Test Bank Physical Examination Health Assessment 7th Edition, Jarvis
Chapter 01: Evidence-Based Assessment
1. After completing an initial assessment of a patient, the nurse has charted that his respirations are eupneic and his pulse is 58 beats per minute. These types of data would be:
2. A patient tells the nurse that he is very nervous, is nauseated, and “feels hot.” These types of data would be:
3. The patient’s record, laboratory studies, objective data, and subjective data combine to form the:
a. Data base.
b. Admitting data.
c. Financial statement.
d. Discharge summary.
4. When listening to a patient’s breath sounds, the nurse is unsure of a sound that is heard. The nurse’s next action should be to:
a. Immediately notify the patient’s physician.
b. Document the sound exactly as it was heard.
c. Validate the data by asking a coworker to listen to the breath sounds.
d. Assess again in 20 minutes to note whether the sound is still present.
5. The nurse is conducting a class for new graduate nurses. During the teaching session, the nurse should keep in mind that novice nurses, without a background of skills and experience from which to draw, are more likely to make their decisions using:
b. A set of rules.
c. Articles in journals.
d. Advice from supervisors.
6. Expert nurses learn to attend to a pattern of assessment data and act without consciously labeling it. These responses are referred to as:
b. The nursing process.
c. Clinical knowledge.
d. Diagnostic reasoning.
7. The nurse is reviewing information about evidence-based practice (EBP). Which statement best reflects EBP?
a. EBP relies on tradition for support of best practices.
b. EBP is simply the use of best practice techniques for the treatment of patients.
c. EBP emphasizes the use of best evidence with the clinician’s experience.
d. The patient’s own preferences are not important with EBP.
8. The nurse is conducting a class on priority setting for a group of new graduate nurses. Which is an example of a first-level priority problem?
a. Patient with postoperative pain
b. Newly diagnosed patient with diabetes who needs diabetic teaching
c. Individual with a small laceration on the sole of the foot
d. Individual with shortness of breath and respiratory distress
9. When considering priority setting of problems, the nurse keeps in mind that second-level priority problems include which of these aspects?
a. Low self-esteem
b. Lack of knowledge
c. Abnormal laboratory values
d. Severely abnormal vital signs
10. Which critical thinking skill helps the nurse see relationships among the data?
b. Clustering related cues
c. Identifying gaps in data
d. Distinguishing relevant from irrelevant
Chapter 02: Cultural Competence
1. The nurse is reviewing the development of culture. Which statement is correct regarding the development of one’s culture? Culture is:
a. Genetically determined on the basis of racial background.
b. Learned through language acquisition and socialization.
c. A nonspecific phenomenon and is adaptive but unnecessary.
d. Biologically determined on the basis of physical characteristics.
2. During a class on the aspects of culture, the nurse shares that culture has four basic characteristics. Which statement correctly reflects one of these characteristics?
a. Cultures are static and unchanging, despite changes around them.
b. Cultures are never specific, which makes them hard to identify.
c. Culture is most clearly reflected in a person’s language and behavior.
d. Culture adapts to specific environmental factors and available natural resources.
3. During a seminar on cultural aspects of nursing, the nurse recognizes that the definition stating “the specific and distinct knowledge, beliefs, skills, and customs acquired by members of a society” reflects which term?
d. Social learning
4. When discussing the use of the term subculture, the nurse recognizes that it is best described as:
a. Fitting as many people into the majority culture as possible.
b. Defining small groups of people who do not want to be identified with the larger culture.
c. Singling out groups of people who suffer differential and unequal treatment as a result of cultural variations.
d. Identifying fairly large groups of people with shared characteristics that are not common to all members of a culture.
5. When reviewing the demographics of ethnic groups in the United States, the nurse recalls that the largest and fastest growing population is:
d. American Indian.
6. During an assessment, the nurse notices that a patient is handling a small charm that is tied to a leather strip around his neck. Which action by the nurse is appropriate?
a. Ask the patient about the item and its significance.
b. Ask the patient to lock the item with other valuables in the hospital’s safe.
c. Tell the patient that a family member should take valuables home.
d. No action is necessary.
7. The nurse manager is explaining culturally competent care during a staff meeting. Which statement accurately describes the concept of culturally competent care? “The caregiver:
a. Is able to speak the patient’s native language.”
b. Possesses some basic knowledge of the patient’s cultural background.”
c. Applies the proper background knowledge of a patient’s cultural background to provide the best possible health care.”
d. Understands and attends to the total context of the patient’s situation.”
8. The nurse recognizes that an example of a person who is heritage consistent would be a:
a. Woman who has adapted her clothing to the clothing style of her new country.
b. Woman who follows the traditions that her mother followed regarding meals.
c. Man who is not sure of his ancestor’s country of origin.
d. Child who is not able to speak his parents’ native language.
9. After a class on culture and ethnicity, the new graduate nurse reflects a correct understanding of the concept of ethnicity with which statement?
a. “Ethnicity is dynamic and ever changing.”
b. “Ethnicity is the belief in a higher power.”
c. “Ethnicity pertains to a social group within the social system that claims shared values and traditions.”
d. “Ethnicity is learned from birth through the processes of language acquisition and socialization.”
10. The nurse is comparing the concepts of religion and spirituality. Which of the following is an appropriate component of one’s spirituality?
a. Belief in and the worship of God or gods
b. Attendance at a specific church or place of worship
c. Personal effort made to find purpose and meaning in life
Chapter 03: The Interview
1. The nurse is conducting an interview with a woman who has recently learned that she is pregnant and who has come to the clinic today to begin prenatal care. The woman states that she and her husband are excited about the pregnancy but have a few questions. She looks nervously at her hands during the interview and sighs loudly. Considering the concept of communication, which statement does the nurse know to be most accurate? The woman is:
a. Excited about her pregnancy but nervous about the labor.
b. Exhibiting verbal and nonverbal behaviors that do not match.
c. Excited about her pregnancy, but her husband is not and this is upsetting to her.
d. Not excited about her pregnancy but believes the nurse will negatively respond to her if she states this.
2. Receiving is a part of the communication process. Which receiver is most likely to misinterpret a message sent by a health care professional?
a. Well-adjusted adolescent who came in for a sports physical
b. Recovering alcoholic who came in for a basic physical examination
c. Man whose wife has just been diagnosed with lung cancer
d. Man with a hearing impairment who uses sign language to communicate and who has an interpreter with him
3. The nurse makes which adjustment in the physical environment to promote the success of an interview?
a. Reduces noise by turning off televisions and radios
b. Reduces the distance between the interviewer and the patient to 2 feet or less
c. Provides a dim light that makes the room cozy and helps the patient relax
d. Arranges seating across a desk or table to allow the patient some personal space
4. In an interview, the nurse may find it necessary to take notes to aid his or her memory later. Which statement is true regarding note-taking?
a. Note-taking may impede the nurse’s observation of the patient’s nonverbal behaviors.
b. Note-taking allows the patient to continue at his or her own pace as the nurse records what is said.
c. Note-taking allows the nurse to shift attention away from the patient, resulting in an increased comfort level.
d. Note-taking allows the nurse to break eye contact with the patient, which may increase his or her level of comfort.
5. The nurse asks, “I would like to ask you some questions about your health and your usual daily activities so that we can better plan your stay here.” This question is found at the __________ phase of the interview process.
d. Opening or introduction
6. A woman has just entered the emergency department after being battered by her husband. The nurse needs to get some information from her to begin treatment. What is the best choice for an opening phase of the interview with this patient?
a. “Hello, Nancy, my name is Mrs. C.”
b. “Hello, Mrs. H., my name is Mrs. C. It sure is cold today!”
c. “Mrs. H., my name is Mrs. C. How are you?”
d. “Mrs. H., my name is Mrs. C. I’ll need to ask you a few questions about what happened.”
