HAP FINAL EXAM STUDY QUESTIONS WITH CORRECT ANSWERS GRADED A+ 2023-2024 ASSURED SUCCESS, Exams of Nursing

Download HAP FINAL EXAM STUDY QUESTIONS WITH CORRECT ANSWERS GRADED A+ 2023-2024 ASSURED SUCCESS and more Exams Nursing in PDF only on Docsity! HAP FINAL EXAM STUDY QUESTIONS WITH CORRECT ANSWERS GRADED A+ 2023-2024 ASSURED SUCCESS The nurse is percussing the seventh right intercostal space at the midclavicular line over the liver. Which sound should the nurse expect to hear? a. Dullness b.Tympany c. Resonance d. Hyperresonance Answer- a (The liver is located in the right upper quadrant and would elicit a dull percussion note.) Which structure is located in the left lower quadrant of the abdomen? a. Liver b. Duodenum c. Gallbladder d. Sigmoid colon Answer- d (The sigmoid colon is located in the left lower quadrant of the abdomen.) A patient is having difficulty swallowing medications and food. The nurse would document that this patient has: a. Aphasia. b. Dysphasia. c. Dysphagia. d. Anorexia. Answer- c (Dysphagia is a condition that occurs with disorders of the throat or esophagus and results in difficulty swallowing. Aphasia and dysphasia are speech disorders. Anorexia is a loss of appetite.) The nurse suspects that a patient has a distended bladder. How should the nurse assess for this condition? a. Percuss and palpate in the lumbar region. b. Inspect and palpate in the epigastric region. c. Auscultate and percuss in the inguinal region. d. Percuss and palpate the midline area above the suprapubic bone. Answer- d (Dull percussion sounds would be elicited over a distended bladder, and the hypogastric area would seem firm to palpation.) The nurse is aware that one change that may occur in the gastrointestinal system of an aging adult is: a. Increased salivation. b. Increased liver size. c. Increased esophageal emptying. d. Decreased gastric acid secretion. Answer- d (Gastric acid secretion decreases with aging. As one ages, salivation decreases, esophageal emptying is delayed, and liver size decreases.) A 22-year-old man comes to the clinic for an examination after falling off his motorcycle and landing on his left side on the handle bars. The nurse suspects that he may have injured his spleen. Which of these statements is true regarding assessment of the spleen in this situation? a. The spleen can be enlarged as a result of trauma. b. The spleen is normally felt on routine palpation. c. If an enlarged spleen is noted, then the nurse should thoroughly palpate to determine its size. d. An enlarged spleen should not be palpated because it can easily rupture. Answer- d (If an enlarged spleen is felt, then the nurse should refer the person and should not continue to palpate it. An enlarged spleen is friable and can easily rupture with overpalpation.) A patient's abdomen is bulging and stretched in appearance. The nurse should describe this finding as: a. Obese. b. Herniated. c. Scaphoid. d. Protuberant. Answer- d (A protuberant abdomen is rounded, bulging, and stretched (see Figure 21-7). A scaphoid abdomen caves inward.) The nurse is describing a scaphoid abdomen. To the horizontal plane, a scaphoid contour of the abdomen depicts a profile. a. Flat b. Conve x c. Bulging d. Concave Answer- d (Contour describes the profile of the abdomen from the rib margin to the pubic bone; a scaphoid contour is one that is concave from a horizontal plane (see Figure 21-7).) While examining a patient, the nurse observes abdominal pulsations between the xiphoid process and umbilicus. The nurse would suspect that these are: a. Pulsations of the renal arteries. b. Pulsations of the inferior vena cava. c. Normal abdominal aortic pulsations. d. Increased peristalsis from a bowel obstruction. Answer- c (Normally, the pulsations from the aorta are observed beneath the skin in the epigastric area, particularly in thin persons who have good muscle wall d. Dull percussion note in the left upper quadrant at the midclavicular line Answer- B (Tympany should predominate in all four quadrants of the abdomen because air in the intestines rises to the surface when the person is supine. Vascular bruits are not usually present. Normally, the spleen is not palpable. Dullness would not be found in the area of lung resonance (left upper quadrant at the midclavicular line).) The nurse is assessing the abdomen of a pregnant woman who is complaining of having "acid indigestion" all the time. The nurse knows that esophageal reflux during pregnancy can cause: a. Diarrhea. b. Pyrosis. c. Dysphagia. d. Constipation. Answer- b (Pyrosis, or heartburn, is caused by esophageal reflux during pregnancy. The other options are not correct.) The nurse is performing percussion during an abdominal assessment. Percussion notes heard during the abdominal assessment may include: a. Flatness, resonance, and dullness. b. Resonance, dullness, and tympany. c. Tympany, hyperresonance, and dullness. d. Resonance, hyperresonance, and flatness. Answer- C (Percussion notes normally heard during the abdominal assessment may include tympany, which should predominate because air in the intestines rises to the surface when the person is supine; hyperresonance, which may be present with gaseous distention; and dullness, which may be found over a distended bladder, adipose tissue, fluid, or a mass.) An older patient has been diagnosed with pernicious anemia. The nurse knows that this condition could be related to: a. Increased gastric acid secretion. b. Decreased gastric acid secretion. c. Delayed gastrointestinal emptying time. d. Increased gastrointestinal emptying time. Answer- B (Gastric acid secretion decreases with aging and may cause pernicious anemia (because it interferes with vitamin B12 absorption), iron-deficiency anemia, and malabsorption of calcium.) A patient is complaining of a sharp pain along the costovertebral angles. The nurse is aware that this symptom is most often indicative of: a. Ovary infection. b. Liver enlargement. c. Kidney inflammation. d. Spleen enlargement. Answer- C (Sharp pain along the costovertebral angles occurs with inflammation of the kidney or paranephric area. The other options are not correct.) A nurse notices that a patient has ascites, which indicates the presence of: a. Fluid. b. Feces. c. Flatus. d. Fibroid tumors. Answer- A (Ascites is free fluid in the peritoneal cavity and occurs with heart failure, portal hypertension, cirrhosis, hepatitis, pancreatitis, and cancer.) patient with a large amount of ascites? a. Dullness across the abdomen b. Flatness in the right upper quadrant c. Hyperresonance in the left upper quadrant d. Tympany in the right and left lower quadrants Answer- A (A large amount of ascitic fluid produces a dull sound to percussion.) A 40-year-old man states that his physician told him that he has a hernia. He asks the nurse to explain what a hernia is. Which response by the nurse is appropriate? a. "No need to worry. Most men your age develop hernias." b. "A hernia is a loop of bowel protruding through a weak spot in the abdominal muscles." c. "A hernia is the result of prenatal growth abnormalities that are just now causing problems." d. "I'll have to have your physician explain this to you." Answer- B (The nurse should explain that a hernia is a protrusion of the abdominal viscera through an abnormal opening in the muscle wall.) A 45-year-old man is in the clinic for a physical examination. During the abdominal assessment, the nurse percusses the abdomen and notices an area of dullness above the right costal margin of approximately 11 cm. The nurse should: a. Document the presence of hepatomegaly. b.Ask additional health history questions regarding his alcohol intake. c. Describe this dullness as indicative of an enlarged liver, and refer him to a physician. d. Consider this finding as normal, and proceed with the examination. Answer- D (A liver span of 10.5 cm is the mean for males and 7 cm for females. Men and taller individuals are at the upper end of this range. Women and shorter individuals are at the lower end of this range. A liver span of 11 cm is within normal limits for this individual.) When palpating the abdomen of a 20-year-old patient, the nurse notices the presence of tenderness in the left upper quadrant with deep palpation. Which of these structures is most likely to be involved? a. Spleen b. Sigmoid colon c. Appendix d. Gallbladder Answer- A (The spleen is located in the left upper quadrant of the abdomen. The gallbladder is in the right upper