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Health & Physical Assessment in Nursing, Canadian Edition By Donita T D’Amico, Colleen Barbarito – Test Bank 

 

Chapter 1

 

MULTIPLE CHOICE.  Choose the one alternative that best completes the statement or answers the question.

 

1)   A nurse is obtaining a health history from a client who reports that he is healthy and has no health concerns. As part of the health history, the nurse documents that the client reported that he has high blood pressure and suffers from a leg ulcer that remains unhealed after 6 months. What is the most appropriate response by the nurse at this point in the interview?

1)   “I feel that you may be in denial about your health status.”

2)   “Tell me about your definition of being healthy.”

3)   “Do you understand what hypertension is?”

4)   “Is there anything else you are not telling me?”

 

 

2)   What is the best description of the assessment component of SOAP charting?

1)   Objective data obtained from the physical assessment

2)   The client’s chief complaint

3)   Subjective statements the client makes regarding feelings

4)   Conclusions drawn from the data obtained

 

 

  • A nurse is reviewing a client’s medical record. Which is an example of a constant piece of data?
  • The client has B negative blood type.
  • The blood pressure at 0900 was 110/74 mmHg.
  • The sodium level is 145 mmol/L.
  • The client is 64 years of age.

 

4)   A nurse is developing a handout for clients in a physician’s office.  What content areas would be included in this handout to emphasize current changes in the healthcare delivery system?

1)   Symptom management, environmental control

2)   Management of outbreaks of disease, eradicating the use of toxins

3)   Illness care, pain management, prevention of complications

4)   Wellness, health maintenance, health promotion, prevention of disease

 

 

5)   What is the best method for the nurse to obtain subjective data during a health assessment?

  • Interviewing a primary source
  • Reviewing an indirect source like health records
  • Completing a physical assessment
  • Obtaining information from a family member

 

 

6)   A nurse is reviewing a client’s medical records and notes various forms of information. What piece of information is an example of subjective data?

1)   Symptoms described by the client

2)   Physical examination results

3)   Results of radiographic studies

4)   Laboratory analysis reports

 

 

7)  A nurse is reviewing a client’s medical records. What is an example of objective data?

1)   “I hurt my head.”

2)   “I am six-years-old and I’m here because I fell.”

3)   Six-year-old Hispanic female sitting on examination table holding a towel to her forehead.

4)   Client states that she fell at the playground.

 

 

8)   A nurse is evaluating the plan of care and notes that none of the goals have been met for the client. What should the nurse do next in this situation?

1)   Report the lack of achievement of the goals to the physician

2)   Review the data and modify the plan

3)   Re-formulate the nursing diagnosis to a more realistic one

4)   Nothing as long as the client is stable

 

 

 

 

9)  A nurse is obtaining a health history from the client. What phase of the nursing process is the nurse using?

1)   Planning

2)   Assessment

3)   Diagnosis

4)   Interviewing

 

 

 

10) A nurse is developing a plan of care for a client.  What types of data must the nurses consider when developing nursing diagnoses?

1)   Assessment, planning, and evaluation

2)   Subjective and objective

3)   Family history, laboratory results

4)   Standard and normative

 

 

  • A nurse is interpreting the findings from a health assessment she completed on a college student with influenza. The student was sent home because the student dormitory was closed due to an influenza outbreak. What determinant of health is present in this situation?
  • Ethnocultural
  • Family
  • Environmental
  • Psychological

 

12) What statement most accurately describes the World Health Organization (WHO) definition of health?

1)   Health is the absence of illness, disease, and symptoms.

2)   Health is a state of well-being and the use of every power the person possesses to the fullest extent.

3)   Health is a culturally defined, valued, and practiced state of well-being

4)   Health is a state of complete physical, mental, and social well-being.

 

 

13) A nurse is developing a plan of care for a client with surgical incision pain. What is the most appropriate goal statement for this client?

1)   The client will verbalize pain relief using an intensity rating in 4 hours.

2)   The client will state that they feel fine.

3)   The client will state understanding of the cause of pain in 3 days.

4)   The client will verbalize no pain.

 

 

14) A nurse is developing the plan of care and needs to develop interventions to achieve a specific goal.  What source should the nurse use to determine interventions?

1)   Nursing diagnosis

2)   Defining characteristics of the nursing diagnosis

3)   Etiology of the nursing diagnosis

4)   Client’s stated wishes

 

 

15)  Ms. Benoit, 38 years old, is admitted with chest pain. What is an example of a holistic approach to nursing care?

1)   Considering all the factors that impact Ms. Benoit’s well-being

2)   Completing a thorough chest assessment

3)   Reviewing Ms. Benoit’s life style

4)   Obtaining a detailed family history

 

 

16) A nurse is evaluating the client’s progress toward meeting the following objective of a teaching plan, “The client will list signs of hypoglycemia before discharge.”  What missing factor will make it difficult for the nurse to evaluate whether the client has met this objective?

1)   Time frame

2)   Specific criteria to be met

3)   Method of evaluation

4)   How the information was taught

 

17) A nurse is required to teach Mr. Hammond how to administer his insulin injection.  What is an appropriate teaching strategy for the nurse to use?

  • Discussion
  • Demonstration
  • Printed directions
  • Role play

 

 

 

18) A nurse is caring for a newly admitted patient with Methicillin-resistant Staphylococcus Aureus (MRSA). What is the primary goal of the initial health assessment?

1)   Determine the client’s current state of health

2)   Assess the client’s knowledge about MRSA

3)   To determine client allergies

4)   Determine how frequently the client is able to change positions

 

 

 

19) While the nurse assesses a client who is hospitalized for an acute exacerbation of chronic obstructive pulmonary disease, the client becomes short of breath. The nurse recognizes the need to stop the assessment to initiate respiratory support interventions. This is an example of which phase of critical thinking?

1)   Collection of information

2)   Evaluation

3)   Generation of alternatives

4)   Analysis of the situation

 

 

 

20) What is an example of subjective data?

1)   The bowel sounds are hyperactive in all four quadrants.

2)   The client states, “I have pain in my belly that is 7 out of 10.”

3)   Abdominal assessment reveals a firm, hard abdomen.

4)   The client is weak and looks very pale.

 

 

21) A client with hepatitis B is admitted to the hospital.  What should the nurse keep in mind regarding client confidentiality?

1)   Information sharing is limited to those directly involved in the client’s care.

2)   All members of the health care team should be aware of this information.

3)   This information should not be included in the client’s chart.

4)   The medical records are open to any hospital employee, including administration.

 

 

22) What is included in the planning step of the nursing process?

1)   Setting priorities

2)   Teaching the client

3)   Making a referral

4)   Analyzing the assessment data

 

 

23) Mr. James, 59 years old, is hospitalized with end stage liver failure secondary to years of alcoholism. What is the nurse’s first step when using a critical thinking approach to collect information about this client?

1)   Organizing the approach to use

2)   Identifying assumptions

3)   Identifying missing information

4)   Identifying any inconsistencies

 

 

24) In the nurse’s teaching plan, what objective addresses the psychomotor domain?

1)   The client will discuss three interventions for low blood sugar.

2)   The client will describe four symptoms of low blood sugar.

3)   The client will demonstrate how to draw up the correct dose of insulin.

4)   The client will define diabetes mellitus.

 

 

25) Which statement best describes the active role of the nurse as an educator?

1)   Nurses must consider learning needs, goals, objectives, content, teaching methods, and evaluation when carrying out client education.

2)   Teaching plans are developed for informal teaching when distinct needs are identified or when common needs are recognized.

3)   The nurse should refer the client to other health care providers who specialize in the area of need.

4)   Teaching is to be delegated to the advanced practice nurse specialist or the nurse educator.

 

 

SHORT ANSWER.  Write the word or phrase that best completes each statement or answers the question.

 

26) A nurse is admitting a client and notes a place for subjective data on the history form.  What method will the nurse use to gather the required subjective data? ______________________

 

 

Chapter 2

 

MULTIPLE CHOICE. Choose the one alternative that best completes the statement or answers the question.

 

1)   What statement most accurately describes the concept of health promotion?

1)   A psychological model that attempts to explain and predict health behaviours

2)   A process of enabling people to increase control over their health and its determinants

3)   The economic and social conditions that influence the health of individuals and their communities

4)   Understanding the psychosocial and physical processes of disease in order to promote good health

 

 

2)   A couple who both have a positive family history of sickle cell anemia are concerned about the potential of having a child with sickle cell disease. Which statement indicates that the couple wishes to participate in primary prevention?

1)   “We both need to be treated for sickle cell anemia before we can have a baby.”

2)   “We will have blood tests to determine if we are carriers.”

3)   “We need to see a genetics counsellor to discuss the potential for having a child with sickle cell disease.”

4)   “Neither one of us has sickle cell disease, so any baby we had would be safe from the disease as well.”

 

3)   A nurse is working to develop a community garden to provide food security for people living in an impoverished area of the city. What social determinant of health is present in this situation?

1)   Income and social status

2)   Culture

3)   Social environment

4)   Physical environment

 

4)   A nurse is discharging a client who had a cerebral vascular accident (CVA) and will be cared for at home by her husband. The nurse knows that the client’s husband understands the need for tertiary prevention when he makes which statement?

1)   “She will need instruction on using her walker.”

2)   “She will need to have her flu shot this year.”

3)   “She must have coagulation studies completed weekly.”

4)   “She needs to have her cholesterol checked every 2 months.”

 

 

 

 

5)   A nurse works in a large urban hospital using telehealth to provide cardiac consultations to clients in rural settings. What principle of primary health care is evident in this scenario?

  • Public participation
  • Intersectoral cooperation
  • Activism
  • Accessibility

 

 

  • A mother calls the provincial ‘Nurse Hotline’ concerned about her toddler’s flu symptoms. What principle of primary healthcare is evident in this situation?
  • Public participation
  • Intersectoral collaboration
  • Appropriate technology
  • Advocacy

 

 

 

 

7)   A nurse working in a remote northern community has noticed a sharp increase in the number of teens coming to the clinic with sexually transmitted infections (STIs). What strategy is an example of an upstream approach to the problem?

1)   Have a condom machine installed in the washrooms at the high school

2)   Schedule more nurses to work at the clinic to handle the increased case load

3)   Hold an educational session with the students on STIs

4)   Provide free condoms at the health clinic

 

8)   A group of nursing students are organizing a health fair at the university. What activity is an example of secondary prevention?

1)   Provide free condoms at the health booth

2)   Have participants complete a screening tool to determine mental health wellness

3)   Develop a handout on the adverse effects of alcohol abuse

4)   Supply a pamphlet on Canada’s Food Guide with a sample meal plan

 

 

  • Smith has been living in a one bedroom apartment with six other people. He has recently been diagnosed with drug resistant tuberculosis (XDR-TB). What nursing action is consistent with the goals of tertiary prevention?
  • Complete TB skin testing on Mr. Smith’s roommates
  • Start prophylactic TB medications with each roommate
  • Schedule a daily appointment for the client to be given his TB medication
  • Have the client wear a surgical mask

 

10) Mrs. Singh, 70 years old and a widow of two years, is at the clinic for a follow-up health assessment. Mrs. Singh was diagnosed with hypertension 6 months ago and was started on health plan that includes two different antihypertensive medications, an exercise program, and dietary changes. Mrs. Singh reports that she has not attended the exercise program at the community centre and did not renew her prescription. What question should the nurse ask to better understand the client’s situation?

1)   “What social supports do you have at home and in the community?”

2)   “What cultural barriers are preventing you from following the health plan?”

3)   “What is your financial status?”

4)   “What challenges are you experiencing with following the health plan?”

 

 

CASE 1

A nurse is working with a student council at a local high school to develop a health promotion project that will benefit the entire school. The students identified a need to address bullying within the school.

 

QUESTIONS 11 to 13 refer to this case.

 

11) The students want to develop anti-bullying policies at the school and have arranged a meeting with the parent advisory committee, teachers, administrators, and other students. What principle of primary health care is evident?

1)   Public participation

2)   Advocacy

3)   Intersectoral collaboration

4)   Social justice

 

 

12) The nurse is aware of the need for evidence-based decisions to strengthen the development of the anti-bullying health promotion activities that the student council wants to pursue. What would be a credible source to consult?

  • Bullying sites on the internet
  • A needs assessment completed at the school
  • Another high school’s anti-bullying program
  • Peer-reviewed research studies

 

 

13) The student council, in collaboration with the nurse, developed an anti-bullying school program that includes a social marketing campaign, educational sessions, and a safe reporting mechanism. What would be the most effective approach for delivering the educational session?

1)   Use an expert like the nurse to deliver the session at a school-wide assembly

2)   Have peers deliver the session to each grade

3)   Develop a handout that can be distributed throughout the school

4)   Make and post a YouTube video.

 

 

14) What statement best defines the concept of social justice?

1)   Entails direct action taken to support a health goal

2)   All people have an equal entitlement to health

3)  The practice of supporting something or someone

4)  Fair distribution of society’s benefits, responsibilities, and consequences

 

15) A nursing student is preparing an educational program concerning breast cancer. The focus of the program is primary prevention. What topic would meet the goal of a primary prevention strategy?

1)   A dietary discussion concerning the connection between breast cancer and dietary intake

2)   Yearly clinical breast examination

3)   Canadian Cancer Society recommendations for mammography

4)   Treatment options available for breast cancer clients

 

16) A nurse is performing a health assessment. What question will provide the most information about a client’s social support network?

