedal perfusion
      G)
      Fasting blood glucose
    Page 6 of 9