quadrant, the sigmoid colon is in the left lower quadrant, and the appendix is in the right lower quadrant.) The nurse is reviewing statistics for lactose intolerance. In the United States, the incidence of lactose intolerance is higher in adults of which ethnic group? a. Blacks b. Hispanics c. Whites d. Asians Answer- A (A recent study found estimates of lactose-intolerance prevalence as follows: 19.5% for Blacks, 10% for Hispanics, and 7.72% for Whites.) The nurse is assessing a patient for possible peptic ulcer disease. Which condition or history often causes this problem? a. Hypertension b. Streptococcal infections c. Recurrent constipation with frequent laxative use d. Frequent use of nonsteroidal antiinflammatory drugs Answer- D (Peptic ulcer disease occurs with the frequent use of nonsteroidal antiinflammatory drugs, alcohol use, smoking, and Helicobacter pylori infection.) During reporting, the student nurse hears that a patient has hepatomegaly and recognizes that this term refers to: a. Enlarged liver. b. Enlarged spleen. c. Distended bowel. d. Excessive diarrhea. Answer- A (The term hepatomegaly refers to an enlarged liver. The term splenomegaly refers to an enlarged spleen. The other responses are not correct.) During an assessment, the nurse notices that a patient's umbilicus is enlarged and everted. It is positioned midline with no change in skin color. The nurse recognizes that the patient may have which condition? a. Intra-abdominal bleeding b. Constipation c. Umbilical hernia d. Abdominal tumor Answer- C (The umbilicus is normally midline and inverted with no signs of discoloration. With an umbilical hernia, the mass is enlarged and everted. The other responses are incorrect.) During an abdominal assessment, the nurse tests for a fluid wave. A positive fluid wave test occurs with: a. Splenomegaly. b. Distended bladder. c. Constipation. d. Ascites. Answer- D (If ascites (fluid in the abdomen) is present, then the examiner will feel a fluid wave when assessing the abdomen. A fluid wave is not present with splenomegaly, a distended bladder, or constipation.) The nurse is preparing to examine a patient who has been complaining of right lower quadrant pain. Which technique is correct during the assessment? The nurse should: a. Examine the tender area first. b. Examine the tender area last. c. Avoid palpating the tender area. d. Palpate the tender area first, and then auscultate for bowel sounds. Answer- B (The nurse should save the examination of any identified b. Ventricular fibrillation. c. Bradycardia. d. Mitral valve prolapse. Answer- A (Even moderate drinking leads to hypertension and cardiomyopathy, with an increase in left ventricular mass, dilation of ventricles, and wall thinning. Ventricular fibrillation, bradycardia, and mitral valve prolapse are not associated with chronic heavy use of alcohol.) 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? a. 2 b. 4 c. 6 d. 8 Answer- B (In men, alcohol consumption of at least four standard drinks per day is associated with increased deaths from liver cirrhosis, cancers of the mouth, esophagus and other areas, and deaths from injuries and other external causes.) 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 b. Heroin c. Marijuana d. Hallucinogens Answer- C (In persons age 12 years and older who reported using during the past month, marijuana (hashish) was the most commonly used illicit drug reported.) 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." Answer- D (No amount of alcohol has been determined to be safe for pregnant women. The potential adverse effects of alcohol use on the fetus are well known; women who are pregnant should be screened for alcohol use, and abstinence should be recommended.) 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 Answer- B (Decreased liver and kidney functioning increases the bioavailability of alcohol in the blood for longer periods. Aging people experience decreased muscle mass (not increased), which also increases the alcohol concentration in the blood because the (Withdrawal symptoms of opiates, such as heroin, are similar to the clinical picture of influenza and include symptoms such as dilated pupils, lacrimation, runny nose, tachycardia, fever, restlessness, muscle and joint pains, and other symptoms) The nurse is reviewing aspects of substance abuse in preparation for a seminar. Which of these statements illustrates the concept of tolerance to an illicit substance? The person: a. Has a physiologic dependence on a substance. b. Requires an increased amount of the substance to produce the same effect. c. Requires daily use of the substance to function and is unable to stop using it. d. Experiences a syndrome of physiologic symptoms if the substance is not used. Answer- B (The concept of tolerance to a substance indicates that the person requires an increased amount of the substance to produce the same effect. Abuse indicates that the person needs to use the substance daily to function, and the person is unable to stop using it. Dependence is an actual physiologic dependence on the substance. Withdrawal occurs when cessation of the substance produces a syndrome of physiologic symptoms.) A patient with a known history of heavy alcohol use has been admitted to the ICU after he was found unconscious outside a bar. The nurse closely monitors him for symptoms of withdrawal. Which of these symptoms may occur during this time? Select all that apply. a. Bradycardia b. Coarse tremor of the hands c. Transient hallucinations d. Somnolence e. Sweating Answer- B, C, E (Symptoms of uncomplicated alcohol withdrawal start shortly after the cessation of drinking, peak at the second day, and improve by the fourth or fifth day. Symptoms include coarse tremors of the hands, tongue, and eyelids; anorexia; nausea and vomiting; autonomic hyperactivity ) A patient visits the clinic to ask about smoking cessation. He has smoked heavily for 30 years and wants to stop "cold turkey." He asks the nurse, "What symptoms can I expect if I do this?" Which of these symptoms should the nurse share with the patient as possible symptoms of nicotine withdrawal? Select all that apply. a. Headaches b. Hunger c. Sleepiness d. Restlessness e. Nervousness f. Sweating Answer- A, B, D, E (Symptoms of nicotine withdrawal include vasodilation, headaches, anger, irritability, frustration, anxiety, nervousness, awakening at night, difficulty concentrating, depression, hunger, impatience, and the desire to smoke) 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. Answer- B (Culture is learned from birth through language acquisition and socialization. It is not biologically or genetically determined and is learned by the individual.) 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. Answer- D (Culture has four basic characteristics. Culture adapts to specific conditions related to environmental and technical factors and to the availability of natural resources, and it is dynamic and ever changing. Culture is learned from birth through the process of language acquisition and socialization, but it is not most clearly reflected in one's language and behavior.) 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? a. Mores b. Norms c. Culture d. Social learning Answer- C (The culture that develops in any given society is always specific and distinctive, encompassing all of the knowledge, beliefs, customs, and skills acquired by members of the society. The other terms do not fit the given definition.) 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. Answer- D (Within cultures, groups of people share different beliefs, values, and attitudes. Differences occur because of ethnicity, religion, education, occupation, age, and gender. When such groups function within a large culture, they are referred to as subcultural groups) When reviewing the demographics of ethnic groups in the United States, the nurse recalls that the largest and fastest growing population is: through the processes of language acquisition and socialization. Religion is the belief in a higher power.) 