1)   “Do you live alone?”

2)   “Did you graduate from high school?”

3)   “Are you involved in any type of exercise programs?”

4)   “Who will assist in your care after discharge?”

 

 

 

 

17) A nurse is working with an elementary school to develop a healthier school environment. The teachers are particularly concerned about the numbers of overweight children they see in their classrooms. The school is on a tight budget. What would be the most appropriate health promotion strategy to implement at this school?

1)   Initiate a lunch hour walking program

2)   Implement a quality school meals program

3)   Start a course in health education

4)   Work with the vending machine company to provide healthier drink and food options

 

 

18) Mr. Walters, 54 years old, had emergency abdominal surgery last night for a perforated bowel. He also has a history of hypertension, type 2 diabetes, and glaucoma. The nurse is administering his morning medications. Which drug classification is a secondary prevention initiative?

1)   Enalapril, antihypertensive

2)   Metformin, oral anti-diabetic agent

3)   Pilocarpine, miotic

4)   Enoxaparin, low molecular weight heparin

 

 

19) A nurse working in a remote northern community wants to improve the health of the community by decreasing the number of low-birth-weight infants in the community. What strategy would be best to achieve this goal?

1)   Establish a public education program on the benefits of eliminating tobacco use during pregnancy

2)   Speak about the importance of daily folic acid supplementation in prenatal classes

3)   Develop a pamphlet on the benefits of breastfeeding

4)   Ask physicians to spend more time discussing nutritional needs during pregnancy

 

 

20) Mr. Bob, 30 years old, is in hospital recovering from injuries sustained in a motor vehicle accident. The nurse notes on the admission history that Mr. Bob is a smoker. The nurse approaches Mr. Bob to assess whether he is interested in strategies to help him quit smoking. What process is the nurse engaging in?

1)   Primary prevention

2)   Tertiary prevention

3)   Health belief modification

4)   Health promotion

 

 

21) A family has contacted the public health nurse wanting to know more about how to promote their cardiovascular health because they are overweight and sedentary. During the family health assessment the nurse learns that many of the first degree relatives have hypertension and angina. What determinant of health is present in this family?

1)   Education

2)   Genetic

3)   Gender

4)   Physical environment

 

 

22) What is an example of an upstream policy that benefits the whole community?

1)   Establish a free needle exchange program

2)   Develop a campaign on the daily folic acid supplementation for women in childbearing years

3)   Seat belt laws for all motorized vehicles

4)   Launch HPV vaccination program for girls aged 9 to 13 years

 

23) A nurse has been contracted to complete annual spirometry testing for the city’s firefighters. What level of prevention is this activity?

1)   Primary

2)   Secondary

3)   Tertiary

4)   This is not a prevention activity.

 

 

24) The union at a large industrial company has contacted the occupational health nurse to discuss ways to decrease employee stress. What would be an appropriate stress relieving strategy?

  • Organize a monthly after work social at the bar
  • Arrange for a noon hour yoga class
  • Hold a focus group with the employees
  • Offer one-to-one counselling sessions

 

 

 

25)  Mrs. Langois, 48 years old, lives alone in an apartment. She is taking medications to lower her blood pressure. What secondary prevention strategy should the nurse advocate?

1) Get annual flu vaccination

2) Have an annual Papanicolau test

3) Have blood pressure checked monthly

4) Exercise at least three times a week

 

 

 

SHORT ANSWER. Write the word or phrase that best completes each statement or answers the question.

 

26) What were the original principles of primary health care as established by the World Health Organization in 1978? (select all that apply)

  • Equitable access to health and health services
  • Public participation
  • Appropriate technology
  • Intersectoral collaboration
  • Reorientation of the health system
  • Promotion of health and prevention of disease and injury

 

 

 

Chapter 3

 

MULTIPLE CHOICE. Choose the one alternative that best completes the statement or answers the question.

 

1)   The mother of a two-year-old tells the nurse that she is concerned about her child’s lower back curving in and the child’s belly sticking out. How should the nurse respond?

1)   Ask the mother to buy the child bigger clothes

2)   Give the mother the first available appointment to see the physician

3)   Obtain a referral to the pediatric orthopedic clinic

4)   Reassure the mother that this is normal for a toddler

 

 

 

2)   A nurse is teaching parents of a child in Piaget’s sensorimotor stage of development. What would be an appropriate activity to help the child accomplish developmental tasks of this stage?

1)   Buying more colourful toys

2)   Playing with water toys in the bathtub

3)   Buying some blocks with numbers

4)   Playing peek-a-boo

 

 

3)   A nurse is writing a care plan for a pediatric client who is working on Erickson’s developmental Stage 4. What would be an appropriate goal for a child in this stage?

1)   Stating that the sense of shame and self-doubt has become less intense

2)   Helping the child develop a sense of identify and exploring attitudes and beliefs

3)   Completing school homework and have passing grades within one month

4)   Volunteering to help with one or more community projects each week

 

 

4)   A nurse is working at a Senior Centre and has just counselled a client experiencing a crisis in Erickson’s Integrity vs. Despair developmental stage. What suggestion would be the most appropriate?

1)   Buying a bigger house to house a divorced adult child

2)   Getting a pet

3)   Cataloguing family pictures

4)   Playing sports

 

 

5)   A nurse is interviewing the mother of a toddler who complains that her child continues to hide and have bowel movements in the diaper, but will use the toilet to void. The nurse would correctly tell the mother that the child is in which of the following Freudian phases of psychological development?

1)   Genital

2)   Phallic

3)   Anal

4)   Latency

 

 

 

6)   The mother of a 5-month-old infant calls the health unit to report to the nurse that she has noticed that her infant still has tremors of the extremities and chin at times. How should the nurse respond?

1)   Reassure the mother that these tremors are a normal part of the infant’s development

2)   Give the mother the first available appointment to see the physician

3)   Contact the pediatrician to see if he/she wants an EEG to be completed

4)   Ask the mother to document the time of day of tremors and come in next week

 

7)   A nurse is counselling a middle-aged couple. The husband has been told by his wife that both men and women experience decreasing hormonal production during middle adulthood, and he asks the nurse if this is true. How should the nurse respond?

1)   “Your wife has obtained some incorrect data.”

2)   “Why do you ask?”

3)   “Your hormonal levels increase, not decrease with age.”

4)   “Your wife is correct. Men do have a decrease in hormone production with aging.”

 

8)   The father of Danny, 5 years old, tells the nurse that he is concerned that his son cannot ride a tricycle. What action should the nurse take first?

1)   Reassure the father that this is normal

2)   Refer the father to the pediatrician

3)   Complete further growth and development assessments

4)   Ask the father about any siblings and when they rode a tricycle

 

9)   A nurse is working in a health clinic and performing a height and weight check of a young client. When plotting the findings on a growth chart, the nurse notes a slowed growth pattern. What action would be appropriate for the nurse at this time?

1)   Obtain an endocrinologist referral

2)   Perform a nutritional assessment

3)   Wait until the next visit to intervene

4)   Assess for circulatory problems

 

 

10) What would be the best assessment tool for a nurse to use for a 14-year-old male who is experiencing behavioural problems?

1)   Family Psychosocial Screening

2)   Eyberg Child Behaviour Inventory

3)   Ages and Stages Questionnaire

4)   Child Development Inventory

 

 

 

11) Aniljit, 6 months old, has been admitted to hospital for observation. The nurse is assessing the family and family interaction and learns that the family recently emigrated from India. The mother does all the care for her son while the father sits in the chair talking on the phone. What would be an appropriate assessment of this family?

1)   Compromised family coping

2)   A disinterested father

3)   Risk for family violence

4)   Cultural differences in childrearing

 

 

12) A nurse is completing discharge teaching to the family of a hospitalized elderly adult. What is the most important point for the nurse to include in the teaching?

1)   Reduce the amount of odour in the client’s immediate environment

2)   Install grab bars by the toilet and in the shower.

3)   Speak louder as client’s hearing decreases

4)   Increase the lighting if the client wants to stay up at night

 

13) A nurse is assessing the behaviours of preschoolers using Piaget’s theories of development. What behaviour would the nurse expect of this group?

1)   Pretending that they are princes and princesses

2)   Focusing on many aspects of a given situation at once

3)   Assuming everyone else in their world sees things as they do

4)   Collecting and sorting objects by size

 

14) Mrs. Dubois, 27 years old, is to receive a routine health check-up. What intervention would the nurse include in this check-up?

1)   Counselling on injury prevention

2)   Vaccines for tetanus and diphtheria

3)   Counselling on fluoride supplements

4)   Information on diet and exercise

 

 

15) What behaviour indicates a 5-year-old child is successfully moving through Piaget’s cognitive stage of development appropriately?

1)   Considering the differing opinions of their playmates

2)   Recalling the good time experienced the previous weekend at the playground

3)   Rationalizing why it is better to eat fruit than candy

4)   Understanding their mother loves them as much as their older siblings

 

 

16) During a routine well child check-up, the mother of a 3-year-old child reports concern with her child’s difficulty becoming toilet trained. When questioned, she reports the child has most difficulty using the toilet for bowel movements. What phase of Freud’s stages of development is the child having difficulty completing?

1)   Oral

2)   Phallic

3)   Anal

4)   Latency

 

17) Mr. Adams, 73 years old, voices concerns to the nurse regarding the seemingly continued loss of family and friends to illness and death. He states he is better off not making new friends as they will die anyway. What interpretation of this client is most accurate?

1)   He is mastering Erickson’s stage of Integrity vs. Despair successfully.

2)   He is having difficulty passing through the stage of Generativity vs. Stagnation.

3)   He is struggling with the stage of Integrity vs. Despair.

4)   Demonstrating unsuccessful completion of the Intimacy vs. Isolation stage of development

 

18) Yuri, 3 months old, is hospitalized with a respiratory infection. The parents report they do not believe in responding too rapidly when Yuri is crying, as they do not wish to spoil their child. What response by the nurse is most appropriate?

1)   “I agree with your philosophy of child rearing.”

2)   “There are many studies which support this belief.”

3)   “Responding quickly to your baby’s cries will assist him in feeling secure.”

4)   “Children who experience separation anxiety have been spoiled by their parents.”

 

19) During a well baby check-up, the nurse notices the infant does not demonstrate the expected developmental milestones for this age. What should the nurse do first?

1)   Initiate a consultation with social services for a home assessment

2)   Get a referral to a pediatrician

3)   Ask the parents questions about their play activities with the infant

4)   Prepare the family for hospitalization for a neurological assessment

 

 

20) The parent of a 3-year-old child voices concerns about the child’s potential developmental delays. The parent reports their older child reached milestones significantly ahead of the younger child. An assessment reveals that the child is able to assist in dressing themselves and can play catch. Which response by the nurse is appropriate?

1)   “Your child appears to be on target with the expected milestones for age.”

2)   “Your older child may simply be smarter than your 3-year-old.”

3)   “I would recommend extensive testing to determine the source of the delays.”

4)   “Have you spoken with your physician about these delays?”

 

 

21) The nurse is reviewing the developmental behaviours of an 8-month-old infant. Which behaviour indicates the need for follow-up assessments?

1)   Can transfer objects from hand to hand

2)   Moro reflex present

3)   Positive Babinski reflex

4)   Pulls self to standing position

 

 

22) A nurse is performing the data collection for a physical examination on a 16-year-old boy. The boy, who is currently 162 cm, voices concerns about his lack of stature. He asks if he has reached his full height. What response by the nurse is most correct?

1)   “You are finished growing at your age.”

2)   “Is your father very tall?”

3)   “Why do you hope to grow taller?”

4)   “You may continue to grow into your early 20s.”

 

23) Mrs. Wilmot, 43 years old, reports concern about the weight gained over the past two years despite not having made any significant changes in her diet or exercise patterns. What factor may be responsible for the client’s reported changes in weight?

1)   Increasing hormone levels

2)   Increase in body mass index

3)   Reduction in muscle nerve conduction

4)   Hormonal changes of the female climacteric

 

 

24) The adult children of a 69-year-old man report they are becoming frustrated. They relate they are trying to get their father to “take it easy,” stop working, and reduce his social activities. They feel this will reduce his stress and allow him to live longer. How should the nurse respond?

1)   “A slower pace will allow your father to remain productive longer.”

2)   “Seniors who lack intellectual challenges demonstrate cognitive declines.”

3)   “Reducing your father’s activities will increase his quality of life.”

4)   “Retirement will promote rest and relaxation for your father.”

 

 

 

25) What statement is true about factors that influence the growth and development of children?

1) Children in lower socioeconomic groups tend to weigh more.

2) Poor nutrition in childhood may cause some forms of dementia in older adults.

3) Cognitive and emotional well-being is seen in children who have affluent parents.

4) Growth patterns are primarily determined by nutrition.

 

 

SHORT ANSWER. Write the word or phrase that best completes each statement or answers the question.

 

26) How does growth and development proceed? (Select all that apply)

____  Cephalocaudal direction

____  Generalized response to specific response

____  Distal to proximal direction

____  Simple to complex

26)

__X_  Cephalocaudal direction

__X_  Generalized response to specific response

____  Distal to proximal direction

__X_  Simple to complex

 

 

 

Chapter 4

 

MULTIPLE CHOICE.  Choose the one alternative that best completes the statement or answers the question.

