Question 1

To correctly determine the strength of a patient's lower extremities during a neurological examination, the nurse asks the patient to:

Accepted Answer

A)  wiggle the toes of both feet at the same time. 
B)  push against his hand with the sole of one foot and then the other. 
C)  pull both feet up at the same time to stretch the Achilles tendons. 
D)  stand up independently. 
A)  wiggle the toes of both feet at the same time. 
B)  push against his hand with the sole of one foot and then the other. 
C)  pull both feet up at the same time to stretch the Achilles tendons. 
D)  stand up independently. B

Question 2

A female patient of Asian descent was admitted to the medical-surgical unit with possible lung cancer. A male nurse is preparing to perform a physical assessment. It is best for the male nurse to:

Accepted Answer

A)  ask the family members to leave the room to ensure patient privacy. 
B)  perform the procedure accurately and quickly to lessen patient anxiety. 
C)  examine only the affected body systems to decrease patient discomfort. 
D)  ask the patient for permission to perform the assessment before starting. 
A)  ask the family members to leave the room to ensure patient privacy. 
B)  perform the procedure accurately and quickly to lessen patient anxiety. 
C)  examine only the affected body systems to decrease patient discomfort. 
D)  ask the patient for permission to perform the assessment before starting. D

Question 3

When educating a patient about the warning signs of cancer, the nurse includes which of the following? (Select all that apply.)

Accepted Answer

A)  Difficulty in swallowing 
B)  Persistent cough 
C)  Hyperactive bowel sounds 
D)  Vesicular breath sounds 
E)  Changes in pulse rate
F) Obvious change in a mole 
A)  Difficulty in swallowing 
B)  Persistent cough 
C)  Hyperactive bowel sounds 
D)  Vesicular breath sounds 
E)  Changes in pulse rate
F) Obvious change in a mole A, B, C, F

Question 4

The nurse who is assessing a patient for heart sounds anticipates that the S2 sound (the "dub" sound") can be heard best at the ________ area.

Accepted Answer

aorta
The S₂ sound,

Question 5

The nurse is assessing a patient's lung sounds and hears a wheeze in the lower left lobe. This wheeze is categorized as a(n) ______________ sound.

Accepted Answer

adventitious
Adventi

Question 6

When performing deep palpation, the nurse should:

Accepted Answer

A)  use one hand and exert pressure to depress tissue about one half to three fourths of an inch. 
B)  use either one or two hands to depress the tissue about 1 inch. 
C)  use either one or two hands to depress the tissue about 1.5 to 2 inches. 
D)  use two hands and exert pressure to depress the tissue about 3 to 4 inches. 
A)  use one hand and exert pressure to depress tissue about one half to three fourths of an inch. 
B)  use either one or two hands to depress the tissue about 1 inch. 
C)  use either one or two hands to depress the tissue about 1.5 to 2 inches. 
D)  use two hands and exert pressure to depress the tissue about 3 to 4 inches.

Question 7

Prior to preparing a female patient for a pelvic examination, the nurse should:

Accepted Answer

A)  encourage her to void in the bathroom. 
B)  provide a pillow for the head and the hips. 
C)  hand the patient a sheet and allow her to drape herself. 
D)  cleanse the external genitalia with soap and water. 
A)  encourage her to void in the bathroom. 
B)  provide a pillow for the head and the hips. 
C)  hand the patient a sheet and allow her to drape herself. 
D)  cleanse the external genitalia with soap and water.

Question 8

The nurse takes special care in the draping of a patient in the lithotomy position in order to diminish ____________________________.

Accepted Answer

exposure
embarrassment
A patie

Question 9

When the nurse asks the neurologically impaired patient to follow the motion of the nurse's fingers, the patient's eyes track the fingers with jerky movements, which should be documented as ______________________.

Accepted Answer

nystagmus
Nystagmus is the ter

Question 10

A patient was admitted with possible head trauma after a motor vehicle accident. The nursing implementation with the highest priority is to:

Accepted Answer

A)  monitor intake and output. 
B)  auscultate lung and abdominal sounds. 
C)  check for verbal and motor response. 
D)  monitor daily weight. 
A)  monitor intake and output. 
B)  auscultate lung and abdominal sounds. 
C)  check for verbal and motor response. 
D)  monitor daily weight.