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 d. Being closely tied to one's ethnic background Answer- C (Spirituality refers to each person's unique life experiences and his or her personal effort to find purpose and meaning in life. The other responses apply to religion.) A woman who has lived in the United States for a year after moving from Europe has learned to speak English and is almost finished with her college studies. She now dresses like her peers and says that her family in Europe would hardly recognize her. This nurse recognizes that this situation illustrates which concept? a.Assimilation b. Heritage consistency c. Biculturalism d. Acculturation Answer- A (Assimilation is the process by which a person develops a new cultural identity and becomes like members of the dominant culture. This concept does not reflect heritage consistency. Biculturalism is a dual pattern of identification; acculturation is the process of adapting to and acquiring another culture.) The nurse is conducting a heritage assessment. Which question is most appropriate for this assessment? a. "What is your religion?" b. "Do you mostly participate in the religious traditions of your family?" c. "Do you smoke?" d. "Do you have a history of heart disease?" Answer- B (Asking questions about participation in the religious traditions of family enables the nurse to assess a person's heritage. Simply asking about one's religion, smoking history, or health history does not reflect heritage.) In the majority culture of America, coughing, sweating, and diarrhea are symptoms of an illness. For some individuals of Mexican-American origin, however, these symptoms are a normal part of living. The nurse recognizes that this difference is true, probably because Mexican- Americans: a. Have less efficient immune systems and are often ill. b. Consider these symptoms part of normal living, not symptoms of ill health. c. Come from Mexico, and coughing is normal and healthy there. d. Are usually in a lower socioeconomic group and are more likely to be sick. Answer- B (The nurse needs to identify the meaning of health to the patient, remembering that concepts are derived, in part, from the way in which members of the cultural group define health.) The nurse is reviewing theories of illness. The germ theory, which states that microscopic organisms such as bacteria and viruses are responsible for specific disease conditions, is a basic belief of which theory of illness? a. Holistic b. Biomedical depends on the actions of supernatural forces for good or evil. The other answers do not reflect the magicoreligious perspective.) If an American Indian woman has come to the clinic to seek help with regulating her diabetes, then the nurse can expect that she: a. Will comply with the treatment prescribed. b. Has obviously given up her belief in naturalistic causes of disease. c. May also be seeking the assistance of a shaman or medicine man. d. Will need extra help in dealing with her illness and may be experiencing a crisis of faith. Answer- C (When self-treatment is unsuccessful, the individual may turn to the lay or folk healing systems, to spiritual or religious healing, or to scientific biomedicine. In addition to seeking help from a biomedical or scientific health care provider, patients may also seek help from folk or religious healers.) An older Mexican-American woman with traditional beliefs has been admitted to an inpatient care unit. A culturally sensitive nurse would: a. Contact the hospital administrator about the best course of action. b.Automatically get a curandero for her, because requesting one herself is not culturally appropriate. c. Further assess the patient's cultural beliefs and offer the patient assistance in contacting a curandero or priest if she desires. d.Ask the family what they would like to do because Mexican-Americans traditionally give control of decision making to their families. Answer- C (In addition to seeking help from the biomedical or scientific health care provider, patients may also seek help from folk or religious healers. Some people, such as those of Mexican-American or American-Indian origins, may believe that the cure is incomplete unless the body, mind, and spirit are also healed (although the division of the person into parts is a Western concept).) A 63-year-old Chinese-American man enters the hospital with complaints of chest pain, shortness of breath, and palpitations. Which statement most accurately reflects the nurse's best course of action? a. The nurse should focus on performing a full cardiac assessment. b.The nurse should focus on psychosomatic complaints because the patient has just learned that his wife has cancer. c. This patient is not in any danger at present; therefore, the nurse should send him home with instructions to contact his physician. d. It is unclear what is happening with this patient; consequently, the nurse should perform an assessment in both the physical and the psychosocial realms. Answer- D (Wide cultural variations exist in the manner in which certain symptoms and disease conditions are perceived, diagnosed, labeled, and treated. Chinese-Americans sometimes convert mental experiences or states into bodily symptoms (e.g., complaining of cardiac symptoms because the center of emotion in the Chinese culture is the heart).) Symptoms, such as pain, are often influenced by a person's cultural heritage. Which of the following is a true statement regarding pain? a. Nurses' attitudes toward their patients' pain are unrelated to their own experiences with pain. b. Nurses need to recognize that many cultures practice silent suffering as a response to pain. c.A nurse's area of clinical practice will most likely determine his or her assessment of a patient's pain. d.A nurse's years of clinical experience and current position are strong indicators of his or her response to patient pain. Answer- B (Silent suffering is a potential response to pain in many cultures. The nurse's assessment of pain needs to be embedded in a cultural context. The other responses are not correct.) The nurse is reviewing concepts of cultural aspects of pain. Which statement is true regarding pain? a.All patients will behave the same way when in pain. b. Just as patients vary in their perceptions of pain, so will they vary in their expressions of pain. c. Cultural norms have very little to do with pain tolerance, because pain tolerance is always biologically determined. d.A patient's expression of pain is largely dependent on the amount of tissue injury associated with the pain. Answer- B (In addition to expecting variations in pain perception and tolerance, the nurse should expect variations in the expression of pain. It is well known that individuals turn to their social environment for validation and comparison. The other statements are incorrect.) During a class on religion and spirituality, the nurse is asked to define spirituality. Which answer is correct? "Spirituality: a. Is a personal search to discover a supreme being." b. Is an organized system of beliefs concerning the cause, nature, and purpose of the universe." c. Is a belief that each person exists forever in some form, such as a belief in reincarnation or the afterlife." d.Arises out of each person's unique life experience and his or her personal effort to find purpose in life." Answer- D (Spirituality arises out of each person's unique life experience and his or her personal effort to find purpose and meaning in life. The other definitions reflect the concept of religion.) The nurse recognizes that working with children with a different cultural perspective may be especially difficult because: a. Children have spiritual needs that are influenced by their stages of development. b. Children have spiritual needs that are direct reflections of what is occurring in their homes. c. Religious beliefs rarely affect the parents' perceptions of the illness. d. Parents are often the decision makers, and they have no knowledge of their children's spiritual needs. Answer- A (Illness during childhood may be an especially difficult clinical situation. Children, as well as adults, have spiritual needs that vary according to the child's developmental level and the religious climate that exists in the family. The other statements are not correct.) A 30-year-old woman has recently moved to the United States with her husband. They are living with the woman's sister until they can get a home of their own. When company arrives to visit with the woman's sister, the woman feels suddenly shy and retreats to the back bedroom to hide until the company leaves. She explains that her reaction to guests is simply because she does not know how to speak "perfect English." This woman could be experiencing: a. Culture shock. b. Cultural taboos. c. Cultural unfamiliarity. d. Culture disorientation. Answer- A (Culture shock