7. During an interview, the nurse states, “You mentioned having shortness of breath. Tell me more about that.” Which verbal skill is used with this statement?
c. Direct question
d. Open-ended question
8. A patient has finished giving the nurse information about the reason he is seeking care. When reviewing the data, the nurse finds that some information about past hospitalizations is missing. At this point, which statement by the nurse would be most appropriate to gather these data?
a. “Mr. Y., at your age, surely you have been hospitalized before!”
b. “Mr. Y., I just need permission to get your medical records from County Medical.”
c. “Mr. Y., you mentioned that you have been hospitalized on several occasions. Would you tell me more about that?”
d. “Mr. Y., I just need to get some additional information about your past hospitalizations. When was the last time you were admitted for chest pain?”
9. In using verbal responses to assist the patient’s narrative, some responses focus on the patient’s frame of reference and some focus on the health care provider’s perspective. An example of a verbal response that focuses on the health care provider’s perspective would be:
10. When taking a history from a newly admitted patient, the nurse notices that he often pauses and expectantly looks at the nurse. What would be the nurse’s best response to this behavior?
a. Be silent, and allow him to continue when he is ready.
b. Smile at him and say, “Don’t worry about all of this. I’m sure we can find out why you’re having these pains.”
c. Lean back in the chair and ask, “You are looking at me kind of funny; there isn’t anything wrong, is there?”
d. Stand up and say, “I can see that this interview is uncomfortable for you. We can continue it another time.”
Chapter 04: The Complete Health History
1. The nurse is preparing to conduct a health history. Which of these statements best describes the purpose of a health history?
a. To provide an opportunity for interaction between the patient and the nurse
b. To provide a form for obtaining the patient’s biographic information
c. To document the normal and abnormal findings of a physical assessment
d. To provide a database of subjective information about the patient’s past and current health
2. 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.
3. A 59-year-old patient tells the nurse that he has ulcerative colitis. He has been having “black stools” for the last 24 hours. How would the nurse best document his reason for seeking care?
a. J.M. is a 59-year-old man seeking treatment for ulcerative colitis.
b. J.M. came into the clinic complaining of having black stools for the past 24 hours.
c. J.M. is a 59-year-old man who states that he has ulcerative colitis and wants it checked.
d. J.M. is a 59-year-old man who states that he has been having “black stools” for the past 24 hours.
4. A patient tells the nurse that she has had abdominal pain for the past week. What would be the nurse’s best response?
a. “Can you point to where it hurts?”
b. “We’ll talk more about that later in the interview.”
c. “What have you had to eat in the last 24 hours?”
d. “Have you ever had any surgeries on your abdomen?”
5. A 29-year-old woman tells the nurse that she has “excruciating pain” in her back. Which would be the nurse’s appropriate response to the woman’s statement?
a. “How does your family react to your pain?”
b. “The pain must be terrible. You probably pinched a nerve.”
c. “I’ve had back pain myself, and it can be excruciating.”
d. “How would you say the pain affects your ability to do your daily activities?”
6. In recording the childhood illnesses of a patient who denies having had any, which note by the nurse would be most accurate?
a. Patient denies usual childhood illnesses.
b. Patient states he was a “very healthy” child.
c. Patient states his sister had measles, but he didn’t.
d. Patient denies measles, mumps, rubella, chickenpox, pertussis, and strep throat.
7. A female patient tells the nurse that she has had six pregnancies, with four live births at term and two spontaneous abortions. Her four children are still living. How would the nurse record this information?
a. P-6, B-4, (S)Ab-2
b. Grav 6, Term 4, (S)Ab-2, Living 4
c. Patient has had four living babies.
d. Patient has been pregnant six times.
8. A patient tells the nurse that he is allergic to penicillin. What would be the nurse’s best response to this information?
a. “Are you allergic to any other drugs?”
b. “How often have you received penicillin?”
c. “I’ll write your allergy on your chart so you won’t receive any penicillin.”
d. “Describe what happens to you when you take penicillin.”
9. The nurse is taking a family history. Important diseases or problems about which the patient should be specifically asked include:
b. Head trauma.
c. Mental illness.
d. Fractured bones.
10. The review of systems provides the nurse with:
a. Physical findings related to each system.
b. Information regarding health promotion practices.
c. An opportunity to teach the patient medical terms.
d. Information necessary for the nurse to diagnose the patient’s medical problem.
Chapter 05: Mental Status Assessment
1. 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 intelligence quotient (IQ) test
c. Observing the patient and inferring health or dysfunction
d. Examining the patient’s response to a specific set of questions
2. The nurse is assessing the mental status of a child. Which statement about children and mental status is true?
a. All aspects of mental status in children are interdependent.
b. Children are highly labile and unstable until the age of 2 years.
c. Children’s mental status is largely a function of their parents’ level of functioning until the age of 7 years.
d. A child’s mental status is impossible to assess until the child develops the ability to concentrate.
3. 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 ability typically decreases with age.
c. May take a little longer to respond, but his general knowledge and abilities should not have declined.
d. Will exhibit had a decrease in his response time because of the loss of language and a decrease in general knowledge.
4. When assessing aging adults, the nurse knows that one of the first things that should be assessed before making judgments about their mental status is:
a. Presence of phobias
b. General intelligence
c. Presence of irrational thinking patterns
d. Sensory-perceptive abilities
5. The nurse is preparing to conduct a mental status examination. Which statement is trueregarding the mental status examination?
a. A patient’s family is the best resource for information about the patient’s coping skills.
b. Gathering mental status information during the health history interview is usually sufficient.
c. Integrating the mental status examination into the health history interview takes an enormous amount of extra time.
d. To get a good idea of the patient’s level of functioning, performing a complete mental status examination is usually necessary.
6. A woman brings her husband to the clinic for an examination. She is particularly worried because after a recent fall, he seems to have lost a great deal of his memory of recent events. Which statement reflects the nurse’s best course of action?
a. Perform a complete mental status examination.
b. Refer him to a psychometrician.
c. Plan to integrate the mental status examination into the history and physical examination.
d. Reassure his wife that memory loss after a physical shock is normal and will soon subside.
7. The nurse is conducting a patient interview. Which statement made by the patient should the nurse more fully explore during the interview?
a. “I sleep like a baby.”
b. “I have no health problems.”
c. “I never did too good in school.”
d. “I am not currently taking any medications.”
8. A patient is admitted to the unit after an automobile accident. The nurse begins the mental status examination and finds that the patient has dysarthric speech and is lethargic. The nurse’s best approach regarding this examination is to:
a. Plan to defer the rest of the mental status examination.
b. Skip the language portion of the examination, and proceed onto assessing mood and affect.
c. Conduct an in-depth speech evaluation, and defer the mental status examination to another time.
d. Proceed with the examination, and assess the patient for suicidal thoughts because dysarthria is often accompanied by severe depression.
9. A 19-year-old woman comes to the clinic at the insistence of her brother. She is wearing black combat boots and a black lace nightgown over the top of her other clothes. Her hair is dyed pink with black streaks throughout. She has several pierced holes in her nares and ears and is wearing an earring through her eyebrow and heavy black makeup. The nurse concludes that:
a. She probably does not have any problems.
b. She is only trying to shock people and that her dress should be ignored.
c. She has a manic syndrome because of her abnormal dress and grooming.
d. More information should be gathered to decide whether her dress is appropriate.