 

1)   A nurse is preparing an in-service for the staff on cultural considerations.  The nurse includes the following definition, “The adoption and incorporation of characteristics, customs, and values of the dominant culture by those new to that culture.”  What term has the nurse defined?

1)   Ethnicity

2)   Assimilation

3)   Ethnocentrism

4)   Culture

 

 

2)   A nurse is admitting a client of the Muslim faith during the holy month of Ramadan. The client tells the nurse that he must fast during this time. What would be an appropriate response by the nurse?

1)   “What can we do to accommodate your needs during your stay here?”

2)   “I will let your doctor know so he can discharge you.”

3)   “Fasting is harmful to your body.”

4)   “You must have food during times of illness.”

 

3)   Mr. Crowfoot, 68 years old, is experiencing severe chest pain. A tribal elder has accompanied him to the hospital at the insistence of the client. The elder tells the nurse that their culture teaches acceptance of death as part of the natural cycle of life and that treatments must be stopped. The client’s son insists that his father be treated, and states he feels the tribe’s teachings are antiquated.  What is the best action for the nurse to take in this situation?

1)   Call the social worker to plan a family meeting without the tribesman

2)   Interview the client and ascertain his wishes and beliefs

3)   Convene the hospital ethics committee

4)   Call the nursing supervisor

4)   A nurse is assessing an Asian-appearing teenager, who is fluent in English, participates in high school sports, values riding his dirt bike, and who plans to go to college after graduating from high school. When asked where he is from, he says “Vancouver.” What does this behaviour indicate about the client?

1)   He has no interest in answering the nurse’s questions.

2)   He is embarrassed about his ethnicity.

3)   He has adopted characteristics of the Canadian culture.

4)   He is in denial of his Asian heritage.

 

 

5)   What should be included in a definition of culture?

1)   A community maintained by a shared heritage, language, and religion.

2)   The socially transmitted beliefs, behaviours, values, customs, lifestyles, and ways of thinking of a specific population that guides worldview and decision making.

3)   The tendency to believe that one’s own beliefs, way of life, values, and customs are superior to others.

4)   The identification of an individual or group by shared genetic heritage and biological characteristics.

 

6)   A nurse is completing a self-assessment to determine cultural competence.  What behaviour would the nurse identify as being culturally competent?

1)   Obtaining a ham sandwich for a Jewish client

2)   Referring to an Asian client as an Oriental

3)   Permitting a Bedouin to sleep on the floor

4)   Advising a Catholic client that he will have to take mass at a time that does not interfere with lunchtime

 

–     1)  Creation of reserves

2)  Forcing Aboriginal people to speak English

3)  Outlawing spiritual practices

4)  Restricting self-government

 

 

 

8)   A nurse is interviewing a client and wishes to determine the roles of various members of an extended family living together in one household.  What statement would be appropriate for the nurse to use to obtain this information?

1)   “What language is spoken in your house?”

2)   “Are all of your family members working?”

3)   “Tell me about the responsibilities of family members in your home.”

4)   “Who makes the decisions for your family members?”

9)   A nurse manager wants to ensure that the unit is delivering culturally appropriate healthcare.  What would demonstrate this approach?

1)   Insisting the staff teach clients English during their hospitalization

2)   Paying the staff to learn a predominate language

3)   Providing written materials in predominate languages

4)   Developing phonetically written translation cards for the nurses to use

 

10) A nurse is interviewing a client and wishes to determine health practices that are important to the client’s beliefs.  Which of the following would be appropriate for the nurse to use to obtain this information?

1)   “Do you use any nontraditional medicines?”

2)   “Tell me what you do to try to improve your health.”

3)   “How many times have you been sick in your life?”

4)   “How often do you have an annual physical examination?”

 

 

11) Mrs. Choudary, 73 years old, has been admitted to hospital with pneumonia. Her extended family wants to stay with Mrs. Choudary as she does not speak English. What should the nurse do?

1)   Tell the family to select one person who can stay

2)   Ask the family to leave so that Mrs. Choudary can rest

3)   Arrange for a room at a nearby hotel for the family

4)   Discuss the situation with the family to arrive at a compromise

 

12) The female nurse is examining a Vietnamese male and notes that he will not make eye contact with her during the assessment. The client appears very uncomfortable and is sweating and flushed. What action would be appropriate for the nurse in this situation?

1)   Obtain a blood sugar reading

2)   Ask the client if he would like a male to perform the examination

3)   Assure the client that the exam will be over quickly

4)   Continue with the examination

 

 

13) A nurse is admitting a client and asks to see all medications taken.  Among the bottles are various herbal preparations with unfamiliar names to the nurse.  What action should the nurse take?

1)   Write down all the names of the herbals and look them up later

2)   Tell the client that herbals are ineffective and to throw them away

3)   Inform the physician of the herbals

4)   Ask the client what they are taken for and how often

 

14) A nurse is assessing a nine-year-old child who has been admitted to the pediatric unit because of fever and an unexplained rash. Upon skin examination, the nurse notes large circles drawn around patches of the rash in indelible ink. The mother explains that the circles are there to prevent the rash from spreading. What action should the nurse take?

1)   Notify child protective services with suspicion of neglect

2)   Explain that drawing on the body will not contain the rash

3)   Wash the circles away while cleaning the skin

4)   Note the information in the client’s record

 

 

15) A nurse is preparing her client to eat lunch.  She notes that the client refuses to look at the food on the meal tray and tells the nurse to take it away. The meal contains a chicken breast, green beans, fruit cocktail, and cottage cheese. What is the nurse’s most appropriate response?

1)   “I know you are not hungry so just let me know when you want your tray.”

2)   “It is important for you to eat so that you will get better.”

3)   “Is there a problem with the food being sent to you?”

4)   “I will get you some juice and crackers from the unit kitchen.”

 

16) While acting as a preceptor for a student nurse, the registered nurse notices the student voices frustration and a lack of appreciation for the healthcare beliefs and practices of clients whose beliefs differ from the student’s own. What action will best assist the preceptor to improve the student’s practice?

1)   Advise the student to reduce displays of frustration

2)   Encourage the student to look closely at his/her own cultural practices and beliefs

3)   Give the student a written reprimand

4)   Require the student to meet with a counselor concerning ethnic biases

 

 

17) What activity, by nurses, will help to ensure culturally safe care?

1)   Basing care on the cultural beliefs of the client

2)   Becoming familiar with the client’s culture and religion

3)   Providing translators for non-English speaking clients

4)   Looking at the assumptions and stereotypes held about a particular group

 

 

18) When providing an in-service to new graduate nurses, the nurse manager discusses the role of the nurse regarding acceptance of client cultural beliefs. What statement by a participant indicates further teaching is needed?

1)   “The acceptance of different cultural values is needed to provide quality nursing care.”

2)   “Cultural values may dictate my client assignments on the nursing unit.”

3)   “My own cultural values are irrelevant to the acceptance of the values of others.”

4)   “My knowledge of the cultural values of others will increase in time.”

 

 

19) A nurse is collecting data concerning the client’s primary health concern. The client reports having attempted to manage their illness using herbs.  What response by the nurse is most therapeutic?

1)   “What herbs have been used to manage your condition?”

2)   “Does your physician know about your herbal remedies?”

3)   “Don’t you realize your recovery may have been impeded by these herbal preparations?”

4)   “When was the last dosage of the herbal remedies taken?”

 

20) A nurse is preparing to perform an assessment of the client’s social support systems.  Which question will provide the needed information?

1)   Where was the client born?

2)   What is the primary language spoken in the family home?

3)   What nonverbal communication behaviours are observed during the nurse-client interaction?

4)   Is there a religious affiliation linked with the cultural affiliation?

 

 

21) While working in an ambulatory care clinic, a client who speaks limited English seeks care. What is the responsibility of the nurse in providing discharge teaching?

1)   Ask the client to call in a family member to translate

2)   Provide instructions written in English along with the contact number for a translator

3)  Seek all available resources to provide information the client will understand

4)   Provide a translator fluent in the client’s primary language

 

22) Mrs. Lui, 62 years old, is recovering from abdominal surgery. She recently moved to Canada from China. What traditional Chinese cultural concepts may impact the nurse-client interaction?

1)   The client may dislike being touched by strangers.

2)   Health is associated with being overweight.

3)   There is a strong belief that ginseng can cure illness.

4)   Ceremonies are an important part in the recognition of illness and disease.

 

23) An Asian client is preparing for discharge from the hospital. While providing instructions concerning follow-up care, the nurse notes the client is nodding in agreement in response to the nurse’s statements. After completing the discharge teaching, what should the nurse do next?

1)   Document the client’s understanding of the discharge instructions

2)   Ask the client if she understood the information being relayed

3)   Ask the client questions to assess understanding of the information provided

4)   Have the client sign the discharge paperwork

 

 

24)  What is the primary cause of poor health in Canada?

1) Geographical distance from health care facilities

2) Inadequate funding of Canada’s healthcare system

3) Language barriers

4) Poverty

 

 

25) What statement is true regarding Canada’s Aboriginal population?

1)  The 2006 census stated there were less than 1 million Aboriginal peoples in Canada.

2)  Infant mortality rates are three times higher than the national average.

3)  The Metis have a higher percentage of their population under age 14 than non-Aboriginal people.

4)  The majority of First Nations peoples live on reserves.

 

 

26)  What is the third largest ‘first language’ group in Canada?

1)  Cree

2)  Inuktitut

3)  Chinese

4)  Punjabi

 

SHORT ANSWER.  Write the word or phrase that best completes each statement or answers the question.

 

27) When preparing to perform a cultural assessment for a client, the nurse is aware of the numerous components which will aid in the identification of ethnicity. When preparing to ask appropriate questions to assess unique needs, which of the following questions will be beneficial?  (Select all that apply.)

___“What is your religious preference?”

___“Can you identify any food practices which will impact your prescribed plan of care?”

___“To what ethnic group do you identify yourself?”

___“Does your mother practice the same religion as you?”

 

=========================================================

 

Chapter 5

MULTIPLE CHOICE. Choose the one alternative that best completes the statement or answers the question.

 

1)   A nurse is caring for a woman who is complaining of chest pain. She states that she was walking from her apartment to the grocery store when the pain became severe. She reported that people were following her. She said she couldn’t really see them but she could hear them talking about “grabbing me.” While the woman is explaining the event, she alternates between wringing her hands and manipulating the items in her purse over and over. The nurse would obtain what further assessment data in this situation?

1)   Spiritual affiliations

2)   Dietary preferences and habits

3)   Review of systems

4)   Focused psychosocial interview

 

 

2)   A nurse is interviewing a client prior to a physical examination. The client tells the nurse, “ I have been experiencing a lot of aches, pains, and abdominal discomfort.” What factor should the nurse suspect is impacting physical health?

1)   Income

2)   Stress

3)   Ethnicity

4)   Occupation

 

3)   Julian, 17 years old, looks downward and speaks softly when answering questions. He has a flat affect. The nurse identifies a problem with Julian’s self-concept. What would support this conclusion?

1)   Increased desire to form lasting relationships

2)   Decreased ability to form attachments with other people

3)   Inability to maintain stable employment

4)   Feelings of worthlessness, anxiety, and/or depression

 

4)   Andrew, 7 years old, was admitted to the hospital following an appointment in the oncology clinic. His mother, who is distraught over his recent leukemic relapse, accompanies Andrew. She is crying and asking, “What did I do wrong?… Why does he deserve this?… Why can’t it be me?” What do these statements indicate to the nurse?

1)   Ineffective coping

2)   Emotional emptiness

3)   Spiritual distress

4)   Psychological anxiety

 

 

 

5)   Which client is at greatest risk for suicide?

1)   34-year-old married man who drives a transport truck

2)   18-year-old male who recently broke up with his girlfriend

3)   42-year-old Metis woman who has a fear of closed spaces

4)   21-year-old woman whose sister is cognitively impaired

 

6)   What is the definition of psychosocial health?

1)   The state of being emotionally balanced and socially astute

2)   Being mentally stable, physically fit, and psychologically well

3)   Becoming spiritually and psychologically mature

4)   The state of being mentally, emotionally, socially, and spiritually well

7)   A nurse is conducting a class on health promotion and uses the following definition: “The ability to perform daily tasks vigorously and alertly, with energy left over for enjoying leisure-time activities and meeting emergency demands.” What has the nurse defined?

1)   Physical fitness

2)   Emotional health

3)   Physical health

4)   Psychological well-being

 

 

8)   Mrs. Murphy, 47 years old, has recently experienced the loss of three close family members and has withdrawn from all social activities. What is the best tool for the nurse to use to assess Mrs. Murphy’s level of stress?

1)   Social Readjustment Scale

2)   HOPE

3)   Mental Status

4)   Spiritual Well-being Scale

 

 

9)   A nurse administered the Holmes Social Adjustment Scale to her client. The client scored 270. What is the client’s risk of developing a serious illness within the next two years based on stress alone?

1)   25%

2)   33.3%

3)   50%

4)   90%

 

 

10) Ben, 16 years old, has been admitted for observation. He jokingly tells the nurse, “Sometimes I get so angry that I want to get into my dad’s car and drive it straight into a bus.” What should the nurse do next?