is a term used to describe the state of disorientation or inability to respond to the behavior of a different cultural group because of its sudden strangeness, unfamiliarity, and incompatibility with the individual's perceptions and expectations. The other terms are not correct.) After a symptom is recognized, the first effort at treatment is often self- care. Which of the following statements about self-care is true? "Self-care is: a. Not recognized as valuable by most health care providers." b. Usually ineffective and may delay more effective treatment." c. Always less expensive than biomedical alternatives." d. Influenced by the accessibility of over-the-counter medicines." Answer- D (After a symptom is identified, the first effort at treatment is often self-care. The availability of over-the-counter medications, the relatively high literacy level of Americans, and the influence of the mass media in communicating health-related information to the general population have contributed to the high percentage of cases of self-treatment.) The nurse is reviewing the hot/cold theory of health and illness. Which statement best describes the basic tenets of this theory? a. The causation of illness is based on supernatural forces that influence the humors of the body. b. Herbs and medicines are classified on their physical characteristics of hot and cold and the humors of the body. c. The four humors of the body consist of blood, yellow bile, spiritual connectedness, and social aspects of the individual. d.The treatment of disease consists of adding or subtracting cold, heat, dryness, or wetness to restore the balance of the humors of the body. Answer- D (The hot/cold theory of health and illness is based on the four humors of the body: blood, phlegm, black bile, and yellow bile. These humors regulate the basic bodily functions, described in terms of temperature, dryness, and moisture. The treatment of disease consists of adding or subtracting cold, heat, dryness, or wetness to restore the balance of the humors. The other statements are not correct.) . In the hot/cold theory, illnesses are believed to be caused by hot or cold d. Spirituality. Answer- B (Religion is defined as an organized system of beliefs concerning the cause, nature, and purpose of the universe, especially belief in or the worship of God or gods. Spirituality is born out of each person's unique life experiences and his or her personal efforts to find purpose and meaning in life. Ethnicity pertains to a social group within the social system that claims to possess variable traits, such as a common geographic origin, religion, race, and others.) When planning a cultural assessment, the nurse should include which component? a. Family history b. Chief complaint c. Medical history d. Health-related beliefs Answer- D (Health-related beliefs and practices are one component of a cultural assessment. The other items reflect other aspects of the patient's history.) Which of the following reflects the traditional health and illness beliefs and practices of those of African heritage? Health is: a. Being rewarded for good behavior. b. The balance of the body and spirit. c. Maintained by wearing jade amulets. d. Being in harmony with nature. Answer- D (The belief that health is being in harmony with nature reflects the health beliefs of those of African heritages. The other examples represent Iberian and Central and South American heritages, American-Indian heritages, and Asian heritages (See Table 2-3).) The nurse is reviewing aspects of cultural care. Which statements illustrate proper cultural care? Select all that apply. a. Examine the patient within the context of one's own cultural health and illness practices. b. Select questions that are not complex. c. Ask questions rapidly. d. Touch patients within the cultural boundaries of their heritage. e. Pace questions throughout the physical examination. Answer- B, D, E (Patients should be examined within the context of their own cultural health and illness practices. Questions should be simply stated and not rapidly asked.) The nurse is asking questions about a patient's health beliefs. Which questions are appropriate?Select all that apply. a. "What is your definition of health?" b. "Does your family have a history of cancer?" c. "How do you describe illness?" d. "What did your mother do to keep you from getting sick?" e. "Have you ever had any surgeries?" f. "How do you keep yourself healthy?" Answer- A, C, D, F (The questions listed are appropriate questions for an assessment of a patient's health beliefs and practices. The questions regarding family history and surgeries are part of the patient's physical history, not the patient's health beliefs.) Nursing is best exemplified by which of the following definitions of health? a) Biomedical b)Prevention b)A determination of the etiology of a disease c) A pattern of coping d) An individual's perception of health Answer- a 10.A patient admitted to the hospital with asthma has the following problems identified based on an admission health history and physical assessment. Which problem is a first-level priority? a) Ineffective self-health management b) Impaired gas exchange c) Risk for infection d)Readiness for enhanced spiritual well-being Answer- b 11.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 Answer- c 12.Spirituality is defied as: a) Participating in religious services on a regular basis b) A personal effort to find meaning and purpose in life c) The process of being raised within a culture d) A social group that claims to possess variable traits Answer- b 13.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 Answer- b 14.Which of the following symptoms is greatly influenced by a person's cultural heritage? a) Hearing loss b) Breast lump c) Food intolerance d) Pain Answer- d 15.The nurse recognizes that the concept of prevention in describing health is essential because: a) Disease can be prevented by treating the external environment b)The majority of deaths among Americans under age 65 years are not preventable c) Prevention places the emphasis on the link between health and personal behavior d) The means to prevention is through treatment provided by primary health care practitioners Answer- c 16.Which of the following statements regarding language barriers and health care is true? a) There is a law that addresses language barriers and health care b)Limited English proficiency is associated with a higher quality of care c) English proficiency is associated with a lower quality of care d) Patients with language barriers have a decreased risk of nonadherence to medication regimens Answer- a 17.The first step to cultural competency by a nurse is to: a) Identify the meaning of health to the patient b)Understand how a health care delivery system works c) Develop a frame of reference as to traditional healing practices d)Understand his or her own heritage and cultural values Answer- d 18.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 Answer- a 19.When preparing the physical setting for an interview, the interviewer should: a) Set the room temperature between 64° F and 66° F b) Reduce noise by turning the volume on the television or radio down c) Conduct the interview at eye level and at a distance of 4 to 5 feet d) Stand next to the patient to convey a professional demeanor Answer- c 20.Viewing the world from another person's inner frame of reference is called: a) Reflection b) Empathy c) Sympathy d) Clarification Answer- b 21.Parents or caretakers accompany children to the health care setting. Starting at years of age, the interviewer asks the child directly about his or her presenting symptoms. a) 5 b)7 c) 9 d)11 Answer- b 22.Which of the following statements made by the interviewer would be an appropriate response? a) "I know just how you feel." b) "If I were you, I would have the surgery." c) "Why did you wait so long to make an appointment?" d) "Tell me what you mean by 'bad blood.'" Answer- c d) Assessment, diagnosis, outcome identification, planning, implementation, and evaluation Answer- d 30.What is one way nurses use critical thinking in regard to the nursing process? a) Critical thinking helps nurses decide which parts of the nursing process are not needed in regard to a particular client b) Nurses do not need to think critically; they just need to follow the doctor's orders c) Critical thinking helps nurses work through the analysis, develop alternatives, and implement the best