Question 11

A nurse records absence of bowel sounds after assessing the abdomen:

Accepted Answer

A)  in the two lower quadrants for 2 minutes each. 
B)  in the two upper quadrants for 5 minutes. 
C)  in all quadrants for 3 minutes each. 
D)  in each quadrant for 1 minute. 
A)  in the two lower quadrants for 2 minutes each. 
B)  in the two upper quadrants for 5 minutes. 
C)  in all quadrants for 3 minutes each. 
D)  in each quadrant for 1 minute.

Question 12

The nurse is informed that a patient had abnormal heart sounds during the night shift. When auscultating abnormal heart sounds, the nurse knows to listen to heart sounds with the:

Accepted Answer

A)  bell of the stethoscope directly on the patient's skin. 
B)  bell of the stethoscope on top of the patient's gown. 
C)  diaphragm of the stethoscope directly on the patient's skin. 
D)  diaphragm of the stethoscope on top of the patient's gown. 
A)  bell of the stethoscope directly on the patient's skin. 
B)  bell of the stethoscope on top of the patient's gown. 
C)  diaphragm of the stethoscope directly on the patient's skin. 
D)  diaphragm of the stethoscope on top of the patient's gown.

Question 13

The nurse lightly palpates the abdomen of a patient during a physical examination. On palpation to the right side of the abdomen, the patient cries out and draws the knees to the chest. The nurse should:

Accepted Answer

A)  discontinue the examination and report findings to the primary care provider. 
B)  palpate the abdominal skin 1.5 to 2 inches to determine the cause of pain. 
C)  continue the examination and have the patient take deep breaths. 
D)  proceed to percuss the abdomen with a quick snap of the wrist. 
A)  discontinue the examination and report findings to the primary care provider. 
B)  palpate the abdominal skin 1.5 to 2 inches to determine the cause of pain. 
C)  continue the examination and have the patient take deep breaths. 
D)  proceed to percuss the abdomen with a quick snap of the wrist.

Question 14

To the breath sounds of a patient correctly, the nurse should:

Accepted Answer

A)  inspect the chest wall for characteristics of movements and respirations. 
B)  use a stethoscope and properly position the earpieces and diaphragm. 
C)  percuss the chest by quickly tapping on the chest wall surface to produce sounds. 
D)  touch the chest wall and note the texture, temperature, and moisture of the skin. 
A)  inspect the chest wall for characteristics of movements and respirations. 
B)  use a stethoscope and properly position the earpieces and diaphragm. 
C)  percuss the chest by quickly tapping on the chest wall surface to produce sounds. 
D)  touch the chest wall and note the texture, temperature, and moisture of the skin.

Question 15

To perform the Weber test, the tuning fork is struck and placed:

Accepted Answer

A)  at the nape of the neck. 
B)  in the middle of the bridge of the nose. 
C)  behind the right and then the left ear. 
D)  in the middle of the forehead or skull. 
A)  at the nape of the neck. 
B)  in the middle of the bridge of the nose. 
C)  behind the right and then the left ear. 
D)  in the middle of the forehead or skull.

Question 16

The nurse is assessing a patient's heart sounds and hears a "swish" that is recorded as a ___________.

Accepted Answer

murmur
Heart murmurs

Question 17

During a health interview, an older adult patient has difficulty remembering information about the health history. In order to get the information more reliably, the nurse should:

Accepted Answer

A)  repeat the questions at the end of the visit to cross check for accuracy of data. 
B)  reassure the patient that forgetfulness is a normal part of the aging process. 
C)  gather information from a family member accompanying the patient. 
D)  omit the interview and proceed to a physical examination. 
A)  repeat the questions at the end of the visit to cross check for accuracy of data. 
B)  reassure the patient that forgetfulness is a normal part of the aging process. 
C)  gather information from a family member accompanying the patient. 
D)  omit the interview and proceed to a physical examination.

Question 18

The nurse notes that a patient has an exaggerated lumbar curve. This is indicative of __________.

Accepted Answer

lordosis
Lordosis is

Question 19

The nurse who is assessing the patient with the Glasgow Coma Scale finds a patient who can open his eyes spontaneously, obeys all commands, and is oriented. The nurse documents a score of:

Accepted Answer

A)  7. 
B)  10. 
C)  12. 
D)  15. 
A)  7. 
B)  10. 
C)  12. 
D)  15.