1)   Ask Ben if it is easy to get access to his father’s car

2)   Tell Ben that lot of teenagers feel this way

3)   Talk to Ben’s parents about anger management

4)   Explore with Ben ways he might cope with his anger

 

 

 

11) Sister MacDonald, 59 years old, has been admitted to hospital. She asks the nurse if they hold mass in the Chapel. What assessment tool should the nurse use to assess spirituality and spiritual needs?

1)   Healthy Day Measures

2)   Multidimensional Health Profile

3)   HOPE

4)   Duke Social Support and Stress Scale

 

 

12) While being interviewed, a client admits to the nurse, “I have been hearing voices and sounds recently.” What would be the nurse’s best response?

1)   “How long have you been hearing these voices?”

2)   “Tell me about what the voices are tell you to do.”

3)   “There must be other things you are hearing.”

4)   “Do the voices bother you during the night only?”

 

13) What internal factor can influence psychosocial health?

1)   Mother who is bipolar

2)   Culture

3)   Growing up in a supportive family

4)   Spiritual beliefs

 

14) A nurse is completing the psychosocial history on a newly admitted adult client. The client reports trouble concentrating, rapid heartbeats, irritability, and inability to make decisions. What might the nurse suspect is happening to the client?

1)   Stress reaction

2)   Role confusion

3)   Impending heart attack

4)   Dysfunctional anxiety

 

15) An elderly client, who is hard of hearing, is observed withdrawing form conversation and sitting quietly in the corner of the room. This client’s physical ailment is impacting which psychosocial dimension?

1)   Mental

2)   Emotional

3)   Social

4)   Spiritual

 

 

16) Mrs. Petrenko, 53 years old, cares for her elderly mother. Mrs. Petrenko states, “When my mother takes ill, you can predict I’ll be sick in about six weeks.” What does this statement indicate?

1)   Her mother has a communicable disease.

2)   Mrs. Petrenko has uncared for health problems.

3)   Mrs. Petrenko is more ill than her mother.

4)   Mrs. Petrenko is experiencing emotional stress.

17) A client tells the nurse, “I want to make sure my children have every possible opportunity to complete their education.” The nurse realizes this client’s philosophy on education will influence which aspect of her children’s health?

1)   Meeting immediate needs

2)   Helping to elevate self-concept

3)   Contributing to ongoing family disturbances

4)   Preventing mental illness

 

18) Based on statements made by the client during a physical assessment, the nurse believes the client is at risk for developing a major illness. What statement would cause the nurse to be concerned for this client?

1)   “Look at that person’s pants! Don’t they realize how ugly they are?”

2)   “That sounds like a good idea! I think I will try that at home.”

3)   “I just love spending time outside. It energizes me!”

4)   “I set aside a period of time each day for myself.”

 

19) Mr. Knapp, 41 years old, has hypertension. He stops into the clinic for his weekly blood pressure measurement and tells the nurse that he is in a hurry because he started a new job and has to get back to work. What evidence might indicate that the Mr. Knapp is responding to his new job in a stressful way?

1)   Elevated blood pressure

2)   Respirations 16 and regular

3)   Temperature within normal limits

4)   Heart rate 86 and regular

 

20) A nurse is assessing a client’s spiritual and belief patterns and is currently asking the client about participation in organized religion. The nurse is on which step of the HOPE assessment with this client?

1)   H

2)   O

3)   P

4)   E

21) Asal, 10 years old, has recently been adopted from an orphanage in Afghanistan by a Canadian couple. What might impact Asal’s psychological health?

1)   Access to better education

2)   Living with a supportive family

3)   Growing up in Canada, a country not in turmoil

4)   Being physically healthy

 

22) A nurse is concerned that a client is having a problem with self-concept. What statement would cause the nurse to have this concern?

1)   “I never have any fun.”

2)   “I am the oldest in the family.”

3)   “I think I’m pretty much outgoing.”

4)   “At times I like to be alone.”

 

23) Which assessment question would best help the nurse identify the client’s coping ability?

1)   Who is your closest friend?

2)   What social groups do you belong to?

3)   What is your birth order in your family?

4)   Who do you call when you need help?

 

24) During an assessment, the nurse observes the client jumping from one idea to another, unable to completely answer any of the assessment questions. What speech pattern is the client using?

1)   Circumlocution

2)   Flight of ideas

3)   Neologisms

4)   Echolalia

 

25) Mr. Kuromi, 34 years old, has been admitted for observation. He tells the nurse, “Pink happies are flying on me but no woman likes short fish.” What speech pattern is this?

1) Neologism

2) Word salad

3) Clanging

4) Echolalia

 

 

26) Mrs. Danachuk, 43 years old, was widowed four months ago. She has missed her third appointment with the health nurse. When called, Mrs. Danachuk is weeping and tells the nurse she was really tired and could not get out of bed this morning. What should the nurse suspect is causing Mrs. Danachuk to feel so tired?

1) Poor nutrition

2) Working too hard

3) Abusing sleep medication

4) Depression

 

 

SHORT ANSWER. Write the word or phrase that best completes each statement or answers the question.

 

27) Mr. Barton, 51 years old, is admitted with a broken arm after a fall. He appears disheveled and has a body odour. The family arrives and expresses surprise at Mr. Barton’s appearance. They report that this is not his normal appearance and that he is usually clean and meticulously groomed. What assessment(s) does the nurse need to complete? (Select all that apply.)

___      Dietary history

___      Psychosocial assessment

___      Memory assessment and orientation

___    Family medical history

___      Lab studies

___      Physical examination

 

 

 

Chapter 6

MULTIPLE CHOICE. Choose the one alternative that best completes the statement or answers the question.

 

  • A nurse has completed a cardiovascular assessment on a college athlete with a pulse of 50 beats per minute. What is the most appropriate interpretation of this assessment finding?
  • This result is outside the normal range, therefore is an abnormal assessment finding.
  • This assessment finding fits within the expected normal range for the adult pulse rate.
  • The client’s pulse rate is a variation from the normal but is not a concern.
  • The pulse is abnormal and the nurse must re-assess the pulse rate.

 

 

2)   A nurse is assessing for fremitus of the client’s chest wall. What is the correct method for performing this assessment?

1)   Palmar surface of the fingers

2)   Base of the fingers

3)   Dorsal surface of the fingers

4)   Finger pads

 

 

3)   A nurse is assessing a client who appears very anxious and is experiencing abdominal tenderness. What is the best approach to put the client at ease during this portion of the examination?

1)   Palpate known painful areas first

2)   Touch the abdomen before palpating it

3)   Explain each movement after completion

4)   Provide the client with an analgesic

 

 

4)   A nurse is using percussion to assess the liver. What sound would the nurse expect to hear?

1)   Dullness

2)   Hyperresonance

3)   Tympany

4)   Flatness

 

 

 

5)   A nurse is examining a client in the Emergency Department. What finding would cue the nurse to complete a detailed neurological assessment?

1)   Asymmetry of the client’s smile

2)   Grimacing with movement

3)   Talking in a loud voice

4)   Edema to both legs

 

 

6)   What is the correct technique to percuss the thorax of an infant?

1)   Strike the nondominant hand with a closed fist of the dominant hand

2)   Deliver two sharp blows to a hyperextended middle finger of the nondominant hand

3)   Place the palmar surface of dominant hand against the body surface and apply gentle pressure.

4)   Tap the area being examined directly with the fingertips of the dominant hand.

 

 

7)   A nurse is auscultating breath sounds on an adult male client and hears a crackling sound over most of the chest. What should the nurse do next?

1)   Document this as an abnormal finding.

2)   Wet the chest hair and re-auscultate.

3)   Ask the client to cough, then auscultate again.

4)   Turn the diaphragm of the stethoscope to the bell.

 

 

8)   A nurse is performing an abdominal assessment and has just completed inspection. What is the next step in this assessment?

1)   Percussion

2)   Palpation

3)   Documentation

4)   Auscultation

 

9)   A nurse is preparing to examine several clients in the clinic setting. Which client would need the greatest degree of special consideration during a physical examination?

1)   Fifty-nine-year-old with influenza

2)   Nineteen-year-old who complains of fatigue

3)   Three-year-old child in for a well check-up

4)   Seventy-eight-year-old with COPD

 

 

10) What is the correct technique for moderate palpation of the abdomen?

1)   Downward one to two cm

2)   Side to side one-half to one cm

3)   Upward three to four cm

4)   Side to side two to three cm

 

 

11) A nurse is assessing a client when he refuses to allow the nurse to continue the examination. What should the nurse do next?

1)   Provide a translator to explain the examination process to the client.

2)   Document which procedures took place and which were refused.

3)   Ask a nurse of the same gender as the client to stay in the room as a witness.

4)   Suggest a family member tell the client to allow the examination to proceed.

 

 

12) What special equipment is required to accurately measure the degree of joint flexion?

  • Transilluminator
  • Wood’s lamp
  • Sphygmomanometer
  • Goniometer

 

 

13) A nurse is using a Doppler ultrasonic stethoscope to assess a pulse and does not hear anything. What is the most appropriate nursing action?

1)   Check the pressure applied to the probe

2)   Add more gel to the end of the probe

3)   Immediately inform a physician

4)   Send the equipment for repair

 

 

14) A nurse is using an ophthalmoscope with a red-free filter to assess the optic disc in a client. What colour indicates hemorrhaging of the optic disc?

1)   Green

2)   Black

3)   Red

4)   Yellow

 

15) A nurse is preparing to assess a client’s abdomen. What is the correct order to assess this body area?

1)   Inspection, Palpation, Percussion, Auscultation

2)   Inspection, Palpation, Auscultation, Percussion

3)   Inspection, Palpation, Percussion, Auscultation

4)   Inspection, Auscultation, Percussion, Palpation

 

 

16) What initial nursing action can help alleviate a client’s anxiety about a physical examination?

  • Provide the client with teaching during the examination
  • Ask another nurse to be present during the physical assessment.
  • Allow the client to void prior to starting the examination.
  • Perform assessments that a client knows such as height and weight

 

 

17) What is the best approach to accurately assess for vocal fremitus?

1)   The ulnar surface of the fingers of the dominant hand.

2)   The dorsal surface of the fingers on the nondominant hand.

3)   The palmar aspect of the fingers of the dominant hand.

4)   The fingertips of either hand.

 

 

18) A client has an inflamed area on the left forearm. What assessment techniques should the nurse use to assess this area?

1)   Percussion

2)   Light palpation

3)   Moderate palpation

4)   Deep palpation

 

 

19) A client has a visible pulsation in the middle of his abdomen. What assessment technique should the nurse use to assess this pulsation?

1)   Direct percussion

2)   Light palpation

3)   Moderate palpation

4)   Deep palpation

 

 

20) A nurse has documented that a client’s lung sounds are hyperresonant. What is the correct interpretation of this assessment finding?

  • Air is trapped in the lungs and has hollow quality.
  • High pitched sound that is drum like in quality.
  • Flat, soft tone that indicates the lung is solidified.
  • Dull, high-pitched tone that is of short duration

 

21) A nurse is preparing to percuss the lower lobes of a client’s lungs. What is the appropriate percussion technique to use?

1)   Direct percussion

2)   Blunt percussion

3)   Indirect percussion

4)   Any of the percussion techniques

 

 

22) While percussing a client’s lung area the nurse notes a flat tone. What does this flat tone indicate?

1)   The nurse is percussing over a bone.

2)   A normal finding.

3)   The lungs are solidified.

4)   Air is trapped in the lungs.

 

23) While auscultating a client’s lungs, the nurse identifies more than one sound. What is the most appropriate nursing action?

1)   Use a different stethoscope.

2)   Ask another nurse to listen to the lung sounds.

3)   Hold the stethoscope tubing while listening to the lung sounds.

4)   Close the eyes and focus on one sound at a time.

 

 

24) What nursing action would indicate that the nurse is following routine practices during a physical examination?

  • Observe for signs of dizziness when the client takes deep breaths.
  • Explain procedures in advance to alleviate client anxiety.
  • Perform hand hygiene in the presence of the client.
  • Drape the client to preserve privacy and to provide warmth.

 

25) What approach will the nurse use to survey the client during the inspection phase of a physical assessment?

  • Start inspection with the painful area first
  • Compare the right and left sides of the body
  • Proceed from a specific focus to a general overview
  • Instruments are only used during the other phases of assessment

 

 

SHORT ANSWER. Write the word or phrase that best completes each statement or answers the question.

 

26) What part of the stethoscope is used to auscultate heart murmurs? Draw an arrow to identify this part on the stethoscope.

 

 

 

Chapter 7

 

MULTIPLE CHOICE.  Choose the one alternative that best answers the question.

 

1)   A nurse is assessing Ami, 2 years old, when the mother tells the nurse that Ami has had a fever for the past two days.  When the nurse asks the mother what the temperature has been, the mother replies that she hasn’t actually taken it but Ami’s skin has felt very warm. What would be the most appropriate response for the nurse?

1)   “When our skin feels warm, it means our blood vessels are constricted.”

2)   “The only reliable indicator of body temperature is by feeling the forehead.”

3)   “Our skin temperature changes when our surroundings change temperature.”

4)   “The temperature of the skin is not related to what is happening inside our bodies.”

 

 

 

2)   Zavier, 8 months old, is having a well baby examination.  During the examination, Zavier has a liquid stool.  The mother becomes very angry and asks the nurse to change the diaper because she just can’t “deal with the odour”.  What observation should the nurse make?

1)   The child may have an illness causing diarrhea.

2)   It may be a reflection of the mother-child relationship.