interventions d) Critical thinking allows nurses to make decisions regarding client care without involving the client in decisions Answer- c 31.Students frequently ask teachers, "May I ask you a question?" This is an example of which type of question? a) Open- ended b) Reflective c) Closed d) Double-barreled Answer- c 32.Active listening skills include all of the following, EXCEPT: a) Taking detailed notes during the interview b) Watching for clues in body language c) Asking open-ended questions d) Exploring the person's fears about the illness Answer- a 33.A pregnant woman states, "I just know labor will be so painful that I won't be able to stand it. I know it sounds awful, but I really dread going into labor." The nurse responds by stating, "Oh, don't worry about labor so much. I have been through it, and although it is painful, many good medications are available to decrease the pain." Which statement is true regarding this response? The nurse's reply was a: a)Therapeutic response. By sharing something personal, the nurse gives hope to this woman. b)Nontherapeutic response. By providing false reassurance, the nurse actually cut off further discussion of the woman's fears. c)Therapeutic response. By providing information about the medications available, the nurse is giving information to the woman. d)Nontherapeutic response. The nurse is essentially giving the message to the woman that labor cannot be tolerated without medication. Answer- b 34.As the nurse enters a patient's room, the nurse finds her crying. The patient states that she has just found out that the lump in her breast is cancer and says, "I'm so afraid of, um, you know." The nurse's most therapeutic response would be to say in a gentle manner: a) "You're afraid you might lose your breast?" b) "No, I'm not sure what you are talking about." c) "I'll wait here until you get yourself under control, and then we can talk." d) "I can see that you are very upset. Perhaps we should discuss this later." Answer- a 35.A nurse is taking complete health histories on all of the patients attending a wellness workshop. On the history form, one of the written questions asks, "You don't smoke, drink, or take drugs, do you?" This question is an example of: a) Talking too much b) Using confrontation c) Using biased or leading questions d)Using blunt language to deal with distasteful topics Answer- c 36.A 16-year-old boy has just been admitted to the unit for overnight observation after being in an automobile accident. What is the nurse's best approach to communicating with him? a) Use periods of silence to communicate respect for him b)Be totally honest with him, even if the information is unpleasant c)Tell him that everything that is discussed will be kept totally confidential d) Use slang language when possible to help him open up Answer- b 37.The nurse makes this comment to a patient, "I know it may be hard, but you should do what the doctor ordered because she is the expert in this field." Which statement is correct about the nurse's comment? a) This comment is inappropriate because it shows the nurse's bias b)This comment is appropriate because members of the health care team are experts in their area of patient care c)This type of comment promotes dependency and inferiority on the part of the patient and is best avoided in an interview situation d)Using authority statements when dealing with patients, especially when they are undecided about an issue, is necessary at times Answer- c 38.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?" Answer- a 39.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." Answer- d 40.The CAGE test is a screening questionnaire that helps to identify: a) Unhealthy lifestyle behaviors b)Personal response to stress c) Excessive or uncontrollable drinking d) Depression Answer- c 41.The "review of systems" in the health history is: a) An evaluation of past and present health state of each body system b) A documentation of the problem as perceived by the patient d) "I'm able to transfer myself from the wheelchair to the bed without d 49.The nurse is preparing to do a functional assessment. Which statement best describes the purpose of a functional assessment? a) The functional assessment assesses how the individual is coping with life at home b) It determines how children are meeting developmental milestones c)The functional assessment can identify any problems with memory the individual may be experiencing d) It helps determine how a person is managing day-to-day activities Answer- d 50.The nurse is preparing to complete a health assessment on a 16-year- old girl whose parents have brought her to the clinic. Which instruction would be appropriate for the parents before the interview begins? a) "While I interview your daughter, will you step out to the waiting room and complete these family health history questionnaires?" b) "Please stay during the interview; you can answer for her if she does not know the answer." c) "It would help to interview the three of you together." d) "While I interview your daughter, will you please stay in the room and complete these family health history questionnaires?" Answer- a 51.Which of the following examples is typically exhibited by a novice nursing student? a) Weighs benefits and risks before acting b) Trusts intuition c) Individualizes care d)Follows a concrete set of rules Answer- d 52.The nurse has a "hunch" that the patient's elevated blood pressure is due to pain; however, the patient received blood pressure and pain medication 45 minutes ago. What should the nurse consider in regard to this hunch? a) The nurse should wait until the next prescribed time and reevaluate pain level b)The nurse should consider consulting with the pain management team to evaluate the effectiveness of the pain medication regimen c)The nurse should disregard the hunch because hunches are not effective at incorporating evidence-based practice d)The nurse should administer pain medication based on the hunch Answer- b 53.A student nurse is taking public transportation home after clinical. When she sees a friend, she immediately takes a seat next to her and begins a conversation, saying, "You know that older man who lives in the apartment next to you? Well, I took care of him today in the hospital." The student nurse is not respecting which of the following principles? a) Fidelity b) Veracity c) Confidentiality d)Benevolence Answer- c 54.Expert nurses learn to attend to a pattern of assessment data and act without consciously labeling it. These responses are referred to as: a) Intuition b)The nursing process c) Clinical knowledge d) Diagnostic reasoning Answer- a 55.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 Answer- c 56.Which phase of the interview uses communication techniques to collect data? a) Pre-interaction phase b) Working phase c) Closing phase d) Beginning phase Answer- b 57.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 IQ test c) Observing the patient and inferring health or dysfunction d) Examining the patient's response to a specific set of questions Answer- c 58.Mental status assessment documents: a) Emotional and cognitive functioning b) Intelligence and educational level c)Artistic or writing ability in the mentally ill person d)Schizophrenia or other mental health disorders Answer- a 59.Although a full mental status examination may not be required for every patient, the health care provider must address the four main components during a health history and physical examination. The four components are: a) Memory, attention, thought content, and perceptions b)Language, orientation, attention, and abstract reasoning c) Appearance, behavior, cognition, and thought processes d) Mood, affect, consciousness, and orientation Answer- c 60.A full mental status examination should be completed if the patient: a) Has a change in behavior and the family is concerned b)Developed dysphagia c) Has a new diagnosis of type 2 diabetes mellitus d) Complains of insomnia Answer- a 61.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 73.Abused women have been found to have significantly more health problems, including: a) Cardiovascular disease b) Cancer c) Chronic pain d)Chronic anemia Answer- c 74.The nurse caring for an older adult suspects elder abuse. Which action is appropriate? a) Collect proof of abuse before notifying the authorities b) Notify the authorities of suspected elder abuse c) Confront the caretakers about the suspicion of abuse d)Report the abuse of the older adult give permission Answer- c 75.