10. A patient has been in the intensive care unit for 10 days. He has just been moved to the medical-surgical unit, and the admitting nurse is planning to perform a mental status examination. During the tests of cognitive function, the nurse would expect that he:
a. May display some disruption in thought content.
b. Will state, “I am so relieved to be out of intensive care.”
c. Will be oriented to place and person, but the patient may not be certain of the date.
d. May show evidence of some clouding of his level of consciousness.
Chapter 06: Substance Use Assessment
1. A woman has come to the clinic to seek help with a substance abuse problem. She admits to using cocaine just before arriving. Which of these assessment findings would the nurse expect to find when examining this woman?
a. Dilated pupils, pacing, and psychomotor agitation
b. Dilated pupils, unsteady gait, and aggressiveness
c. Pupil constriction, lethargy, apathy, and dysphoria
d. Constricted pupils, euphoria, and decreased temperature
2. The nurse is assessing a patient who has been admitted for cirrhosis of the liver, secondary to chronic alcohol use. During the physical assessment, the nurse looks for cardiac problems that are associated with chronic use of alcohol, such as:
b. Ventricular fibrillation.
d. Mitral valve prolapse.
3. The nurse is conducting a class on alcohol and the effects of alcohol on the body. How many standard drinks (each containing 14 grams of alcohol) per day in men are associated with increased deaths from cirrhosis, cancers of the mouth, esophagus, and injuries?
4. During a session on substance abuse, the nurse is reviewing statistics with the class. For persons aged 12 years and older, which illicit substance was most commonly used?
a. Crack cocaine
5. A woman who has just discovered that she is pregnant is in the clinic for her first obstetric visit. She asks the nurse, “How many drinks a day is safe for my baby?” The nurse’s best response is:
a. “You should limit your drinking to once or twice a week.”
b. “It’s okay to have up to two glasses of wine a day.”
c. “As long as you avoid getting drunk, you should be safe.”
d. “No amount of alcohol has been determined to be safe during pregnancy.”
6. When reviewing the use of alcohol by older adults, the nurse notes that older adults have several characteristics that can increase the risk of alcohol use. Which would increase the bioavailability of alcohol in the blood for longer periods in the older adult?
a. Increased muscle mass
b. Decreased liver and kidney functioning
c. Decreased blood pressure
d. Increased cardiac output
7. During an assessment, the nurse asks a female patient, “How many alcoholic drinks do you have a week?” Which answer by the patient would indicate at-risk drinking?
a. “I may have one or two drinks a week.”
b. “I usually have three or four drinks a week.”
c. “I’ll have a glass or two of wine every now and then.”
d. “I have seven or eight drinks a week, but I never get drunk.”
8. The nurse is asking an adolescent about illicit substance abuse. The adolescent answers, “Yes, I’ve used marijuana at parties with my friends.” What is the next question the nurse should ask?
a. “Who are these friends?”
b. “Do your parents know about this?”
c. “When was the last time you used marijuana?”
d. “Is this a regular habit?”
9. The nurse has completed an assessment on a patient who came to the clinic for a leg injury. As a result of the assessment, the nurse has determined that the patient has at-risk alcohol use. Which action by the nurse is most appropriate at this time?
a. Record the results of the assessment, and notify the physician on call.
b. State, “You are drinking more than is medically safe. I strongly recommend that you quit drinking, and I’m willing to help you.”
c. State, “It appears that you may have a drinking problem. Here is the telephone number of our local Alcoholics Anonymous chapter.”
d. Give the patient information about a local rehabilitation clinic.
10. A patient is brought to the emergency department. He is restless, has dilated pupils, is sweating, has a runny nose and tearing eyes, and complains of muscle and joint pains. His girlfriend thinks he has influenza, but she became concerned when his temperature went up to 39.4° C. She admits that he has been a heavy drug user, but he has been trying to stop on his own. The nurse suspects that the patient is experiencing withdrawal symptoms from which substance?
c. Crack cocaine
Chapter 07: Domestic and Family Violence Assessments
1. As a mandatory reporter of elder abuse, which must be present before a nurse should notify the authorities?
a. Statements from the victim
b. Statements from witnesses
c. Proof of abuse and/or neglect
d. Suspicion of elder abuse and/or neglect
2. During a home visit, the nurse notices that an older adult woman is caring for her bedridden husband. The woman states that this is her duty, she does the best she can, and her children come to help when they are in town. Her husband is unable to care for himself, and she appears thin, weak, and exhausted. The nurse notices that several of his prescription medication bottles are empty. This situation is best described by the term:
a. Physical abuse.
b. Financial neglect.
c. Psychological abuse.
d. Unintentional physical neglect.
3. The nurse is aware that intimate partner violence (IPV) screening should occur with which situation?
a. When IPV is suspected
b. When a woman has an unexplained injury
c. As a routine part of each health care encounter
d. When a history of abuse in the family is known
4. Which statement is best for the nurse to use when preparing to administer the Abuse Assessment Screen?
a. “We are required by law to ask these questions.”
b. “We need to talk about whether you believe you have been abused.”
c. “We are asking these questions because we suspect that you are being abused.”
d. “We need to ask the following questions because domestic violence is so common in our society.”
5. Which term refers to a wound produced by the tearing or splitting of body tissue, usually from blunt impact over a bony surface?
6. During an examination, the nurse notices a patterned injury on a patient’s back. Which of these would cause such an injury?
a. Blunt force
b. Friction abrasion
c. Stabbing from a kitchen knife
d. Whipping from an extension cord
7. When documenting IPV and elder abuse, the nurse should include:
a. Photographic documentation of the injuries.
b. Summary of the abused patient’s statements.
c. Verbatim documentation of every statement made.
d. General description of injuries in the progress notes.
8. A female patient has denied any abuse when answering the Abuse Assessment Screen, but the nurse has noticed some other conditions that are associated with IPV. Examples of such conditions include:
d. Frequent colds.
9. The nurse is using the danger assessment (DA) tool to evaluate the risk of homicide. Which of these statements best describes its use?
a. The DA tool is to be administered by law enforcement personnel.
b. The DA tool should be used in every assessment of suspected abuse.
c. The number of “yes” answers indicates the woman’s understanding of her situation.
d. The higher the number of “yes” answers, the more serious the danger of the woman’s situation.
10. The nurse is assessing bruising on an injured patient. Which color indicates a new bruise that is less than 2 hours old?
Chapter 08: Assessment Techniques and Safety in the Clinical Setting
1. When performing a physical assessment, the first technique the nurse will always use is:
2. The nurse is preparing to perform a physical assessment. Which statement is true about the physical assessment? The inspection phase:
a. Usually yields little information.
b. Takes time and reveals a surprising amount of information.
c. May be somewhat uncomfortable for the expert practitioner.
d. Requires a quick glance at the patient’s body systems before proceeding with palpation.
3. The nurse is assessing a patient’s skin during an office visit. What part of the hand and technique should be used to best assess the patient’s skin temperature?
a. Fingertips; they are more sensitive to small changes in temperature.
b. Dorsal surface of the hand; the skin is thinner on this surface than on the palms.
c. Ulnar portion of the hand; increased blood supply in this area enhances temperature sensitivity.
d. Palmar surface of the hand; this surface is the most sensitive to temperature variations because of its increased nerve supply in this area.
4. Which of these techniques uses the sense of touch to assess texture, temperature, moisture, and swelling when the nurse is assessing a patient?