3)   The mother is behaving inappropriately.

4)   The child may have an illness that is increasing the odour of stool.

 

 

3)   A nursing assistant brings the nurse the following vital signs for a 90-year-old client: Temperature 36.3 o C (oral), BP 165/70 mmHg, Pulse 84 and Respirations 24.  After examining the vital signs, what action should the nurse take?

1)   Continue to monitor the client.

2)   Tell the nursing assistant to recheck the temperature.

3)   Obtain an order for an antihypertensive.

4)   Obtain an order for oxygen therapy.

 

4)   A nurse is obtaining the height and weight of an 84-year-old client.  The client asks why the height is 2 cm less than last year.  What would be the best response by the nurse?

1)   “Your bones are weaker and are shrinking.”

2)   “I am sure you are mistaken and just don’t remember from last year.”

3)   “Your height decreases with age due to bone changes.”

4)   “Stand up straighter this time and we will measure again.”

 

 

5)   A nurse is obtaining the initial vital signs on a client in the emergency room following a seizure.  What method should the nurse use for obtaining the client’s temperature?

1)   Axillary

2)   Oral

3)   Rectal

4)   Tympanic

 

 

6)   Mr. Dwyer, 29 years old, is admitted with pneumonia. His vital signs are: Temperature 38.5 0 C (oral), BP 100/70 mm Hg, Pulse Rate 110/min and Respirations 22. The client’s oxygen saturation level is 96%.  Which order should the nurse clarify with the physician?

1)   Administer PRN antipyretic

2)   Administer intravenous fluids

3)   Start oxygen therapy

4)   Send for chest x-ray

 

 

7)   A nurse is caring for a client with an irregular heart rhythm.  How long should the nurse count beats for this client when taking a pulse rate?

1)   Two minutes

2)   A full minute

3)   30 seconds and multiply by 2

4)   15 seconds and multiply by 4

 

8)   A nurse is admitting a client with diabetic ketoacidosis.  The LPN asks the RN if the pulse oximeter needs to be placed on the client.  What is the nurse’s best response to the LPN?

1)   “Please place the pulse oximeter on the client.”

2)   “I will let you know after I complete my assessment.”

3)   “Thanks, for that is something I have to do for the client.”

4)   “We don’t have an order to do that.”

 

 

9)   What is the purpose of a general survey?

1)   Allows for vital signs prior to starting exam.

2)   Provides an opportunity for the patient to relax before the exam.

3)   Yields information to guide the physical assessment.

4)   Provides the information necessary for the diagnosis.

 

 

 

10) Mrs. Sandler, 34 years old, is being admitted. She is changing her position frequently, wringing her hands, and laughing at inappropriate times.  What should the nurse include in the assessment based on this information?

1)   Anxiety assessment

2)   Mental status testing

3)   Attention deficit testing

4)   Nutrition assessment

 

 

11) Mrs. Kellogg, 69 years old, is admitted with a fractured hip.  She points to the painful hip and describes it as a constant throbbing.  What would the nurse include in a pain assessment?

1)   Precipitating and relieving factors, impact on ADLs, and coping strategies

2)   Location, quality, and impact on ADLs

3)   Quality, pattern, and precipitating factors

4)   Precipitating and relieving factors, location, and impact on ADLs

 

 

12) During an interview with a client, the nurse notes confusion as to day and time.  What aspect of the mental status examination should the nurse evaluate further?

1)   Affect and mood

2)   Orientation

3)   Willingness to cooperate

4)   Level of anxiety

 

 

13) Mr. Sandhu, 85 years old, is admitted with arteriosclerosis. His blood pressure at 06h00 is 172/98 mm Hg. What factor may contribute to Mr. Sandhu’s blood pressure?

1)   Blood pressure is increased in obese people

2)   Arteriosclerosis increases blood vessel elasticity

3)   Blood pressure is highest in the morning

4)   Blood vessels lose their elasticity with age

 

14) What is the meaning of the numbers in a blood pressure reading?

1)   Bottom number is the pressure between ventricular contractions

2)   Bottom number is a reflection of cardiac output

3)   Top number is the result of the heart rate

4)   Top number reflects the pressure of blood generated when the right ventricle contracts

 

 

 

15) A nurse needs to take a blood pressure on a thin client, and the only cuff available is a standard sized cuff.  The nurse would correctly anticipate what readings?

1)   Accurate reading

2)   Falsely elevated reading

3)   Reading will depend of the overall health of the client

4)   False low reading

 

 

 

16) Mrs. Choi, 48 years old, had a left-sided mastectomy two days ago.  The nurse has delegated vital signs on this client to an unregulated health care provider.  What specific instructions would the nurse provide in delegating this task?

1)   Take the blood pressure on the right arm

2)   Use the electronic blood pressure machine

3)   Take the blood pressure on the left arm

4)   Take the blood pressure on both arms for a baseline

 

 

17) Mandy, 6 weeks old, needs her vital signs taken as part of a well baby assessment.  What represents appropriate routes and sequence for obtaining vital signs on Mandy?

1)   Rectal temperature, respirations, pulse rate

2)   Respirations, pulse rate, blood pressure, rectal temperature

3)   Respirations, apical pulse rate, axillary temperature

4)   Oral temperature, respirations, pulse rate, blood pressure

 

18) A nurse educator is preparing an in-service on pain management for the staff.  One of the staff nurses asks what the most important part of a pain assessment would be.  What is the most appropriate response by the nurse educator?

1)   “Pain is only partially subjective and primarily a physiological experience, so vital signs are the most important assessment.”

2)   “A client’s response to pain is always based on the underlying cause, so the admission diagnosis is important.”

3)   “If you observe the client sleeping, they are not experiencing very much pain.”

4)   “The response to pain is unique and based on numerous factors which need to be assessed.”

 

 

19) A nurse observes the client walking into the room and climbing up on the examination table.   What aspect of the general survey has the nurse completed?

1)   Mobility status

2)   Subjective assessments related to ambulation

3)   Activity tolerance

4)   Strength of upper and lower extremities

 

 

20) How can a nurse assess a client’s mental status within the general survey?

1)   Observe the client walking into the examination room.

2)   Ask the client to describe elements of his health history.

3)   Study the client’s clothing selections.

4)   Notice the client’s ability to make eye contact during the examination.

 

21) During a physical assessment the client asks the nurse repeatedly, “Is everything ok?” What is the most appropriate interpretation of this client’s behaviour?

1)   A poor self concept

2)   Inappropriate affect

3)   Effective body image

4)   Anxiety

 

 

 

22) Mrs. Davidson, 72 years old, has edema of her lower extremities despite being prescribed medication for this symptom. What should the nurse do first?

1)   Discuss the finding with the client’s physician.

2)   Provide the client with support hose.

3)   Review the client’s current medications.

4)   Document the finding in the medical record.

 

23) Mr. Cohan, 34 years old, tells the nurse that he is “180 cm. tall and weighs 91 kg.” Upon assessment the client is found to be 175 cm. tall with a weight of 101 kg. What does this discrepancy indicate about Mr. Cohan?

1)   Does not have a scale at home

2)   Self-image is not in sync with actual findings

3)   Didn’t want to tell the truth

4)   Trying to hide a chronic illness

 

 

24) Mrs. Choi, 83 years old, says to the nurse, “I’m losing weight from my waist up but gaining it in my legs.” What would be an appropriate response?

1)   “Subcutaneous tissue decreases in the upper body as a person ages.”

2)   “Your diet must be working, to an extent.”

3)   “This happens to everyone. Don’t worry about it.”

4)   “Let’s talk about your diet to see why you’re gaining weight in your legs.”

 

 

25) A resident in an extended care facility had a low body temperature in the morning and has a higher temperature at 19h00. What does this variation in temperature indicate?

1)   The morning temperature was assessed incorrectly

2)   The resident is developing an infection

3)   The resident is experiencing stress

4)   The temperatures reflect diurnal variations

 

26) During the assessment of a client with abdominal pain, the nurse assesses a lower than normal blood pressure and a rapid pulse. What would these findings suggest to the nurse?

1)   The client is a child and these are normal findings.

2)   The client could have an abdominal infection.

3)   The client is anxious.

4)   The client’s medications are causing the blood pressure to be low.

 

27) In taking a client’s blood pressure, the nurse assessed the following: First sound heard: 136; Swishing sounds: 120; Tapping sounds: 100; Muffled sounds: 98; Sounds stop: 76. What blood pressure would the nurse document?

1)   136/76 mm Hg

2)   120/76 mm Hg

3)   120/98 mm Hg

4)   136/98 mm Hg

 

 

28) What location should the nurse use to assess the pulse of an 11-month-old infant?

1)   The femoral artery

2)   The brachial artery

3)   The apical site

4)   The radial artery

 

29) Mrs. Wayne, 42 years old, has pain due to spinal stenosis. She identifies her current pain level to be 5 on a scale from 0 to 10. Mrs. Wayne’s vital signs are all within normal limits. What does this indicate about Mrs. Wayne’s pain?

1)   Less than she is rating.

2)   A defense mechanism.

3)   Worse than she is rating.

4)   Ongoing, yet controlled with coping mechanisms.

 

30)  Mr. Fitzhugh, 68 years old, has been admitted for elective surgery. The nurse notes he is overweight, walks with a slight limp, has difficulty hearing the nurse’s questions, and his breathing appears to be laboured. What should the nurse do first?

1)  Review his nutritional intake

2)  Do a height and weight

3)  Use an otoscope to assess his ears

4)  Complete a respiratory assessment

 

 

SHORT ANSWER.  Write the word or phrase that best answers the question.

 

 

31) A client appears disheveled in appearance, with uncoordinated clothes, body odor, and uncombed hair.  What would the nurse assess during the history and physical exam?  (Select all that apply.)

__  Anxiety

__  Depression

__  Mental illness

__              Self concept

 

 

 

Chapter 8

 

 

MULTIPLE CHOICE.  Choose the one alternative that best completes the statement or answers the question.

 

1)   A nurse is assessing a teenager’s pain level. The client is clearly uncomfortable but when the nurse asks for a description of the pain the client says, “It just hurts.  Why can’t I have something?” What should the nurse do?

1)   Leave the room and come back later

2)   Provide questions that require yes or no answers related to pain

3)   Ask the client what they would like to have for pain

4)   Do a set of vital signs to confirm the client has pain

 

 

2)   A nurse is working at a pain clinic and is preparing an orientation for new staff nurses.  What principle of pain management would the nurse correctly choose to include in this orientation?

  1. Unpleasant sensations typically experienced upon movement
  2. Whatever the experiencing person says it is
  3. Very subjective so observations must be used to assess levels and intensity

 

 

3)   A client arrives in the Emergency Department complaining of chest and arm pain. The client also reports jaw pain, but states that the chest pain hurts more. The nurse observes the client rubbing his left arm. What is the most accurate description of this client’s pain?

1)   Phantom

2)   Radiating

3)   Intractable

4)   Cutaneous

 

 

4) A nurse is caring for two clients who have sustained similar injuries as a result of a motor vehicle accident. Neither has received any pain medication in six hours and both have asked. However, one client is in greater distress than the other. What pain theory is useful in explaining this phenomenon?

1)   Pattern

2)   Specificity

3)   Stress

4)   Gate control

 

 

5)   A client with chronic pain from spinal stenosis has asked the nurse for assistance with pain management. The client is well dressed and composed, with normal vital signs. The nurse observes that the client grimaces when sitting but rates the pain at only 2 out of 10.  What is the best explanation for this client’s response to pain?

1)   Only certain movements cause pain.

2)   Is not in severe pain and does not need treatment.

3)   The pain is getting better.

4)   Has adapted to the pain and is able to control behaviours.

 

 

6)   A nurse is caring for a client with sickle cell anemia who rates his pain as 7 out of 10. This client is moving around easily and is eating well, but has asked for pain medication. What is the most appropriate nursing action?

1)   Wait 30 minutes and see if the client is still requesting the pain medicine.

2)   Administer half the ordered does of pain medication.

3)   Administer the pain medication if it has been longer than the ordered interval.

4)   Notify the physician that the client is faking his pain.

 

 

7)   What type of unidimensional pain assessment tool would be most appropriate for assessing the location of the pain with a preschooler?

  1. Simple Verbal Descriptive Scale
  2. Oucher Scale
  3. Body Diagram scale
  4. McGill Pain Questionnaire

 

 

8)   A nurse is caring for a client with back discomfort and administers ibuprofen (Advil).  What nociception process is being disrupted with the administration of ibuprofen?

1)   Transduction

2)   Transmission

3)   Perception

4)   Modulation

 

 

9)   A nurse is interviewing a client who reports having daily migraines. The nurse decides to further assess the impact of the client’s pain. What would be the most appropriate assessment tool?

1)   Psychological well-being inventory

2)   Body Diagram tool

3)   Intensity Rating scale

4)   Brief Pain Inventory

 

 

10) What statement best defines the concept of pain threshold?

  1. The amount of pain stimulation a person requires in order to feel pain.
  2. The individual autonomic responses to pain such as heart rate.
  3. The maximum amount of pain that an individual is willing to endure.
  4. The excessive sensitivity to pain that is unique to the client.

 

 

11) A client has recently been discharged after a right above the knee amputation. The client tells the home care nurse that his right foot hurts. What type of pain does this client have?