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 Answer- c 76.The nurse is examining a 3-year-old child who was brought to the emergency department after a fall. Which bruise, if found, would be of most concern? a) Bruise on the knee b) Bruise on the elbow c) Bruising on the abdomen d)Bruise on the shin Answer- c 77.The nurse assesses an older woman and suspects physical abuse. Which questions are appropriate for screening for abuse? Select all that apply. a) "Has anyone made you afraid, touched you in ways that you did not want, or hurt you physically?" b) "Are you being abused?" c) "Have you relied on people for any of the following: bathing, dressing, shopping, banking, or meals?" d) "Have you been upset because someone talked to you in a way that made you feel shamed or threatened?" Answer- a, c, d, 78.The general survey consists of four distinct areas. These areas include: a) Mental status, speech, behavior, and mood and affect b)Gait, range of motion, mental status, and behavior c) Physical appearance, body structure, mobility, and behavior d)Level of consciousness, personal hygiene, mental status, and physical condition Answer- c 79.Data collection for the general survey begins: a) At the first encounter b) At the beginning of the physical examination c) While taking vital signs d) During the mental status examination Answer- a 80.Standard precaution is used with: a) All patients b)Patients who are on isolation c) Patients presenting with respiratory infection only d) Patients presenting with skin infection Answer- a 81.When percussing the area located around the bone the tone we expect to hear is: a) Dull b) Flat c) Tympanic d)Hyperresonant Answer- b 82.The one most important factor is preventing nosocomial infection is: a) Wearing gloves b) Isolating patients c) Hand washing d) Frequent patient assessments Answer- c 83.The nurse is preparing to use a stethoscope for auscultation. Which statement is true regarding the diaphragm of the stethoscope? The diaphragm: a) Is used to listen for high-pitched sounds b) Is used to listen for low- pitched sounds c) Should be lightly held against the person's skin to block out low-pitched sounds d)Should be lightly held against the person's skin to listen for extra heart sounds and murmurs Answer- a 84.To perform an accurate assessment of heart rate, the examiner can do which of the following? (Select all that apply.) a) Count the radial pulse for 30 seconds, if the pulse is regular, and multiply by two b) Auscultate the heart and count beats for 1 minute c) Count the radial pulse for 2 full minutes if the pulse is irregular d)Count the radial pulse for 15 seconds, if the pulse is irregular, and multiply by 2 Answer- a, b 85.During the routine exam of a 4 year old child, vital sign measurement and general survey assessment elements include all of the following EXCEPT: a) Measuring the child's heart rate and blood pressure b) Listening to the child's speech for clarity and complexity of sentences c) Measuring the child's axillary temperature and head circumference d) Measuring the child's height and weight and calculating the BMI Answer- c 86.Which of the following represent elements of the general survey? a) Patient's level of consciousness, personal hygiene, vital signs, and physical condition b)Patient's gait, behavior, physical appearance, and duration of their pain c) Patient's hygiene and dress, speech, posture, and levels d) Patient self-report Answer- d 94.What does the first Korotkoff sound indicate when taking a blood pressure? a) Systolic pressure b) Diastolic pressure c) Brachial pressure d) Cuff malfunction Answer- a 95.The normal respiratory rate for an adult is: a) 12-20 b) 18-30 c) 24-40 d) 30-60 Answer- a 96.When examining a patient, the nurse remembers to follow which principle of Standard Precautions? a) Wear gloves throughout the entire examination of patients b)Wear gloves when in contact with patient's mucous membranes c) Wear eye protection and gown during examination of the patient d) Wear gloves to reduce the need for hand washing Answer- b 97.The dorsa of the hands are used to determine: a) Temperature b)Texture c)An organ's location d) Vibration Answer- a 98.A common error in blood pressure measurement includes: a) Taking the blood pressure in an arm that is at the level of the heart b) Deflating the cuff about 2 mmHg per heart beat c) Palpating the brachial artery before placing the blood pressure cuff d)Waiting less than 15 seconds before repeating the reading on the same arm Answer- d 99.The nurse records that the patient's pulse is 3+ or full and bounding. Which of the following could be the cause? a) Dehydration b) Shock c) Bleeding d)Anxiety Answer- d 100. 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 Answer- c 101.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 Answer- b 102. At the end of the examination, the examiner should: a) Complete documentation before leaving the examination room b) Have findings confirmed by another provider c) Compare objective and subjective data for discrepancies d) Review the findings with the patient Answer- d 103.When evaluating the temperature of older adults, the nurse should remember which aspect about an older adult's body temperature? a) The body temperature of the older adult is lower than that of a younger adult b)An older adult's body temperature is approximately the same as that of a young child c) Body temperature depends on the type of thermometer used d) In the older adult, the body temperature varies widely because of less effective heat control mechanisms Answer- a 104. A 60-year-old male patient has been treated for pneumonia for the past 6 weeks. He is seen today in the clinic for an "unexplained" weight loss of 10 pounds over the last 6 weeks. The nurse knows that: a) Weight loss is probably the result of unhealthy eating habits b) Chronic diseases such as hypertension cause weight loss c) Unexplained weight loss often accompanies short-term illnesses d)Weight loss is probably the result of a mental health dysfunction Answer- c 105. The examiner should use handwashing instead of an alcohol-based hand rub: a) If the patient has an infection with Mycobacterium tuberculosis b) If the patient has an infection with Clostridium difficile c) If the patient has an infection with hepatitis B virus d) If the patient is HIV positive Answer- b 106.Which of the following statements regarding cultural/racial differences in the treatment of pain is true? a) White individuals receive more analgesic therapy than black or Hispanic individuals with similar symptoms. b)Black and Hispanic individuals have been found to have a higher pain tolerance than white individuals. c) Pain modulation is more highly developed in black and Hispanic individuals. d) Neurotransmitters are more concentrated in white individuals than in black and Hispanic individuals. Answer- a 107.When assessing a patient's pulse, the nurse should also notice which of these characteristics? a) Pallor b)Capillary refill time c)Timing in the cardiac cycle d) Force Answer- d 108.When assessing the pulse of a 6-year-old boy, the nurse notices 114.Which of the following is considered when preparing to examine an older adult? a) Base the pace of the examination on the patient's needs and abilities. b)Avoid physical touch to avoid making the older adult uncomfortable. c) Be aware that loss will result in poor coping mechanisms. d)Confusion is a normal, expected finding in an older adult. Answer- a 115.Which statement indicates that the nurse understands the pain experienced by an older adult? a) "Pain is a normal process of aging and is to be expected." b) "Pain indicates a pathologic condition or an injury and is not a normal process of aging." c) "Older individuals perceive pain to a lesser degree than do younger individuals." d) "Older adults must learn to tolerate pain." Answer- b 116.During assessment of a patient's pain, the nurse is aware that certain nonverbal behaviors are associated with chronic pain. Which of these behaviors are associated with chronic pain? Select all that apply. a) Sleeping b) Moaning c) Diaphoresis d) Bracing e) Restlessness f) Rubbing Answer- a, d, f 117.Obesity in adults is defined as: a) Excess body fat placed predominately within the hips and thighs b) Excessive body fat leading to body weight 5% above ideal c) A body mass index of 30 or greater d) Overnourished Answer- c 118.Energy requirements for an aging adult decrease as a result of: a) Loss of energy b)Eating habits c) Loss of lean body mass d)Decreasing body fat Answer- c 119.Nutritional status is best determined by: a) Clinical manifestations b)Triglycerides c) 24-hour diet recall d)Serum albumin Answer- d 120. The nurse is performing a nutritional assessment on an 80-year-old patient. The nurse knows that physiologic changes can directly affect the nutritional status of the older adult and include: a) Hyperstimulation of the salivary glands b) Slowed gastrointestinal motility c) Increased sensitivity to spicy and aromatic foods d)Decreased gastrointestinal absorption causing esophageal reflux Answer- b 121. The nurse recognizes which of these persons is at greatest risk for undernutrition? a) 5-month-old infant 135. The nurse is performing an otoscopic examination on an adult. Which of these actions is correct? a) Tilting the person's head forward during the examination b) Once the speculum is in the ear, releasing the traction c) Pulling the pinna up and back before inserting the speculum d)Using the smallest speculum to decrease the amount of discomfort Answer- c 136.