5. The nurse is preparing to assess a patient’s abdomen by palpation. How should the nurse proceed?
a. Palpation of reportedly “tender” areas are avoided because palpation in these areas may cause pain.
b. Palpating a tender area is quickly performed to avoid any discomfort that the patient may experience.
c. The assessment begins with deep palpation, while encouraging the patient to relax and to take deep breaths.
d. The assessment begins with light palpation to detect surface characteristics and to accustom the patient to being touched.
6. 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
7. The nurse is preparing to percuss the abdomen of a patient. The purpose of the percussion is to assess the __________ of the underlying tissue.
8. The nurse is reviewing percussion techniques with a newly graduated nurse. Which technique, if used by the new nurse, indicates that more review is needed?
a. Percussing once over each area
b. Quickly lifting the striking finger after each stroke
c. Striking with the fingertip, not the finger pad
d. Using the wrist to make the strikes, not the arm
9. 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 finding as abnormal, and refer the patient for additional treatment.
10. The nurse is unable to identify any changes in sound when percussing over the abdomen of an obese patient. What should the nurse do next?
a. Ask the patient to take deep breaths to relax the abdominal musculature.
b. Consider this finding as normal, and proceed with the abdominal assessment.
c. Increase the amount of strength used when attempting to percuss over the abdomen.
d. Decrease the amount of strength used when attempting to percuss over the abdomen.
Chapter 09: General Survey, Measurement, Vital Signs
1. The nurse is performing a general survey. Which action is a component of the general survey?
a. Observing the patient’s body stature and nutritional status
b. Interpreting the subjective information the patient has reported
c. Measuring the patient’s temperature, pulse, respirations, and blood pressure
d. Observing specific body systems while performing the physical assessment
2. When measuring a patient’s weight, the nurse is aware of which of these guidelines?
a. The patient is always weighed wearing only his or her undergarments.
b. The type of scale does not matter, as long as the weights are similar from day to day.
c. The patient may leave on his or her jacket and shoes as long as these are documented next to the weight.
d. Attempts should be made to weigh the patient at approximately the same time of day, if a sequence of weights is necessary.
3. A patient’s weekly blood pressure readings for 2 months have ranged between 124/84 mm Hg and 136/88 mm Hg, with an average reading of 126/86 mm Hg. The nurse knows that this blood pressure falls within which blood pressure category?
a. Normal blood pressure
c. Stage 1 hypertension
d. Stage 2 hypertension
4. During an examination of a child, the nurse considers that physical growth is the best index of a child’s:
a. General health.
b. Genetic makeup.
c. Nutritional status.
d. Activity and exercise patterns.
5. A 1-month-old infant has a head measurement of 34 cm and has a chest circumference of 32 cm. Based on the interpretation of these findings, the nurse would:
a. Refer the infant to a physician for further evaluation.
b. Consider these findings normal for a 1-month-old infant.
c. Expect the chest circumference to be greater than the head circumference.
d. Ask the parent to return in 2 weeks to re-evaluate the head and chest circumferences.
6. The nurse is assessing an 80-year-old male patient. Which assessment findings would be considered normal?
a. Increase in body weight from his younger years
b. Additional deposits of fat on the thighs and lower legs
c. Presence of kyphosis and flexion in the knees and hips
d. Change in overall body proportion, including a longer trunk and shorter extremities
7. The nurse should measure rectal temperatures in which of these patients?
a. School-age child
b. Older adult
c. Comatose adult
d. Patient receiving oxygen by nasal cannula
8. The nurse is preparing to measure the length, weight, chest, and head circumference of a 6-month-old infant. Which measurement technique is correct?
a. Measuring the infant’s length by using a tape measure
b. Weighing the infant by placing him or her on an electronic standing scale
c. Measuring the chest circumference at the nipple line with a tape measure
d. Measuring the head circumference by wrapping the tape measure over the nose and cheekbones
9. The nurse knows that one advantage of the tympanic membrane thermometer (TMT) is that:
a. Rapid measurement is useful for uncooperative younger children.
b. Using the TMT is the most accurate method for measuring body temperature in newborn infants.
c. Measuring temperature using the TMT is inexpensive.
d. Studies strongly support the use of the TMT in children under the age 6 years.
10. When assessing an older adult, which vital sign changes occur with aging?
a. Increase in pulse rate
b. Widened pulse pressure
c. Increase in body temperature
d. Decrease in diastolic blood pressure
Chapter 10: Pain Assessment: The Fifth Vital Sign
1. When evaluating a patient’s pain, the nurse knows that an example of acute pain would be:
a. Arthritic pain.
c. Kidney stones.
d. Low back pain.
2. Which statement indicates that the nurse understands the pain experienced by an older adult?
a. “Older adults must learn to tolerate pain.”
b. “Pain is a normal process of aging and is to be expected.”
c. “Pain indicates a pathologic condition or an injury and is not a normal process of aging.”
d. “Older individuals perceive pain to a lesser degree than do younger individuals.”
3. A 4-year-old boy is brought to the emergency department by his mother. She says he points to his stomach and says, “It hurts so bad.” Which pain assessment tool would be the best choice when assessing this child’s pain?
a. Descriptor Scale
b. Numeric rating scale
c. Brief Pain Inventory
d. Faces Pain Scale—Revised (FPS-R)
4. 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?
c. Increased blood pressure and pulse
5. A 60-year-old woman has developed reflexive sympathetic dystrophy after arthroscopic repair of her shoulder. A key feature of this condition is that the:
a. Affected extremity will eventually regain its function.
b. Pain is felt at one site but originates from another location.
c. Patient’s pain will be associated with nausea, pallor, and diaphoresis.
d. Slightest touch, such as a sleeve brushing against her arm, causes severe and intense pain.
6. The nurse is assessing a patient’s pain. The nurse knows that the most reliable indicator of pain would be the:
a. Patient’s vital signs.
b. Physical examination.
c. Results of a computerized axial tomographic scan.
d. Subjective report.
7. A patient has had arthritic pain in her hips for several years since a hip fracture. She is able to move around in her room and has not offered any complaints so far this morning. However, when asked, she states that her pain is “bad this morning” and rates it at an 8 on a 1-to-10 scale. What does the nurse suspect? The patient:
a. Is addicted to her pain medications and cannot obtain pain relief.
b. Does not want to trouble the nursing staff with her complaints.
c. Is not in pain but rates it high to receive pain medication.
d. Has experienced chronic pain for years and has adapted to it.
8. The nurse is reviewing the principles of pain. Which type of pain is due to an abnormal processing of the pain impulse through the peripheral or central nervous system?
9. When assessing the quality of a patient’s pain, the nurse should ask which question?
a. “When did the pain start?”
b. “Is the pain a stabbing pain?”
c. “Is it a sharp pain or dull pain?”
d. “What does your pain feel like?”
10. When assessing a patient’s pain, the nurse knows that an example of visceral pain would be:
a. Hip fracture.
c. Second-degree burns.
d. Pain after a leg amputation.
Chapter 11: Nutritional Assessment
1. The nurse recognizes which of these persons is at greatest risk for undernutrition?
a. 5-month-old infant
b. 50-year-old woman
c. 20-year-old college student
d. 30-year-old hospital administrator
2. When assessing a patient’s nutritional status, the nurse recalls that the best definition of optimal nutritional status is sufficient nutrients that:
a. Are in excess of daily body requirements.
b. Provide for the minimum body needs.
c. Provide for daily body requirements but do not support increased metabolic demands.
d. Provide for daily body requirements and support increased metabolic demands.