1)   Phantom

2)   Radiating

3)   Intractable

4)   Cutaneous

 

 

12) A nurse is assessing a client admitted with chronic back pain. What subjective data would the nurse anticipate the client reporting?

1)   Sudden onset

2)   Interferes with daily activities

3)   Is diaphoretic

4)   Short in duration

 

1)   Have the parents leave the area during the procedure.

2)   Tell the parents to touch and reassure the infant during the procedure.

3)   Wait until the infant is asleep to do the procedure.

4)   Administer an analgesic thirty minutes before the procedure.

 

 

14) A client, 47 years old, continues to request intravenous pain medications 4 days after being placed in skeletal traction due to a complex fracture of the hip.  While giving report to the next shift, the nurse who cared for the client during the day states, “I just do not know why she still needs medication 4 days after surgery.  The client we had last month with the same injury and procedure did not need any medication after 2 days.”  Which response by a nursing colleague best illustrates client advocacy?

1)   “I just think this client needs more because of their age.”

2)   “Have you tried getting the doctor to order oral pain medications to see if they work?”

3)   “Wouldn’t you want all of the pain medication you could have if you were in traction?”

4)   “Everyone does not have the same pain perception or response to a similar injury.”

 

 

15) A teenage client has multiple fractures following a motor vehicle accident.  What nursing intervention would be useful in reducing the client’s perception of pain?

1)   Suggest listening to music as a distraction

2)   Use imagery to turn off “pain switches”

3)   Administering morphine intravenously as ordered

4)   Try diversion techniques like blowing bubbles

 

 

16) A nursing student is reviewing the home medications of a client who has just been admitted with chronic back pain.  The nursing instructor asks the student why the client is on a tricyclic antidepressant. What response by the student demonstrates her understanding of this medication and chronic pain?

1)   “This drug is treating the client’s depression as a result of long term chronic pain.”

2)   “There is an increase in Substance P resulting in pain and this drug inhibits this response”

3)   “This medication inhibits the reuptake of serotonin thus decreasing the pain.”

4)   “The client needs a medication to block the nociceptors to control pain.”

 

 

17) A nurse is performing a physical assessment on a young adult with undiagnosed acute abdominal pain.  The client is unable to communicate verbally.  What finding is the best indicator that the client is in acute pain?

1)   Temperature of 38.10C

2)   Pulse rate of 100

3)   Dilated pupils

4)   Blood pressure of 120/84 mmHg

 

 

18) What type of nociceptor fiber is responsible for the transmission of dull, aching pain?

  1. A-beta
  2. A-delta
  3. C-alpha
  4. C

 

 

19) Jake, 12 years old, is brought to the emergency room after falling on his arm during a football game. The nurse tells Jake that pain medication will be administered through the intravenous line; he begins to scream and wave his unhurt arm.  The parents ask the nurse why their child is behaving this way.  What is the nurse’s best response?

1)   “He is just immature for his age.”

2)   “I am sure he is just scared.”

3)   “He might have also hit his head during the fall.”

4)   “He may be thinking of another time when he had to get a “shot” for pain.”

 

 

20) What physiologic process is responsible for the reflexive action of withdrawing one’s hand away from a hot stove even before one is aware of the pain?

  1. Modulation
  2. Open gate reflex
  3. Autonomic nerve response
  4. Proprioceptive

 

 

21) What source of assessment data will be most reflective of a client’s pain response following open-heart surgery?

1)   Family report of pain

2)   Response from the client based on the use of a pain tool

3)   Observation of client behaviors while asleep

4)   Measurement of vital signs

 

 

22) A nurse in a health clinic is interviewing a client, 75 years old, who has joint pain.  The client verbalizes that the pain has been present for a few years.  What age related variations must the nurse consider while interviewing this client?

1)   Clients start to complain of many types of pain as they age.

2)   The joint pain is probably not the real reason the client is in the office.

3)   The client is most likely depressed.

4)   Older adults frequently avoid seeking treatment for their pain.

 

 

23) A male, 19 years old, of Middle Eastern descent is in the hospital for a ruptured appendix.  His parents are at the bedside the majority of his waking hours.  The nurse caring for him during the day observes that he denies any pain during the day shift.  The night nurse reported that the client had requested pain medication every 4 hours during the night.  What is the most likely explanation for the difference in the client’s analgesic requirements?

1)   The night nurse had more time to spend with the client.

2)   The client was afraid or lonely at night and is trying to get attention.

3)   He may not report pain in the presence of his parents based on their influence or cultural beliefs.

4)   The request for analgesic medication at night was to help him sleep.

 

 

24) A nurse is assessing a postoperative client that reports a pain level of 10 on a 0 to 10 scale. The client is grimacing and appears anxious.  What should the nurse do?

1)   Administer pain medication if it has been longer than the ordered interval.

2)   Offer to call the pastoral service to provide spiritual counseling.

3)   Obtain an order for an anti-anxiety medication.

4)   Call the family to come in and stay with the client.

 

 

25) A client has an ankle sprain as a result of an injury sustained in a soccer game. The client describes the pain as “spread out” rather than localized. What type of pain is likely based on the origin of the injury?

  1. Visceral
  2. Cutaneous
  3. Non-progressive
  4. Deep somatic

 

SHORT ANSWER.  Write the word or phrase that best completes each statement or answers the question.

 

26) What type of receptor is responsible for transmitting the sensation of pain?

 

 

 

 

Chapter 9      

MULTIPLE CHOICE.  Choose the one alternative that best completes the statement or answers the question.

 

1)   A client weighs 77 kg, is 170 cm tall, and has a body mass index (BMI) of 23.  How should the nurse interpret this finding?

1)   Mild malnutrition

2)   Normal

3)   Overweight

4)   Obese class I

 

 

2)   A nurse is using a dietary recall tool to obtain a nutritional history on a client.  What is a limitation of using this assessment tool?

1)   Clients do not remember liquid intake from day to day.

2)   It does not reflect food preferences of the client.

3)   Clients do not provide reliable nutritional information.

4)   It does not reflect occasional food habits.

 

 

3)   A nurse is obtaining a tricep skinfold measurement on a client.  What is the correct landmark for this assessment?

1)   Midpoint of the arm equidistance from the scapula and the elbow

2)   Five centimeters below the scapula and centered

3)   Use left the arm, 2 cm above the olecranon process of the elbow

4)   Go three finger breadths below the acromion process on the right arm

 

 

4)   What limitation should the nurse be aware of when using the body mass index (BMI) to assess a client’s weight?

1)   There is lack of correlation of the values in the BMI table with those in height-weight tables

2)   Assumption that all individuals have equal body composition at each given weight

3)   BMI is difficult to accurately calculate

4)   BMI is used to determine an individual’s risk for obesity

 

 

5)   A nurse is performing a nutritional assessment and is concerned about undernutrition in a client. What condition would cause the nurse to suspect this nutritional disorder?

1)   Renal failure

2)   Hypertension

3)   Wound that will not heal

4)   Delayed menopause

 

 

6)   A client appears anemic. What diagnostic tests would the nurse anticipate the physician ordering to

assess the client’s anemia?

  • Prealbumin and hematocrit
  • B12 and folate
  • Albumin and transferrin
  • Blood urea nitrogen (BUN) and electrolytes

 

 

1)   Faddism

2)   Religious influence on eating practices

3)   Pica

4)   Culturally based practice

 

 

8)   A nurse is admitting a female client, 69 years old, who is obese and has a possible hip fracture. What health issue is most likely to develop as a result of the client’s obesity?

1)   Decubiti

2)   Degenerative joint disease

3)   Chronic pain

4)   Gestational diabetes

 

 

9)   A nurse is teaching a client about appropriate serving sizes for foods.  What would be a useful way of estimating the size of a single serving of meat?

1)   Tennis ball

2)   As big as a fist

3)   Approximately 175 grams

4)   Deck of cards

 

 

10) What type of anthropometric measurement uses electroconduction to assess body composition?

1)   Bioelectrical Impedance Analysis (BIA)

2)   Near-Infrared Interactance

3)   Dual X-ray Absorptiometry (DEXA)

4)   Body Plethysmography

 

11) A public health nurse is going to assess the nutritional status of an 86-year-old client. What nutritional screening tool would be most useful to the nurse?

1)   WAVE tool

2)   REAP tool

3)   DETERMINE checklist

4)   Canada Food Guide

 

 

12) What individual would be most at risk for protein-calorie malnutrition?

1)   A child, 6 years old, with diarrhea for 2 days.

2)   A client, 3 days post-operative, receiving intravenous fluids only.

3)   A child who overeats breads but eats no fruits and vegetables.

4)   A client, 50 years old, who has been an alcoholic for 15 years.

 

 

13) What is the correct description of anthropometric measurements?

1)   Obtained by dividing weight in kilograms by height squared

2)   Any scientific measurement of the body

3)   Use of growth chart evaluations to plot height and weight

4)   Estimates of skin fold thicknesses

 

 

14) A nurse is preparing an in-service for staff on the risk factors for poor nutritional health.  What is a risk factor for overnutrition?

1)   Sedentary lifestyle

2)   Poor dental health

3)   Extreme age

4)   Depression or loneliness

 

 

15) A 24-year-old client visits the nurse practitioner’s office for a routine yearly gynecological exam. The client tells the nurse that she is trying to get pregnant and wants to know why it is important to take a multi-vitamin that contains folic acid.  How should the nurse respond?

1)   “Folic acid can prevent neural tube defects in the neonate.

2)   “Everyone should take vitamin supplements.”

3)   “Folic acid can help with your chances of getting pregnant.”

4)   “Most people do not get enough folic acid.”

 

 

16) A nurse is teaching an overweight client how to use a food diary.  What would be the best method for the client to estimate recommended portion sizes?

1)   Digital photographs illustrating portion sizes

2)   Food scales

3)   Use analogies such as a deck of cards

4)   Plastic containers

 

 

17) A Jewish client is admitted to the medical unit. What statement by the nurse demonstrates cultural sensitivity to the client’s nutritional needs?

1)   “I have ordered Kosher meals for you.”

2)   “Do you have any special dietary considerations?”

3)   “I see from your last admission you follow a regular diet.”

4)   “Your family will need to bring in your Kosher foods.”

 

 

18) A nurse has collected data on clients who have visited a health fair in the mall.  Which client is most in need of a detailed nutritional assessment?

1)   A female, 21 years old, who has just begun college and has gained 5 pounds in the first semester

2)   A male, 30 years old, with a BMI of 24 and a waist circumference of 91 cm

3)   A male, 50 years old, who reported that, he lost 10 pounds in 6 weeks without even trying

4)   A female, 35 years old, who has 30% body fat 1 year after the birth of her first child

 

 

19) What circumstance could result in an inaccurate waist circumference (WC) measurement?

1)   Abdominal fat that is pendulous

2)   Pear shaped distribution of adipose tissue

3)   Pregnant female

4)   Ascites due to polycystic kidney disease

 

20) A female client, 78 years old, is in the physician’s office for a routine physical exam.  She asks for an explanation of why skinfold measurements are not done on her anymore.  How should the nurse respond?

1)   “Those tests are just not as accurate anymore.”

2)   “As a person ages, the test is not as accurate.”

3)   “The body mass index (BMI) test is easier to use.”

4)   “A detailed dietary history will give us the information that we need.”

 

 

 

21) A nurse is preparing to draw blood to measure transferrin and albumin levels on a 2-year-old child recently adopted from Africa.  The child is below the 10th percentile for weight and height when plotted on a growth chart.  What is the purpose of the blood work?

1)   Used to assess the extent of malnutrition

2)   Looking for macrocytic anemia

3)   Screening for sickle-cell disease

4)   The child may have polycythemia

 

 

22) A nurse interviewing a client, 68 years old, discovers that the client is taking 23 herbal and vitamin supplements daily.  Which response by the client indicates the need for nutritional teaching?

1)   “I have been taking all of them for over 20 years now.”

2)   “My wife also takes the same things.”

3)   “My doctor in my old town recommended most of them.”

4)   “I know that I do not eat right all of the time, so they will keep me healthy.”

 

 

23) A client is 165 cm tall and weighs 75 kg. What is this person’s body mass index (BMI)?

  • 6
  • 5
  • 5
  • 6

 

24) A nurse is calculating the percent weight change of a 40-year-old female, weighing 71kgs one month ago, and 64 kgs on current examination.  What is the weight loss percentage for this client?

  • 25
  • 7
  • 85
  • 12

 

 

25) A nurse is preparing to do a waist circumference on an obese 69-year-old male. What landmark is used when marking a site guide for measuring waist circumference?

1)   Just below the umbilicus

2)   Lateral ilium

3)   The ischium

4)   Mid rectus abdominis

 

SHORT ANSWER.  Write the word or phrase that best completes each statement or answers the question.

 

26) A graduate nurse in orientation notices that a dietician evaluates each postoperative client’s chart.  What is the rationale for this practice?  (Select all that apply.)

1)   Meet a regulatory agency requirement

2)   Determine nutritional needs

3)   Check for any cultural dietary considerations

4)   Check to see if there are any potential food-drug interactions

 

 

 

Chapter 10

MULTIPLE CHOICE.  Choose the one alternative that best completes the statement or answers the question.

 

 

1)   A nurse is interviewing a client and notes a puzzled facial expression.  What should the nurse say?

1)   “Can you tell me if you understand?”

2)   “You look confused.”

3)   “Do you understand the procedure?”