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 Answer- b 137. The tympanic membrane of a child with acute otitis media would be: a) Flat and slightly pulled in at the center b) Mobile and would flutter with the Valsalva maneuver c) Bulging with a distinct red color d) Shiny and translucent, with a pearly gray color Answer- c 138.When an otoscopic examination is performed on an older adult patient, the tympanic membrane may be: a) Pinker than that of a younger adult b) Thinner than that of a younger adult c) Whiter than that of a younger adult d) More mobile than that of a younger adult Answer- c 139. 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? a) I b) III c) X d)XIII Answer- d 140. The nurse is performing an ear examination of an 80-year-old patient. Which of these findings would be considered normal? a) High-tone frequency loss b) Increased elasticity of the pinna c) Thin, translucent membrane d) Shiny, pink tympanic membrane Answer- a 141.In detecting skin related melanoma and using ABCDEs, A stands for:c a) Airway b)Ability c)Asymmetry d)Acuity Answer- c 142. The primary purpose of the ciliated mucous membrane in the nose is to: d)An increased loss of elasticity and a decrease in subcutaneous fat in the elderly Answer- d 150. To determine if a dark-skinned patient is pale, the nurse should assess the color of the: a) Conjunctivae b) Earlobes c) Palms of the hands d)Skin in the antecubital space Answer- a 151. A patient tells the nurse that he has noticed that one of his moles has started to burn and bleed. When assessing his skin, the nurse would pay special attention to the danger signs for pigmented lesions and would be concerned with which additional finding? a) Diameter less than 6 mm b) Symmetry of lesion c) Color variation d)Border regularity Answer- c 152. The nurse notices that a patient has a solid, elevated, circumscribed lesion that is less than 1 cm in diameter. When documenting this finding, the nurse would report this as a: a) Papule b) Wheal c) Bulla d) Nodule Answer- a 153. The nurse just noted from the medical record that the patient has a lesion that is confluent in nature. On examination, the nurse expects to find: a) Lesions that run together b)Annular lesions that have grown together c) Lesions arranged in a line along a nerve route d)Lesions that are grouped or clustered together Answer- a 154. The nurse has discovered decreased skin turgor in a patient and knows that this is an expected finding in which of these conditions? a) Severe dehydration b)Connective tissue disorders such as scleroderma c) Childhood growth spurts d) Severe obesity Answer- a 155. The nurse is assessing for clubbing of the fingernails and would expect to find: a) A nail base that is firm and slightly tender b)Curved nails with a convex profile and ridges across the nail c)A nail base that feels spongy with an angle of the nail base of 150 degrees d)An angle of the nail base of 180° or greater with a spongy nail base Answer- d 156.While inspecting the skin, a nurse notices a lesion on the patient's upper right arm. What is the best way to document the size of this lesion? a) Use a centimeter ruler to measure the lesion b)Trace the lesion onto a piece of paper c) Compare its size to the size of a coin d) Estimate its size to the nearest inch Answer- a 157. The nurse is preparing for a certification course in skin care and needs to be familiar with the various lesions that may be identified on assessment of the skin. Which of the following definitions are correct? Select all that apply. a) Petechiae: Tiny punctate hemorrhages, 1 to 3 mm, round and discrete, dark red, purple, or brown in color b)Bulla: Elevated, circumscribed lesion filled with turbid fluid (pus) c) Papule: Hypertrophic scar d)Vesicle: Known as a friction blister e) Nodule: Solid, elevated, and hard or soft growth that is larger than 1 cm Answer- a, d, e 158. A nurse is performing an admission physical examination on a patient who has been bedridden for a month. The nurse notices a pressure injury on the patient's left trochanter area that involves partial- thickness skin loss with no damage to the subcutaneous tissue. The nurse reports this pressure injury at what stage? a) Stage I b) Stage II c) Stage III d) Stage IV Answer- b 159. The skin is composed of: (Select all that apply.) a) The epidermis b)The dermis c) The subcutaneous layer d)The underdermis Answer- a, b, c 160.When performing an inspection of a 25-year-old patient's throat, the nurse notices that the tonsils are touching the uvula. What grade does the nurse document for the tonsils? a) 1+ b)2+ c) 3+ d)4+ Answer- c 161. A patient's uvula rises midline when she says "ahh" and she has a positive gag reflex. The nurse has just tested which cranial nerves? a) IX, X b) IX, XII c) X, XII d) XI, XII Answer- a 162. An elderly woman was brought to the emergency department after being found lying on a kitchen floor for 2 days, and she is extremely dehydrated. What would the nurse expect to see on examination? a) Pale mucous membranes 169. A patient tells the nurse that she has smoked two packs of cigarettes a day for 20 years. The nurse records this as how many pack- years? a) 10 b)20 c) 40 d)60 Answer- c 170. 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." Answer- c 171.During percussion, the nurse knows that a dull percussion note elicited over a lung lobe most likely results from: a) Shallow breathing b) Normal lung tissue c) Decreased adipose tissue d) Increased density of lung tissue Answer- d 172. The nurse is observing the auscultation technique of another nurse. The correct method to use when progressing from one auscultatory site on the thorax to another is comparison: a) Side-to-side b) Top-to- bottom c) Posterior-to-anterior d) Interspace-to-interspace Answer- a 173.Stridor is a high-pitched, inspiratory crowing sound commonly associated with: a) Pneumothorax b) Upper airway obstruction c) Congestive heart failure d) Atelectasis Answer- b 174. The nurse is comparing pitch and duration of the various types of a patient's breath sounds and recognizes which one of these as an expected finding? a) Bronchial sounds are low-pitched and have a 2:1 inspiratory-versus- expiratory ratio b)Bronchovesicular sounds have a moderate pitch and 1:1 expiratory-versus- inspiratory ratio c) Vesicular breath sounds are high-pitched and have a 1:2 inspiratory-versus- expiratory ratio d)Wheezes are low-pitched and have a 2.5:1 inspiratory-versus- expiratory ratio Answer- b 175.Where does a nurse expect to hear bronchovesicular lung sounds in a healthy adult? a) In the apices of the lungs b) In the lower lobes examination. Which of these positions is most likely to make significant lumps more distinct during breast palpation? a) Sitting with the arms relaxed at her sides b) Supine with the arms raised over her head c) Supine with the arms relaxed at her sides d) Sitting with the arms flexed and fingertips touching her shoulders Answer- b 1. The nurse is performing a breast examination. Which of these statements best describes the correct procedure to use when screening for nipple and skin retraction during a breast examination? Have the woman: a) Bend over and touch her toes b)Lie down on her left side and notice any retraction c) Shift from a supine position to