3. The nurse is providing nutrition information to the mother of a 1-year-old child. Which of these statements represents accurate information for this age group?
a. Maintaining adequate fat and caloric intake is important for a child in this age group.
b. The recommended dietary allowances for an infant are the same as for an adolescent.
c. The baby’s growth is minimal at this age; therefore, caloric requirements are decreased.
d. The baby should be placed on skim milk to decrease the risk of coronary artery disease when he or she grows older.
4. A pregnant woman is interested in breastfeeding her baby and asks several questions about the topic. Which information is appropriate for the nurse to share with her?
a. Breastfeeding is best when also supplemented with bottle feedings.
b. Babies who are breastfed often require supplemental vitamins.
c. Breastfeeding is recommended for infants for the first 2 years of life.
d. Breast milk provides the nutrients necessary for growth, as well as natural immunity.
5. A mother and her 13-year-old daughter express their concern related to the daughter’s recent weight gain and her increase in appetite. Which of these statements represents information the nurse should discuss with them?
a. Dieting and exercising are necessary at this age.
b. Snacks should be high in protein, iron, and calcium.
c. Teenagers who have a weight problem should not be allowed to snack.
d. A low-calorie diet is important to prevent the accumulation of fat.
6. The nurse is assessing a 30-year-old unemployed immigrant from an underdeveloped country who has been in the United States for 1 month. Which of these problems related to his nutritional status might the nurse expect to find?
c. Osteomalacia (softening of the bones)
d. Coronary artery disease
7. For the first time, the nurse is seeing a patient who has no history of nutrition-related problems. The initial nutritional screening should include which activity?
a. Calorie count of nutrients
b. Anthropometric measures
c. Complete physical examination
d. Measurement of weight and weight history
8. A patient is asked to indicate on a form how many times he eats a specific food. This method describes which of these tools for obtaining dietary information?
a. Food diary
b. Calorie count
c. 24-hour recall
d. Food-frequency questionnaire
9. The nurse is providing care for a 68-year-old woman who is complaining of constipation. What concern exists regarding her nutritional status?
a. Absorption of nutrients may be impaired.
b. Constipation may represent a food allergy.
c. The patient may need emergency surgery to correct the problem.
d. Gastrointestinal problems will increase her caloric demand.
10. During a nutritional assessment, why is it important for the nurse to ask a patient what medications he or she is taking?
a. Certain drugs can affect the metabolism of nutrients.
b. The nurse needs to assess the patient for allergic reactions.
c. Medications need to be documented in the record for the physician’s review.
d. Medications can affect one’s memory and ability to identify food eaten in the last 24 hours.
Chapter 12: Skin, Hair, and Nails
1. The nurse educator is preparing an education module for the nursing staff on the epidermal layer of skin. Which of these statements would be included in the module? The epidermis is:
a. Highly vascular.
b. Thick and tough.
c. Thin and nonstratified.
d. Replaced every 4 weeks.
2. The nurse educator is preparing an education module for the nursing staff on the dermis layer of skin. Which of these statements would be included in the module? The dermis:
a. Contains mostly fat cells.
b. Consists mostly of keratin.
c. Is replaced every 4 weeks.
d. Contains sensory receptors.
3. The nurse is examining a patient who tells the nurse, “I sure sweat a lot, especially on my face and feet but it doesn’t have an odor.” The nurse knows that this condition could be related to:
a. Eccrine glands.
b. Apocrine glands.
c. Disorder of the stratum corneum.
d. Disorder of the stratum germinativum.
4. A newborn infant is in the clinic for a well-baby checkup. The nurse observes the infant for the possibility of fluid loss because of which of these factors?
a. Subcutaneous fat deposits are high in the newborn.
b. Sebaceous glands are overproductive in the newborn.
c. The newborn’s skin is more permeable than that of the adult.
d. The amount of vernix caseosa dramatically rises in the newborn.
5. The nurse is bathing an 80-year-old man and notices that his skin is wrinkled, thin, lax, and dry. This finding would be related to which factor in the older adult?
a. Increased vascularity of the skin
b. Increased numbers of sweat and sebaceous glands
c. An increase in elastin and a decrease in subcutaneous fat
d. An increased loss of elastin and a decrease in subcutaneous fat
6. During the aging process, the hair can look gray or white and begin to feel thin and fine. The nurse knows that this occurs because of a decrease in the number of functioning:
7. During an examination, the nurse finds that a patient has excessive dryness of the skin. The best term to describe this condition is:
8. A 22-year-old woman comes to the clinic because of severe sunburn and states, “I was out in the sun for just a couple of minutes.” The nurse begins a medication review with her, paying special attention to which medication class?
a. Nonsteroidal antiinflammatory drugs for pain
b. Tetracyclines for acne
c. Proton pump inhibitors for heartburn
d. Thyroid replacement hormone for hypothyroidism
9. A woman is leaving on a trip to Hawaii and has come in for a checkup. During the examination the nurse learns that she has diabetes and takes oral hypoglycemic agents. The patient needs to be concerned about which possible effect of her medications?
a. Increased possibility of bruising
b. Skin sensitivity as a result of exposure to salt water
c. Lack of availability of glucose-monitoring supplies
d. Importance of sunscreen and avoiding direct sunlight
10. A 13-year-old girl is interested in obtaining information about the cause of her acne. The nurse should share with her that acne:
a. Is contagious.
b. Has no known cause.
c. Is caused by increased sebum production.
d. Has been found to be related to poor hygiene.
Chapter 13: Head, Face, and Neck, Including Regional Lymphatics
1. A physician tells the nurse that a patient’s vertebra prominens is tender and asks the nurse to reevaluate the area in 1 hour. The area of the body the nurse will assess is:
a. Just above the diaphragm.
b. Just lateral to the knee cap.
c. At the level of the C7 vertebra.
d. At the level of the T11 vertebra.
2. A mother brings her 2-month-old daughter in for an examination and says, “My daughter rolled over against the wall, and now I have noticed that she has this spot that is soft on the top of her head. Is something terribly wrong?” The nurse’s best response would be:
a. “Perhaps that could be a result of your dietary intake during pregnancy.”
b. “Your baby may have craniosynostosis, a disease of the sutures of the brain.”
c. “That ‘soft spot’ may be an indication of cretinism or congenital hypothyroidism.”
d. “That ‘soft spot’ is normal, and actually allows for growth of the brain during the first year of your baby’s life.”
3. The nurse notices that a patient’s palpebral fissures are not symmetric. On examination, the nurse may find that damage has occurred to which cranial nerve (CN)?
4. A patient is unable to differentiate between sharp and dull stimulation to both sides of her face. The nurse suspects:
a. Bell palsy.
b. Damage to the trigeminal nerve.
c. Frostbite with resultant paresthesia to the cheeks.
5. When examining the face of a patient, the nurse is aware that the two pairs of salivary glands that are accessible to examination are the ___________ and ___________ glands.
a. Occipital; submental
b. Parotid; jugulodigastric
c. Parotid; submandibular
d. Submandibular; occipital
6. A patient comes to the clinic complaining of neck and shoulder pain and is unable to turn her head. The nurse suspects damage to CN ______ and proceeds with the examination by _____________.
a. XI; palpating the anterior and posterior triangles
b. XI; asking the patient to shrug her shoulders against resistance
c. XII; percussing the sternomastoid and submandibular neck muscles
d. XII; assessing for a positive Romberg sign
7. When examining a patient’s CN function, the nurse remembers that the muscles in the neck that are innervated by CN XI are the:
a. Sternomastoid and trapezius.
b. Spinal accessory and omohyoid.
c. Trapezius and sternomandibular.
d. Sternomandibular and spinal accessory.