4)   “Do you have any questions?”

 

 

2)   A nurse is obtaining a family health history when the client reports that a grandparent had Diabetes Mellitus.  Where in the health history should the nurse document this information?

1)   Health practices

2)   Family genogram

3)   Past medical history

4)   Present health/illness

 

 

3)   What statement by the nurse would show empathy?

1)   “Have you talked this over with your family?”

2)   “I’m going to stay with you through the procedure.”

3)   “The physician will have to answer that question.”

4)   “I understand you’re concerned about your procedure.”

 

 

4)   What is a primary source of information the nurse might utilize to collect data?

1)  Past medical records

2)  The client

3)  Family members

4)  The physician

 

 

5)   A nurse is completing the third phase of the health history.  What piece of information would the nurse include during this interaction?

1)   Biographic data about the client

2)   Information about the client’s current health status

3)   Data from previous medical records

4)   Clarification of previously obtained data

 

 

 

6)   A nurse is interviewing an elderly client who has not received a formal high school education.  What is the best approach for the nurse to take in this situation?

1)   Allow family members to provide the interview information.

2)   Develop a new interview format for this client.

3)   Adhere to the standard format provided by the facility.

4)   Use appropriate words and techniques for this client.

 

 

7)   Mrs. Nagi, 71 years old, has been readmitted to hospital. She does not speak English. What primary source of information should the nurse use to obtain the health history?

1)   Have a translator to assist in talking with Mrs. Nagi.

2)   Get the information from a family member.

3)   Talk to the nurse who previously cared for Mrs. Nagi.

4)   Review Mrs. Nagi’s previous chart.

 

 

 

8)   A client tells the nurse that they have been using herbal remedies to treat their chronic illness. What would be the nurse’s best response?

1)   “Tell me what you are taking so I can see if it is appropriate.”

2)   “Can you tell me what herbal products you are currently using?”

3)   “You should not trust all those remedies.”

4)   “It’s great you are trying everything possible to treat your illness.”

 

 

 

9)   A nurse is obtaining information about a client’s past medical history.  What source would begin to provide the nurse with this data?

1)   Medication list

2)   Lifestyle choices

3)   Immunization records

4)   Current relationships

 

 

10)  A nurse is interacting with a client and desires to show sensitivity to religious beliefs and customs.  Which statement by the nurse would be appropriate during this interaction?

1)   “I will tell the hospital Chaplin to see you daily.”

2)   “Do you attend church on a regular basis?”

3)   “Your amulet cannot be taken to surgery.”

4)   “Where would you like to keep your bible?”

11) A nurse is interviewing a client and wants to engage in effective communicating.  What technique should the nurse use to decode the client’s messages?

1)   Use words and symbols that convey a message

2)   Listen actively and attentively

3)   Be alert for non-verbal messages

4)   Develop and transmit an idea

 

 

 

12) What is an appropriate opening question to start a health history?

1)   “What is your current occupation?”

2)   “What led up to you seeking help with your health?”

3)   “What medications are you currently taking?”

4)   “What surgeries have you had?”

 

 

13) A nurse is interviewing a client who is in acute pain. What action would be the best choice for the nurse during this interview?

1)   Interview the family for the information

2)   Attempt to reduce the pain and complete the interview later

3)   Document why the interview could not be completed

4)   Ask the client if they can complete the interview

 

 

 

14) A nurse is preparing to do a health history on a client. What would be most appropriate in planning for the interview?

1)   Stand at the bedside to conduct the interview

2)   Sit about 0.25 meters away from the client.

3)   Provide water and tissues for the client.

4)   Conduct the interview in the lounge provided for clients

 

15) A client is prescribed the use of a machine to aid with sleep apnea but doesn’t want to use it. What response by the nurse would aid in determining the client’s reluctance to use prescribed medical treatment?

1)   “I guess the machine is complicated to use.”

2)   “You’re not alone; many clients don’t use their sleep apnea machines.”

3)   “I’m sure your doctor will figure something out about your sleep apnea.”

4)   “Tell me what you think about the machine.”

 

 

16) A nurse says to a client, “It sounds like you don’t like your new job because it’s more stressful than you anticipated.” What communication technique is the nurse using?

1)   Listening

2)   Paraphrasing

3)   Questioning

4)   Attending

 

 

17) A client tells the nurse about two abortions she had while in university. The nurse responds, “What university did you go to?” This response is evidence of which type of barrier to communication?

1)   Cross-examination

2)   Changing the subject

3)   False reassurance

4)   Use of technical terms

 

 

18) The nurse is assessing a client through the use of an interpreter. After one response, the interpreter says to the nurse, “I think she’s really sick but doesn’t want to tell you.” How should the nurse respond to the interpreter?

1)   Ask the interpreter to ask the client, “What other health issues have you been experiencing?”

2)   “Tell me why you think that.”

3)   “Are you sure? She hasn’t said anything to me.”

4)   “I think so too, especially when she wouldn’t answer my one question about pain and sleeping.”

 

 

 

19) While conducting a health history, the nurse stands and uses the examination room sink to document client information. Afterwards the nurse states, “The doctor will be in to see you in a few minutes,” and leaves the room. What is the nurse demonstrating to the client?

1)   Concreteness

2)   A lack of genuineness

3)   Positive regard

4)   Empathy

 

 

20) A client comes into the Emergency Department speaking incoherently. What should the nurse do to obtain information about the client’s current health status?

1)   Talk with the immediate family members who brought the client to the hospital.

2)   Call the Medical Records department to obtain other records for the client.

3)   Call the client’s physician.

4)   Conduct a thorough physical assessment and document the health history as unable to obtain.

 

 

21) A nurse says to a client, “Before we provide any care to you, I will need to spend about 30 minutes talking about your current problem and any other health issues that might impact how you are feeling right now.” In which phase of the health assessment interview is the nurse participating?

1)   Closure of the Interview

2)   The Initial Interview

3)   The Clarification Interview

4)   Preinteraction

 

 

22) A nurse is conducting a psychosocial history with a client. What question would be included in this assessment?

1)   Have you noticed any change in your vision?

2)   Are you the head of your family?

3)   Have you had any major surgeries?

4)   How long have you worked for your current employer?

 

 

23) During the course of a health history the nurse would like to review a client’s medications. What should the nurse include in the assessment?

1)   The place in the home where the medications are stored.

2)   List of all the medication the client has ever been prescribed.

3)   List of all over-the-counter and herbal preparations the client is taking.

4)   The number of dosages left for each medication the client is taking.

 

24) During the assessment of an elderly female from another cultural group, the client says, “Please call my husband in. I want him in the room with me.” What should the nurse do in response to this client’s request?

1)   Escort the husband into the room.

2)   Document that the client refuses the assessment.

3)   Ask the client to wait a few minutes until the assessment is completed.

4)   Ask another nurse to assist with the assessment.

 

 

 

  • What is helpful when communicating with a client who does not speak English?
  • Sit facing the translator and client
  • Discuss each question and answer with the translator
  • Use a member of the client’s family to translate
  • Look at the client while telling the translator what to say

 

 

26)  What is a genogram?

1)  Depiction of a client’s support systems.

2)  Representation of family relationships.

3)  Pictorial of family relationships and health history.

4)  Graphical display of all system’s in a client’s life.

 

 

27)  Mrs. Matthews, 63 years old, tells the nurse she was a social drinker. What should the nurse do next?

1)  Document that Mrs. Matthews does not drink alcohol.

2)  Ask what she currently drinks at social gatherings.

3)  Inquire whether Mrs. Matthews smokes.

4)  Ask Mrs. Matthews how many drinks she had per week.

 

28)  What is the purpose of a health history?

1)  Gather data about the cause of the health problem

2)  Document responses to potential and actual health concerns

3)  Collect objective data about the current health problem

4)  Document findings from a physical assessment

 

 

SHORT ANSWER.  Write the word or phrase that best completes each statement or answers the question.

 

29) While observing a nurse interacting with a client, the nursing student notes that the client will not talk with anyone in the room.  Which comment by the nurse would have been non-therapeutic or harmful in this interaction and could have facilitated this silence from the client?  (Select all that apply.)

_______“I’m not sure what time the procedure will be, but I will check for you.”

_______“I’ll try to explain things before they happen to you.”

_______“You shouldn’t feel scared; there is nothing to worry about.”

_______“Let’s not talk about your surgery now; it will only make you worry.”

 

 

 

 

Chapter 11

 

MULTIPLE CHOICE.  Choose the one alternative that best completes the statement or answers the question.

 

1)   A nurse is assessing a client with liver disease and notes that the skin, mucous membranes, and sclerae are yellowish in colour.  How should the nurse document this finding?

1)   Cyanosis

2)   Jaundice

3)   Carotenemia

4)   Uremia

 

 

2)   What assessment finding of a 2 to 3-day-old newborn’s skin may require treatment?

1)   Tiny white facial bumps

2)   Dark spots on the sacral area

3)   Irregular red patches on the back of the neck

4)   Yellow skin colour

 

 

3)   A nurse is admitting a client with skin vitiligo, which is highly visible even from a distance. The client asks you to put a ‘No Visitors’ sign on the door and has called the family to tell them not to visit. What primary problem may occur with this client?

1)   Risk for loneliness

2)   Decrease in self-esteem

3)   Defensive coping

4)   Disturbed body image

 

4)   A nurse is performing a skin assessment on a client and notes a round, elevated, fluid-filled mass approximately 0.5cm in size.  How should the nurse document this finding?

1)   Papule

2)   Tumor

3)   Macule

4)   Vesicle

 

5)   A nurse is conducting a health history on a client’s integumentary status and wants to obtain data related to risk factors. What would be an appropriate question?

1)   “Does your skin itch?”

2)   “Have you noticed a change in the colour or size of a mole?”

3)   “Have you noticed any pain around your cuticles?”

4)   “How much time do you spend outdoors?”

 

 

 

6)   How should the nurse assess for jaundice in a client with dark skin?

1)   Use a bright lamp and a magnifying glass

2)   Inspect the lips, oral mucosa, sclera, conjunctivae, and palms

3)   Assess the skin the same way you would inspect any client

4)   Document “unable to assess” for jaundice

 

 

7)   A nurse is planning to do a head to toe assessment of the skin, hair, and nails of a client from Vietnam.  The interpreter, a relative who speaks Vietnamese and English, has been authorized by the client to be present to translate. What should the nurse do first?

1)   Perform hand hygiene and don gloves.

2)   Ask the client to remove all clothing, put on a gown, and lie down.

3)   Tell the client that an official interpreter needs to be present.

4)   Explain the procedure and ask if you may touch the client’s head.

 

8)   A nurse is caring for a client who is a long-time smoker and notes clubbing of the fingers. What technique would the nurse utilize to validate this assessment?

1)   Place the hands out straight with the palm sides down

2)   Place two of the same fingers from each hand together

3)   Place two index fingers together tip to tip

4)   Place two thumbs touching side by side

 

9)   A nurse is performing an assessment of a client’s skin, hair, and nails when the client becomes pale and diaphoretic. What action should the nurse take first?

1)   Call the physician

2)   Ask about anxiety and explain procedures

3)   Lower the client’s head

4)   Give the client orange juice with extra sugar

 

10) A nurse is assessing a female client and notes facial hirsutism.  The client asks the nurse why this has happened to her. How should the nurse respond?

1)   “You need to take vitamins.”

2)   “There is no known cause for this condition.”

3)   “Your diet is not nutritionally balanced.”

4)   “You may have some hormone imbalances.”

 

11) A nurse is inspecting the fingernails of a client with a diagnosis of polycythemia.  What finding would be expected with this diagnosis?

1)   Pale nail beds

2)   Horizontal white bands

3)   Spoon shaped nails

4)   Bright red nail beds

 

 

12) A nurse is assessing a teenaged male client and notes a musky odour.  The client states that this is embarrassing for him and that he showers daily.  What action should the nurse take in this situation?

1)   Suggest that he use a scented soap

2)   Obtain a dietary referral

3)   Reassure the teen that this is normal

4)   Educate the teen about masturbation

 

13) A nurse is caring for a client complaining of a painful, hot area in the leg.  The area is red and swollen.  What should the nurse do?

1)   Palpate the area

2)   Put client on bed rest

3)   Put ice on the area

4)   Notify the physician

 

14) A nurse is assessing the skin of a newborn infant and notes a bright red, raised lesion on the lateral aspect of the thigh.  The mother has expressed concern about this area, and asks the nurse if it should be removed.  What would be the best response for the nurse in this situation?

1)   “Your pediatrician can make a surgical referral for you.”

2)   “These types of lesions usually disappear by age 3.”

3)   “You should be happy your baby is healthy overall.”

4)   “It really is not that noticeable.”

 

15) A nurse is assessing the skin of an elderly client and notes purplish patches of irregular shapes on both lower extremities.  What action should the nurse take?

1)   Document the findings and notify the physician.

2)   Ask the client how long the patches have been present.

3)   Ask the client what the patches are.

4)   Document that the client has bruises.

16) A client tells the nurse about “sores in the mouth.”  The nurse notes crusted lesions on the lips and inside the cheek.  What type of skin lesion would the nurse suspect?

1)   Herpes simplex

2)   Dermatitis

3)   Herpes zoster

4)   Varicella

 

17) A nurse is performing a skin assessment on a client and notes an elevated, irregular band of scar tissue on the left arm. What term should the nurse use to document this finding?