Question 20

Before starting the initial morning care or the physical assessment of the patient, the first intervention the nurse would perform would be:

Accepted Answer

A)  putting down the side rails. 
B)  washing his or her hands. 
C)  placing the bed at working height. 
D)  turning on the overhead light. 
A)  putting down the side rails. 
B)  washing his or her hands. 
C)  placing the bed at working height. 
D)  turning on the overhead light.

Exam 22: Assessing Health Status

To correctly determine the strength of a patient's lower extremities during a neurological examination, the nurse asks the patient to:

A female patient of Asian descent was admitted to the medical-surgical unit with possible lung cancer. A male nurse is preparing to perform a physical assessment. It is best for the male nurse to:

When educating a patient about the warning signs of cancer, the nurse includes which of the following? (Select all that apply.)

The nurse who is assessing a patient for heart sounds anticipates that the S2 sound (the "dub" sound") can be heard best at the ________ area.

The nurse is assessing a patient's lung sounds and hears a wheeze in the lower left lobe. This wheeze is categorized as a(n) ______________ sound.

When performing deep palpation, the nurse should:

Prior to preparing a female patient for a pelvic examination, the nurse should:

The nurse takes special care in the draping of a patient in the lithotomy position in order to diminish ____________________________.

When the nurse asks the neurologically impaired patient to follow the motion of the nurse's fingers, the patient's eyes track the fingers with jerky movements, which should be documented as ______________________.

A patient was admitted with possible head trauma after a motor vehicle accident. The nursing implementation with the highest priority is to:

A nurse records absence of bowel sounds after assessing the abdomen:

The nurse is informed that a patient had abnormal heart sounds during the night shift. When auscultating abnormal heart sounds, the nurse knows to listen to heart sounds with the:

The nurse lightly palpates the abdomen of a patient during a physical examination. On palpation to the right side of the abdomen, the patient cries out and draws the knees to the chest. The nurse should:

To the breath sounds of a patient correctly, the nurse should:

To perform the Weber test, the tuning fork is struck and placed:

The nurse is assessing a patient's heart sounds and hears a "swish" that is recorded as a ___________.

During a health interview, an older adult patient has difficulty remembering information about the health history. In order to get the information more reliably, the nurse should:

The nurse notes that a patient has an exaggerated lumbar curve. This is indicative of __________.

The nurse who is assessing the patient with the Glasgow Coma Scale finds a patient who can open his eyes spontaneously, obeys all commands, and is oriented. The nurse documents a score of:

Before starting the initial morning care or the physical assessment of the patient, the first intervention the nurse would perform would be:

Nursing and the Health Care System

Concepts of Health, Illness, Stress, and Health Promotion

Legal and Ethical Aspects of Nursing

The Nursing Process and Critical Thinking

Assessment, Nursing Diagnosis, and Planning

Implementation and Evaluation

Documentation of Nursing Care

Communication and the Nurse Patient Relationship

Patient Education and Health Promotion

Delegation, Leadership, and Management

Growth and Development: Infancy Through Adolescence

Adulthood and the Family

Promoting Healthy Adaptation to Aging

Cultural and Spiritual Aspects of Patient Care

Loss, Grief, and End-of-Life Care

Infection Prevention and Control: Protective Mechanisms and Asepsis

Infection Prevention and Control in the Hospital and Home

Safe Lifting, Moving, and Positioning of Patients

Assisting with Hygiene Personal Care Skin Care and the Prevention of Pressure Ulcers

Patient Environment and Safety

Measuring Vital Signs

Admitting Transferring and Discharging Patients

Diagnostic Tests and Specimen Collection

Fluid, Electrolyte, and Acid-Base Balance

Concepts of Basic Nutrition and Cultural Considerations

Nutritional Therapy and Assisted Feeding

Assisting with Respiration and Oxygen Delivery

Promoting Urinary Elimination

Promoting Bowel Elimination

Pain Comfort and Sleep

Complementary and Alternative Therapies

Pharmacology and Preparation for Drug Administration

Administering Oral, Topical, and Inhalant Medications

Administering Intradermal, Subcutaneous, and Intramuscular Injections

Administering Intravenous Solutions and Medications

Care of the Surgical Patient

Providing Wound Care and Treating Pressure Ulcers

Promoting Musculoskeletal Function

Common Physical Care Problems of the Older Adult

Common Psychosocial Care Problems of Older Adults

Filters

The nurse who is assessing a patient for heart sounds anticipates that the S₂ sound (the "dub" sound") can be heard best at the ________ area.