8. A patient’s laboratory data reveal an elevated thyroxine (T4) level. The nurse would proceed with an examination of the _____ gland.
9. A patient says that she has recently noticed a lump in the front of her neck below her “Adam’s apple” that seems to be getting bigger. During the assessment, the finding that leads the nurse to suspect that this may not be a cancerous thyroid nodule is that the lump (nodule):
a. Is tender.
b. Is mobile and not hard.
c. Disappears when the patient smiles.
d. Is hard and fixed to the surrounding structures.
10. The nurse notices that a patient’s submental lymph nodes are enlarged. In an effort to identify the cause of the node enlargement, the nurse would assess the patient’s:
a. Infraclavicular area.
b. Supraclavicular area.
c. Area distal to the enlarged node.
d. Area proximal to the enlarged node.
Chapter 14: Eyes
1. When examining the eye, the nurse notices that the patient’s eyelid margins approximate completely. The nurse recognizes that this assessment finding:
a. Is expected.
b. May indicate a problem with extraocular muscles.
c. May result in problems with tearing.
d. Indicates increased intraocular pressure.
2. During ocular examinations, the nurse keeps in mind that movement of the extraocular muscles is:
a. Decreased in the older adult.
b. Impaired in a patient with cataracts.
c. Stimulated by cranial nerves (CNs) I and II.
d. Stimulated by CNs III, IV, and VI.
3. The nurse is performing an external eye examination. Which statement regarding the outer layer of the eye is true?
a. The outer layer of the eye is very sensitive to touch.
b. The outer layer of the eye is darkly pigmented to prevent light from reflecting internally.
c. The trigeminal nerve (CN V) and the trochlear nerve (CN IV) are stimulated when the outer surface of the eye is stimulated.
d. The visual receptive layer of the eye in which light waves are changed into nerve impulses is located in the outer layer of the eye.
4. When examining a patient’s eyes, the nurse recalls that stimulation of the sympathetic branch of the autonomic nervous system:
a. Causes pupillary constriction.
b. Adjusts the eye for near vision.
c. Elevates the eyelid and dilates the pupil.
d. Causes contraction of the ciliary body.
5. The nurse is reviewing causes of increased intraocular pressure. Which of these factors determines intraocular pressure?
a. Thickness or bulging of the lens
b. Posterior chamber as it accommodates increased fluid
c. Contraction of the ciliary body in response to the aqueous within the eye
d. Amount of aqueous produced and resistance to its outflow at the angle of the anterior chamber
6. The nurse is conducting a visual examination. Which of these statements regarding visual pathways and visual fields is true?
a. The right side of the brain interprets the vision for the right eye.
b. The image formed on the retina is upside down and reversed from its actual appearance in the outside world.
c. Light rays are refracted through the transparent media of the eye before striking the pupil.
d. Light impulses are conducted through the optic nerve to the temporal lobes of the brain.
7. The nurse is testing a patient’s visual accommodation, which refers to which action?
a. Pupillary constriction when looking at a near object
b. Pupillary dilation when looking at a far object
c. Changes in peripheral vision in response to light
d. Involuntary blinking in the presence of bright light
8. A patient has a normal pupillary light reflex. The nurse recognizes that this reflex indicates that:
a. The eyes converge to focus on the light.
b. Light is reflected at the same spot in both eyes.
c. The eye focuses the image in the center of the pupil.
d. Constriction of both pupils occurs in response to bright light.
9. A mother asks when her newborn infant’s eyesight will be developed. The nurse should reply:
a. “Vision is not totally developed until 2 years of age.”
b. “Infants develop the ability to focus on an object at approximately 8 months of age.”
c. “By approximately 3 months of age, infants develop more coordinated eye movements and can fixate on an object.”
d. “Most infants have uncoordinated eye movements for the first year of life.”
10. The nurse is reviewing in age-related changes in the eye for a class. Which of these physiologic changes is responsible for presbyopia?
a. Degeneration of the cornea
b. Loss of lens elasticity
c. Decreased adaptation to darkness
d. Decreased distance vision abilities
Chapter 15: Ears
1. 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:
c. Outer meatus.
d. Mastoid process.
2. The nurse is examining a patient’s ears and notices cerumen in the external canal. Which of these statements about cerumen is correct?
a. Sticky honey-colored cerumen is a sign of infection.
b. The presence of cerumen is indicative of poor hygiene.
c. The purpose of cerumen is to protect and lubricate the ear.
d. Cerumen is necessary for transmitting sound through the auditory canal.
3. When examining the ear with an otoscope, the nurse notes that the tympanic membrane should appear:
a. Light pink with a slight bulge.
b. Pearly gray and slightly concave.
c. Pulled in at the base of the cone of light.
d. Whitish with a small fleck of light in the superior portion.
4. The nurse is reviewing the structures of the ear. Which of these statements concerning the eustachian tube is true?
a. The eustachian tube is responsible for the production of cerumen.
b. It remains open except when swallowing or yawning.
c. The eustachian tube allows passage of air between the middle and outer ear.
d. It helps equalize air pressure on both sides of the tympanic membrane.
5. A patient with a middle ear infection asks the nurse, “What does the middle ear do?” The nurse responds by telling the patient that the middle ear functions to:
a. Maintain balance.
b. Interpret sounds as they enter the ear.
c. Conduct vibrations of sounds to the inner ear.
d. Increase amplitude of sound for the inner ear to function.
6. The nurse is reviewing the function of the cranial nerves (CNs). Which CN is responsible for conducting nerve impulses to the brain from the organ of Corti?
7. The nurse is assessing a patient who may have hearing loss. Which of these statements is trueconcerning air conduction?
a. Air conduction is the normal pathway for hearing.
b. Vibrations of the bones in the skull cause air conduction.
c. Amplitude of sound determines the pitch that is heard.
d. Loss of air conduction is called a conductive hearing loss.
8. A patient has been shown to have a sensorineural hearing loss. During the assessment, it would be important for the nurse to:
a. Speak loudly so the patient can hear the questions.
b. Assess for middle ear infection as a possible cause.
c. Ask the patient what medications he is currently taking.
d. Look for the source of the obstruction in the external ear.
9. During an interview, the patient states he has the sensation that “everything around him is spinning.” The nurse recognizes that the portion of the ear responsible for this sensation is the:
b. CN VIII.
c. Organ of Corti.
10. A patient in her first trimester of pregnancy is diagnosed with rubella. Which of these statements is correct regarding the significance of this in relation to the infant’s hearing?
a. Rubella may affect the mother’s hearing but not the infant’s.
b. Rubella can damage the infant’s organ of Corti, which will impair hearing.
c. Rubella is only dangerous to the infant in the second trimester of pregnancy.
d. Rubella can impair the development of CN VIII and thus affect hearing.
Chapter 16: Nose, Mouth, and Throat
1. The primary purpose of the ciliated mucous membrane in the nose is to:
a. Warm the inhaled air.
b. Filter out dust and bacteria.
c. Filter coarse particles from inhaled air.
d. Facilitate the movement of air through the nares.
2. The projections in the nasal cavity that increase the surface area are called the:
d. Kiesselbach plexus.
3. The nurse is reviewing the development of the newborn infant. Regarding the sinuses, which statement is true in relation to a newborn infant?
a. Sphenoid sinuses are full size at birth.
b. Maxillary sinuses reach full size after puberty.
c. Frontal sinuses are fairly well developed at birth.
d. Maxillary and ethmoid sinuses are the only sinuses present at birth.