a standing position, and note any lag or retraction d) Slowly lift her arms above her head, and note any retraction or lag in movement Answer- d 189.During a discussion about BSEs with a 30-year-old woman, which of these statements by the nurse is most appropriate? a) "The best time to examine your breasts is during ovulation." b) "Examine your breasts every month on the same day of the month." c) "Examine your breasts shortly after your menstrual period." d) "Examine your breasts is immediately before menstruation." Answer- c 190.Which statement by the nurse is correct about BSE? a) "BSE is more important than ever for you because you have never had any children." b) "BSE is so important because one out of nine women will develop breast cancer in her lifetime." c) "BSE on a monthly basis will help you become familiar with your own breasts and feel their normal variations." d) "BSE will save your life because you are likely to find a cancerous lump between mammograms." Answer- c 191. The first heart sound (S1) is produced by the: a) Closure of the semilunar valves b) Opening of the semilunar valves c) Closure of the AV valves d) Opening of the AV valves Answer- c 192. The semilunar valves separate the: a) Ventricles from the arteries b) Right atria from the left atria c) Atria from the ventricles d) Atria from the veins Answer- a 193. The component of the conduction system referred to as the pacemaker of the heart is the: a) Sinoatrial (SA) node b)Atrioventricular (AV) node c) Bundle of branches d) Bundle of His Answer- a 194.During an assessment of a healthy adult, where would the nurse expect to palpate the apical pulse? a) Third left intercostal space at the midclavicular line b) Fourth left intercostal space at the sternal border 203.In assessing the carotid arteries of an older patient with cardiovascular disease, the nurse would: a) Palpate the artery to determine occlusion pressure b)Listen with the bell of the stethoscope to assess for bruits c) Palpate both arteries simultaneously to compare amplitude d) Instruct patient to take slow deep breaths during auscultation Answer- b 204. The jugular venous pressure is an indirect reflection of: a) The heart's efficiency as a pump b)Cardiac cycle c) Conduction effectiveness d)Synchronization of mechanical activity Answer- a 205.When assessing the heart rate of a patient, the nurse identifies a change in rate from 88 to 56 beats per minute. What should the nurse do first? a) Wait half an hour and retake the pulse b) Obtain the other vital signs c) Ask about recent activity d) Tell the nurse in charge Answer- b 206. 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 Answer- d 207. Arteriosclerosis refers to: a) A variation from the heart's normal rhythm b) A sac formed by dilation in the arterial wall c) Thickening and loss of elasticity of the arterial walls d)Deposition of fatty plaques along the intima of the arteries Answer- c 208. The nurse is preparing to assess the ankle-brachial index (ABI) of a patient. Which statement about the ABI is true? a) Normal ABI indices are from 0.5 to 1.0 b)Normal ankle pressure is slightly lower than the brachial pressure c)The ABI is a reliable measurement of peripheral vascular disease in individuals with diabetes d)An ABI of 0.9 to 0.7 indicates the presence of peripheral vascular disease and mild claudication Answer- d 209. A patient has severe bilateral lower extremity edema. The most likely cause is a) An infection of the right great toe b) Raynaud phenomenon c) An aortic aneurysm d) Heart failure Answer- d 210. The nurse is reviewing an assessment of a patient's peripheral pulses and notices that the documentation states that the radial pulses are "2+." The nurse recognizes that this reading indicates what type of pulse? a) Normal b) Bounding c) Weak d) Absent Answer- a 211.During a nutritional assessment, why is it important for the nurse to ask a patient what medications he or she is taking? a) Medications can affect one's memory and ability to identify food eaten in the last 24 hours b)Certain drugs can affect the appetite or cause gastrointestinal discomfort c) Medications need to be documented on the record for the physician's review d) The nurse needs to assess the patient for allergic reactions Answer- b 212.Methods to enhance abdominal wall relaxation during examination include: a) Having the patient place their arms above their head b)Examining painful areas first c) Positioning the patient with knees bent d) A cool environment Answer- c 213. An organ in the right upper quadrant of the abdomen is the: a) Liver b) Spleen c) Cecum d) Sigmoid colon Answer- a 214.Which structure is located in the left lower quadrant of the abdomen? a) Liver b) Duodenum c) Sigmoid colon d) Gallbladder Answer- c 215. Ascites is defined as: a)A bowel obstruction b)A proximal loop of the large intestine c)An abdominal enlargement of the spleen d)An abnormal accumulation of serous fluid within the peritoneal cavity Answer- d 216. The abdomen normally moves with breathing until the age of years. a) 4 b)7 c) 14 d)75 Answer- b 217. The nurse is watching a new graduate nurse perform auscultation of a patient's abdomen. Which statement by the new graduate shows a correct understanding of the reason auscultation precedes percussion and palpation of the abdomen? a) Obese b)Protubera nt c) Scaphoid d) Herniated Answer- b 224.While examining a patient, the nurse observes abdominal pulsations between the xiphoid process and umbilicus. The nurse would suspect that these are: a) Pulsations of the renal arteries b)Pulsations of the inferior vena cava c) Normal abdominal aortic pulsations d) Increased peristalsis from a bowel obstruction Answer- c 225. The nurse is describing a scaphoid abdomen. To the horizontal plane, a scaphoid contour of the abdomen depicts a profile. a) Flat b)Conve x c) Bulging d) Concave Answer- d 226. A patient has hypoactive bowel sounds. The nurse knows that a potential cause of hypoactive bowel sounds is a) Diarrhea b) Ileus c) Laxative use d)Gastroenteritis Answer- b 227.During an abdominal assessment, the nurse is unable to hear bowel sounds in a patient's abdomen. Before reporting this finding as silent bowel sounds, the nurse should listen for at least: a) 1 minute b) 7 minutes c) 10 minutes d) 2 minutes in each quadrant Answer- d 228. A patient is complaining of a sharp pain along the costovertebral angles. The nurse is aware that this symptom is most often indicative of: a) Ovary infection b) Liver enlargement c) Kidney inflammation d)Spleen enlargement Answer- c 229.When palpating the abdomen of a 20-year-old patient, the nurse notices the presence of tenderness in the left upper quadrant with deep palpation. Which of these structures is most likely to be involved? a) Sigmoid colon b) Spleen c) Appendix d) Gallbladder Answer- b 230. The nurse is preparing to examine a patient who has been complaining of right lower quadrant pain. Which technique is correct during the assessment? The nurse should: a) Examine the tender area first b) Examine the tender area last c) Avoid palpating the tender area d) Palpate the tender area first, and then auscultate for bowel sounds Answer- b 231.When testing for muscle strength, the examiner should: a) Observe muscles for the degree of contraction when the individual lifts a heavy object b)Measure the degree of force it takes to overcome joint flexion or extension c)Apply an opposing force when the individual puts a joint in flexion or extension d) Estimate the degree of flexion and extension in each joint Answer- c 232.Crepitation is an audible sound that is produced by: a) Roughened articular surfaces moving over each other b) Tendons or ligaments that slip over bones during motion c) Joints that are stretched when placed in hyperflexion or hyperextension d) Flexion or extension of inflamed bursa Answer- a 233. A patient tells the nurse that she is having a hard time bringing her hand to her mouth when she eats or tries to brush her teeth. The nurse knows that for her to move her hand to her mouth, she must perform which movement? a) Flexion b) Abduction c) Adduction d) Extension Answer- a 234. A patient is being assessed for range-of-joint movement. The nurse asks him to move his arm in toward the center of his body. This movement is called: a) Flexion b) Abduction c) Adduction d) Extension Answer- c 235.Of the 33 vertebrae in the spinal column, there are: a) 5 lumbar b) 5 thoracic c) 7 sacral d) 12 cervical Answer- a