4. The tissue that connects the tongue to the floor of the mouth is the:
5. The salivary gland that is the largest and located in the cheek in front of the ear is the _________ gland.
6. In assessing the tonsils of a 30 year old, the nurse notices that they are involuted, granular in appearance, and appear to have deep crypts. What is correct response to these findings?
a. Refer the patient to a throat specialist.
b. No response is needed; this appearance is normal for the tonsils.
c. Continue with the assessment, looking for any other abnormal findings.
d. Obtain a throat culture on the patient for possible streptococcal (strep) infection.
7. The nurse is obtaining a health history on a 3-month-old infant. During the interview, the mother states, “I think she is getting her first tooth because she has started drooling a lot.” The nurse’s best response would be:
a. “You’re right, drooling is usually a sign of the first tooth.”
b. “It would be unusual for a 3 month old to be getting her first tooth.”
c. “This could be the sign of a problem with the salivary glands.”
d. “She is just starting to salivate and hasn’t learned to swallow the saliva.”
8. The nurse is assessing an 80-year-old patient. Which of these findings would be expected for this patient?
a. Hypertrophy of the gums
b. Increased production of saliva
c. Decreased ability to identify odors
d. Finer and less prominent nasal hair
9. The nurse is performing an oral assessment on a 40-year-old Black patient and notices the presence of a 1 cm, nontender, grayish-white lesion on the left buccal mucosa. Which one of these statements is true? This lesion is:
a. Leukoedema and is common in dark-pigmented persons.
b. The result of hyperpigmentation and is normal.
c. Torus palatinus and would normally be found only in smokers.
d. Indicative of cancer and should be immediately tested.
10. While obtaining a health history, a patient tells the nurse that he has frequent nosebleeds and asks the best way to get them to stop. What would be the nurse’s best response?
a. “While sitting up, place a cold compress over your nose.”
b. “Sit up with your head tilted forward and pinch your nose.”
c. “Just allow the bleeding to stop on its own, but don’t blow your nose.”
d. “Lie on your back with your head tilted back and pinch your nose.”
Chapter 17: Breasts and Regional Lymphatics
1. Which of the following statements is true regarding the internal structures of the breast? The breast is made up of:
a. Primarily muscle with very little fibrous tissue.
b. Fibrous, glandular, and adipose tissues.
c. Primarily milk ducts, known as lactiferous ducts.
d. Glandular tissue, which supports the breast by attaching to the chest wall.
2. In performing a breast examination, the nurse knows that examining the upper outer quadrant of the breast is especially important. The reason for this is that the upper outer quadrant is:
a. The largest quadrant of the breast.
b. The location of most breast tumors.
c. Where most of the suspensory ligaments attach.
d. More prone to injury and calcifications than other locations in the breast.
3. In performing an assessment of a woman’s axillary lymph system, the nurse should assess which of these nodes?
a. Central, axillary, lateral, and sternal
b. Pectoral, lateral, anterior, and sternal
c. Central, lateral, pectoral, and subscapular
d. Lateral, pectoral, axillary, and suprascapular
4. If a patient reports a recent breast infection, then the nurse should expect to find ________ node enlargement.
b. Ipsilateral axillary
c. Contralateral axillary
d. Inguinal and cervical
5. A 9-year-old girl is in the clinic for a sport physical examination. After some initial shyness she finally asks, “Am I normal? I don’t seem to need a bra yet, but I have some friends who do. What if I never get breasts?” The nurse’s best response would be:
a. “Don’t worry, you still have plenty of time to develop.”
b. “I know just how you feel, I was a late bloomer myself. Just be patient, and they will grow.”
c. “You will probably get your periods before you notice any significant growth in your breasts.”
d. “I understand that it is hard to feel different from your friends. Breasts usually develop between 8 and 10 years of age.”
6. A patient contacts the office and tells the nurse that she is worried about her 10-year-old daughter having breast cancer. She describes a unilateral enlargement of the right breast with associated tenderness. She is worried because the left breast is not enlarged. What would be the nurse’s best response? Tell the mother that:
a. Breast development is usually fairly symmetric and that the daughter should be examined right away.
b. She should bring in her daughter right away because breast cancer is fairly common in preadolescent girls.
c. Although an examination of her daughter would rule out a problem, her breast development is most likely normal.
d. It is unusual for breasts that are first developing to feel tender because they haven’t developed much fibrous tissue.
7. A 14-year-old girl is anxious about not having reached menarche. When taking the health history, the nurse should ascertain which of the following? The age that:
a. The girl began to develop breasts.
b. Her mother developed breasts.
c. She began to develop pubic hair.
d. She began to develop axillary hair.
8. A woman is in the family planning clinic seeking birth control information. She states that her breasts “change all month long” and that she is worried that this is unusual. What is the nurse’s best response? The nurse should tell her that:
a. Continual changes in her breasts are unusual. The breasts of nonpregnant women usually stay pretty much the same all month long.
b. Breast changes in response to stress are very common and that she should assess her life for stressful events.
c. Because of the changing hormones during the monthly menstrual cycle, cyclic breast changes are common.
d. Breast changes normally occur only during pregnancy and that a pregnancy test is needed at this time.
9. A woman has just learned that she is pregnant. What are some things the nurse should teach her about her breasts?
a. She can expect her areolae to become larger and darker in color.
b. Breasts may begin secreting milk after the fourth month of pregnancy.
c. She should inspect her breasts for visible veins and immediately report these.
d. During pregnancy, breast changes are fairly uncommon; most of the changes occur after the birth.
10. The nurse is teaching a pregnant woman about breast milk. Which statement by the nurse iscorrect?
a. “Your breast milk is immediately present after the delivery of your baby.”
b. “Breast milk is rich in protein and sugars (lactose) but has very little fat.”
c. “The colostrum, which is present right after birth, does not contain the same nutrients as breast milk.”
d. “You may notice a thick, yellow fluid expressed from your breasts as early as the fourth month of pregnancy.”
Chapter 18: Thorax and Lungs
1. Which of these statements is true regarding the vertebra prominens? The vertebra prominens is:
a. The spinous process of C7.
b. Usually nonpalpable in most individuals.
c. Opposite the interior border of the scapula.
d. Located next to the manubrium of the sternum.
2. When performing a respiratory assessment on a patient, the nurse notices a costal angle of approximately 90 degrees. This characteristic is:
a. Observed in patients with kyphosis.
b. Indicative of pectus excavatum.
c. A normal finding in a healthy adult.
d. An expected finding in a patient with a barrel chest.
3. 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. Primarily consists of an upper lobe on the posterior chest.
d. Is shorter than the right lung because of the underlying stomach.
4. Which statement about the apices of the lungs is true? The apices of the lungs:
a. Are at the level of the second rib anteriorly.
b. Extend 3 to 4 cm above the inner third of the clavicles.
c. Are located at the sixth rib anteriorly and the eighth rib laterally.
d. Rest on the diaphragm at the fifth intercostal space in the midclavicular line (MCL).
5. During an examination of the anterior thorax, the nurse is aware that the trachea bifurcates anteriorly at the:
a. Costal angle.
b. Sternal angle.
c. Xiphoid process.
d. Suprasternal notch.
6. 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 symmetric tactile fremitus.
d. Absent voice sounds and hyperresonant percussion tones.
7. The primary muscles of respiration include the:
a. Diaphragm and intercostals.
b. Sternomastoids and scaleni.
c. Trapezii and rectus abdominis.
d. External obliques and pectoralis major.
8. 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. Obtaining a detailed health history of the patient’s allergies and a history of asthma
b. Telling the patient to sleep on his or her right side to facilitate ease of respirations
c. Assessing for other signs and symptoms of paroxysmal nocturnal dyspnea
d. Assuring the patient that paroxysmal nocturnal dyspnea is normal and will probably resolve within the next week
9. When assessing tactile fremitus, the nurse recalls that it is normal to feel tactile fremitus most intensely over which location?
a. Between the scapulae
b. Third intercostal space, MCL
c. Fifth intercostal space, midaxillary line (MAL)
d. Over the lower lobes, posterior side
10. The nurse is reviewing the technique of palpating for tactile fremitus with a new graduate. Which statement by the graduate nurse reflects a correct understanding of tactile fremitus? “Tactile fremitus:
a. “Is caused by moisture in the alveoli.”
b. “Indicates that air is present in the subcutaneous tissues.”
c. “Is caused by sounds generated from the larynx.”
d. “Reflects the blood flow through the pulmonary arteries.”
Chapter 19: Heart and Neck Vessels
1. The sac that surrounds and protects the heart is called the:
d. Pleural space.
2. The direction of blood flow through the heart is best described by which of these?
a. Vena cava right atrium right ventricle lungs pulmonary artery left atrium left ventricle
b. Right atrium right ventricle pulmonary artery lungs pulmonary vein left atrium left ventricle
c. Aorta right atrium right ventricle lungs pulmonary vein left atrium left ventricle vena cava
d. Right atrium right ventricle pulmonary vein lungs pulmonary artery left atrium left ventricle
3. The nurse is reviewing the anatomy and physiologic functioning of the heart. Which statement best describes what is meant by atrial kick?
a. The atria contract during systole and attempt to push against closed valves.
b. Contraction of the atria at the beginning of diastole can be felt as a palpitation.
c. Atrial kick is the pressure exerted against the atria as the ventricles contract during systole.
d. The atria contract toward the end of diastole and push the remaining blood into the ventricles.
4. When listening to heart sounds, the nurse knows the valve closures that can be heard best at the base of the heart are:
a. Mitral and tricuspid.
b. Tricuspid and aortic.
c. Aortic and pulmonic.
d. Mitral and pulmonic.
5. Which of these statements describes the closure of the valves in a normal cardiac cycle?
a. The aortic valve closes slightly before the tricuspid valve.
b. The pulmonic valve closes slightly before the aortic valve.
c. The tricuspid valve closes slightly later than the mitral valve.
d. Both the tricuspid and pulmonic valves close at the same time.
6. The component of the conduction system referred to as the pacemaker of the heart is the:
a. Atrioventricular (AV) node.
b. Sinoatrial (SA) node.
c. Bundle of His.
d. Bundle branches.
7. The electrical stimulus of the cardiac cycle follows which sequence?
a. AV node SA node bundle of His
b. Bundle of His AV node SA node
c. SA node AV node bundle of His bundle branches
d. AV node SA node bundle of His bundle branches
8. The findings from an assessment of a 70-year-old patient with swelling in his ankles include jugular venous pulsations 5 cm above the sternal angle when the head of his bed is elevated 45 degrees. The nurse knows that this finding indicates:
a. Decreased fluid volume.
b. Increased cardiac output.
c. Narrowing of jugular veins.
d. Elevated pressure related to heart failure.
9. When assessing a newborn infant who is 5 minutes old, the nurse knows which of these statements to be true?
a. The left ventricle is larger and weighs more than the right ventricle.
b. The circulation of a newborn is identical to that of an adult.
c. Blood can flow into the left side of the heart through an opening in the atrial septum.
d. The foramen ovale closes just minutes before birth, and the ductus arteriosus closes immediately after.
10. A 25-year-old woman in her fifth month of pregnancy has a blood pressure of 100/70 mm Hg. In reviewing her previous examination, the nurse notes that her blood pressure in her second month was 124/80 mm Hg. In evaluating this change, what does the nurse know to be true?
a. This decline in blood pressure is the result of peripheral vasodilatation and is an expected change.
b. Because of increased cardiac output, the blood pressure should be higher at this time.
c. This change in blood pressure is not an expected finding because it means a decrease in cardiac output.
d. This decline in blood pressure means a decrease in circulating blood volume, which is dangerous for the fetus.
Chapter 20: Peripheral Vascular System and Lymphatic System
1. Which statement is true regarding the arterial system?
a. Arteries are large-diameter vessels.
b. The arterial system is a high-pressure system.
c. The walls of arteries are thinner than those of the veins.
d. Arteries can greatly expand to accommodate a large blood volume increase.
2. The nurse is reviewing the blood supply to the arm. The major artery supplying the arm is the _____ artery.
d. Deep palmar
3. The nurse is preparing to assess the dorsalis pedis artery. Where is the correct location for palpation?
a. Behind the knee
b. Over the lateral malleolus
c. In the groove behind the medial malleolus
d. Lateral to the extensor tendon of the great toe
4. A 65-year-old patient is experiencing pain in his left calf when he exercises that disappears after resting for a few minutes. The nurse recognizes that this description is most consistent with _______ the left leg.
a. Venous obstruction of
b. Claudication due to venous abnormalities in
c. Ischemia caused by a partial blockage of an artery supplying
d. Ischemia caused by the complete blockage of an artery supplying
5. The nurse is reviewing venous blood flow patterns. Which of these statements best describes the mechanism(s) by which venous blood returns to the heart?
a. Intraluminal valves ensure unidirectional flow toward the heart.
b. Contracting skeletal muscles milk blood distally toward the veins.
c. High-pressure system of the heart helps facilitate venous return.
d. Increased thoracic pressure and decreased abdominal pressure facilitate venous return to the heart.
6. Which vein(s) is(are) responsible for most of the venous return in the arm?
7. A 70-year-old patient is scheduled for open-heart surgery. The surgeon plans to use the great saphenous vein for the coronary bypass grafts. The patient asks, “What happens to my circulation when this vein is removed?” The nurse should reply:
a. “Venous insufficiency is a common problem after this type of surgery.”
b. “Oh, you have lots of veins—you won’t even notice that it has been removed.”
c. “You will probably experience decreased circulation after the vein is removed.”
d. “This vein can be removed without harming your circulation because the deeper veins in your leg are in good condition.”
8. The nurse is reviewing the risk factors for venous disease. Which of these situations best describes a person at highest risk for the development of venous disease?
a. Woman in her second month of pregnancy
b. Person who has been on bed rest for 4 days
c. Person with a 30-year, 1 pack per day smoking habit
d. Older adult taking anticoagulant medication
9. The nurse is teaching a review class on the lymphatic system. A participant shows correct understanding of the material with which statement?
a. “Lymph flow is propelled by the contraction of the heart.”
b. “The flow of lymph is slow, compared with that of the blood.”
c. “One of the functions of the lymph is to absorb lipids from the biliary tract.”
d. “Lymph vessels have no valves; therefore, lymph fluid flows freely from the tissue spaces into the bloodstream.”
10. When performing an assessment of a patient, the nurse notices the presence of an enlarged right epitrochlear lymph node. What should the nurse do next?
a. Assess the patient’s abdomen, and notice any tenderness.
b. Carefully assess the cervical lymph nodes, and check for any enlargement.
c. Ask additional health history questions regarding any recent ear infections or sore throats.
d. Examine the patient’s lower arm and hand, and check for the presence of infection or lesions.
AND MUCH MORE