1)   Fissure

2)   Keloid

3)   Ulcer

4)   Scar

 

 

18) A nurse is caring for a postoperative client who had abdominal surgery.  The client has verbalized concern that their scar is purplish in colour. How should the nurse respond?

1)   “I am sure you are glad your surgery was a success.”

2)   “Having a scar was unavoidable.”

3)   “You can have plastic surgery to remove the scar later.”

4)   “The colouration is normal and will fade with time.”

19) Rebecca, 16 years old, has acne and is pregnant. A nurse is completing a health history to assess the skin, hair, and nails.  What question would be most important for the nurse to include in the interview?

1)   “Do you use any skin creams?”

2)   “Do you use sunscreen and try to avoid exposure to the sun?”

3)   “Have you had any nail changes?”

4)   “Have you lost any hair during your pregnancy?”

 

20) Andrew, 15 years old, has extensive acne over his face and upper neck. He asks the nurse why this is happening to him. How should the nurse respond?

1)   “Expensive creams will take care of the problem.”

2)   “You are not washing your face enough.”

3)   “I have seen a lot worse.”

4)   “This is a normal part of being a teenager.”

 

21) A nurse is assessing a client’s skin and notes that the colour appears similar to chalk.  What description would the nurse use when documenting this finding?

1)   Pallor

2)   Cyanosis

3)   Erythema

4)   Jaundice

 

22) A nurse is preparing to assess a client’s integumentary status. What techniques will the nurse use to conduct this assessment?

1)   Inspection and percussion

2)   Inspection and auscultation

3)   Percussion and palpation

4)   Inspection and palpation

 

23) During the assessment of a client’s integument the nurse notes “vitiligo present bilateral hands.” What would the nurse have seen to lead to this conclusion?

1)   An abnormal loss of melanin in patches

2)   Grouped vesicles

3)   Nodules with ulcerations

4)   Dark, asymmetrical coloured patches

 

24) After the completion of an integumentary status assessment, the nurse documents “+1 edema right lower leg.” How might the nurse describe the edema?

1)   Deeper pitting, no obvious distortion

2)   Pitting is severe, legs are grossly distorted

3)   Slight pitting, no obvious distortion

4)   Pitting is obvious, legs are swollen

 

25) A nurse is planning to assess the integument of a client with dark skin. What finding would indicate the presence of cyanosis in this client?

1)   Yellow-orange tint to the palms

2)   Bluish tinged nail beds

3)   Yellow hue in the eyes

4)   Cherry red lips

 

26) A nurse is planning to document the appearance of herpetic lesions found over a client’s nose and mouth region. What term would the nurse most likely use to describe the appearance of the lesions?

1)   Pustular

2)   Papular

3)   Pruritic

4)   Scaly

 

27) During the assessment of an elderly client’s integument the nurse notes small areas of dark freckles on the client’s hands. What may have caused this finding?

1)   Hyperpigmentation of the skin

2)   Decrease in melanin production

3)   Decreased blood perfusion of the dermis

4)   Increase in sebum production

 

 

28) How would the nurse document the presence of several abdominal lesions that appear in distinct clusters?

1)   Confluent

2)   Annular

3)   Grouped

4)   Discrete

29)  Mrs. Gifford, 32 years old, tells the nurse she has a scaly, reddened, elevated mass on the back of her left hand. It has grown quite quickly over the past two weeks.  What type of lesion should the nurse suspect?

  • Squamous cell carcinoma
  • Eczema
  • Psoriasis
  • Contact dermatitis

 

30)  What is the purpose of the skin?

1)  Protect the body from cold

2)  Prevent infection

3)  Assist in regulating body temperature

4)  Help to synthesize Vitamin B12

 

31)  What stratum is the outermost layer of epidermis on the soles of the feet?

1)  Basale

2)  Granulosum

3)  Germinativum

4)  Corneum

 

32)  Ms. Dhalliwal, 22 years old, has recently moved to Canada from India. She has white skin and pale blond hair. How should the nurse document Ms. Dhalliwal’s appearance?

1)  Pallor

2)  Vitiligo

3)  Tinea versicolour

4)  Albinism

 

 

33)  A nurse is conducting a health history on a client. What question might the nurse ask related to lifestyle behaviour?

1)  “Do you use a sunscreen with a sun protection factor?

2)  “Have you changed your diet recently?”

3)  “Have you had eczema in the past?”

4)  “Are you exposed to x-rays at work?”

 

 

34)  Aniljit, 4 years old, has recently moved to Canada from Pakistan. The nurse notes that he has a purplish-red marking over his left buttock. How should the nurse document this finding?

1)  Bruising from a spanking

2)  Port-wine stain

3)  Mongolian spot

4)  Hemangioma

 

 

35)  What equipment does the nurse require to complete an assessment of the integument?

1)  Magnifying glass

2)  Stethoscope

3)  Infrared lamp

4)  Sterile gloves

 

 

SHORT ANSWER.  Write the word or phrase that best completes each statement or answers the question.

 

36) Mrs. Potvin, 79 years old, is having an assessment of her integument. What finding (s) may be noted in a client of this age?  (Select all that apply.)

___ Cutaneous horn

___ Lentigines

___ Skin tags

___ Angiomas

 

 

 

Chapter 12

MULTIPLE CHOICE.  Choose the one alternative that best completes the statement or answers the question.

 

1)   A nurse is palpating an adult client’s neck and is unable to palpate any lymph nodes. How will the nurse interpret this finding?

1)   Probably due to an infection

2)   Cause to inspect for further malformations

3)   A normal finding in adults

4)   Reason for referral to an ear, nose, and throat specialist

 

2) A nurse is examining a client’s neck.  What is the correct technique to palpate the trachea?

  • Palpate while the client is swallowing
  • Move the finger laterally, first to the right and then to the left
  • Ask client to lower chin and turn head slightly to the right
  • Stand behind the client and ask the client to turn their head

 

 

 

3)   A nurse is assessing a client with hypothyroidism.  What symptom is the client likely to report?

1)   Intolerance to heat

2)   Depression

3)   Insomnia

4)   Exophthalmos

 

 

4)  A nurse is using the posterior approach to palpate the thyroid gland on a client.  What is the correct method for performing this physical assessment?

  • Use right thumb to push the trachea aside and palpate with left thumb and fingers
  • Observe the thyroid as the client swallows water
  • Use the bell of the stethoscope to identify a bruit
  • Left hand is used to displace the trachea, palpate with the fingers of the right hand

 

 

5)   What is the only bone in the body that does not articulate with another bone?

1)   Pinna

2)   Hyoid

3)   Axis

4)   Zygomatic

 

 

6)   A nurse is performing a physical examination on Olivia, a newborn. The mother expresses concern about the flattened areas on each side of Olivia’s head.  How should the nurse respond?

1)   “The baby needs a neurological evaluation.”

2)   “This is normal and will resolve in a few days.”

3)   “The baby will need plastic surgery.”

4)   “What shape is your husband’s head?”

 

7)   A nurse is auscultating the temporal artery and hears a soft blowing sound.  What is the appropriate term to use to document this finding?

1)   Murmur

2)   Occlusion

3)   Stenosis

4)   Bruit

 

 

8)   A client tells a nurse that she suffers headaches that come on suddenly; recur over a period of days followed by a period of remission. What type of headache is this client experiencing?

  • Classic migraine
  • Tension
  • Cluster
  • Premenstrual

 

 

9) A nurse is testing a client’s cranial nerves by applying downward pressure on both shoulders while the client is asked to do a shoulder shrug. What cranial nerve is being assessed?

1)   IX

2)   X

3)   XI

4)   XII

 

 

10) A nurse is assessing a client’s temporomandibular joint (TMJ) and notes a crackling sound on movement. How should the nurse document this finding?

1)   Crepitation at TMJ

2)   Soft clicking noise at TMJ

3)   Melasma noted on movement

4)   The TMJ is normal

 

 

11) A nurse is assessing an infant and needs to document normal assessment findings of the fontanels.  What is the appropriate documentation?

1)   Fontanels diamond shaped

2)   Moulding of head noted around fontanels

3)   Anterior and posterior fontanels level with the skull

4)   Fontanels sunken

 

 

12) A new immigrant from India presents with a history of goitre. During the assessment the nurse notes an enlarged thyroid gland. What question is a priority in this health history?

1)   “How long have you had this problem?”

2)   “Where do you purchase your medication?”

3)   “Do you work around hazardous chemicals?”

4)   “What type of salt do you use in your diet?”

 

 

13) A nurse is auscultating the thyroid gland and notes a bruit.  What does this finding indicate?

1)   Increased blood flow

2)   A normal finding

3)   Occurs with hypothyroidism

4)   Stenosis of the thyroid artery

 

 

 

14) A nurse is demonstrating palpation of the lymph nodes to a nursing student.  What is the correct method to use during this examination?

1)   Strong, deep pressure

2)   Rubbing side to side

3)   Gentle, circular pressure

4)   First on one side, then on the other

 

 

15) Carol, 16 weeks gestation, is concerned about the dark spots that have appeared on her face. How should the nurse respond?

1)   “This often occurs in pregnancy and unfortunately is permanent”.

2)   “This is due to hormonal changes and will subside after childbirth”.

3)   ” I think you have had too much sun exposure”.

4)   “This is a result of using birth control pills for many years”.

 

 

 

16) A nurse is assessing a client with complaints of sudden, intermittent headaches for the past several months.  The client states that the headaches start after seeing flashes of lights and is accompanied nausea.  What type of headache is this client describing?

1)   Premenstrual

2)   Tension

3)   Migraine

4)   Cluster

 

 

17) A nurse is assessing a newborn infant. The infant’s head tilts to one side and the sternocleidomastoid muscle is shortened.  What is the correct medial term to describe this finding?

1)   Craniosynostosis

2)   Acromegaly

3)   Hydrocephalus

4)   Torticollis

 

 

18) A nurse is caring for a client diagnosed with hyperthyroidism.  What symptom would the nurse suspect?

1)   Irritability

2)   Weight gain

3)   Constipation

4)   Fatigue

 

 

19) A nurse is palpating a pregnant client’s thyroid which is slightly enlarged. What is the most appropriate way for the nurse to document this finding?

1)   Client appears to have Grave’s disease.

2)   Thyroid gland within normal limits.

3)   Thyroid gland has a palpable mass.

4)   Thyroid gland midline and round, but slightly enlarged.

 

 

20) A nurse is planning care for a client with hypothyroidism.  What is the priority nursing diagnosis for a client experiencing this disorder?

1)   Nutrition, less than body requirements

2)   Risk for injury

3)   Activity intolerance

4)   Ineffective health maintenance

 

21) A nurse is performing an assessment of the head and neck.  What assessment techniques would the nurse include in the examination?

1)   Inspection, palpation, auscultation

2)   Palpation, auscultation, percussion

3)   Inspection and auscultation

4)   Percussion and palpation

 

 

22) What muscles form the posterior triangle of the neck?

  • Mandible, midline of the neck, and sternocleidomastoid
  • Clavicle, midline of the neck, and trapezius
  • Manubrium, Mastoid, and scapulae
  • Clavicle, sternocleidomastoid, and trapezius

 

 

23) A nurse is taking a physical assessment examination and has been asked to palpate the submandibular

lymph node. What is the landmark for locating this lymph node?

  • Behind the tip of the mandible at midline
  • At the junction of the posterior and lateral walls of the pharynx at the angle of the jaw
  • On the medial border of the mandible
  • Behind the ear, over the outer surface of the mastoid bone

 

 

24) A nurse is examining Jude, 3 months old, and notices plagiocephaly. What question should the nurse ask Jude’s mother?

  • “How much alcohol did you drink during your pregnancy?”
  • “Did the baby experience a birth trauma?”
  • “How is Jude positioned in his crib?”
  • “When did Jude’s sutures fuse?”

 

Difficulty = 3

 

 

25) Mr. Jones, 70 years old, has sudden onset of unilateral facial paralysis. The physician suspects the client has a Bell’s palsy. What cranial nerve is involved in this disorder?

  • VII
  • XI
  • X
  • V

 

 

SHORT ANSWER.  Write the word or phrase that best completes each statement or answers the question.

 

26) A nurse needs to palpate the submental lymph node on a client.  Draw an arrow to the spot where the nurse would palpate.

 

 

 

 

 

27) A nurse is assessing an infant diagnosed with Down syndrome. What characteristics would the nurse expect to find during this examination?  (Select all that apply)

______Slanted eyes

______Cleft palate and lip

______Flat nasal bridge and nose

______Protruding tongue

______Shortened neck

______Drooping eyelids

 

 

 

Chapter 13

 

MULTIPLE CHOICE.  Choose the one alternative that best completes the statement or answers the question.

 

1)   A nurse will be performing a distance vision test on a client. What equipment should be used for this examination?

1)   Ophthalmoscope

2)   Snellen chart

3)   Rosenbaum chart

4)   Pen light

 

 

2)   During an interview with the nurse a 24 –year-old client reports difficulty with near vision. What term should the nurse use to document this finding?

1)   Astigmatism

2)   Myopia

3)   Presbyopia

4)   Hyperopia

 

 

3)   A nurse is triaging clients in an ophthalmology office.  What client condition requires immediate intervention?

1)   Anisocoria

2)   Periorbital edema

3)   Blepharitis

4)   Acute glaucoma

 

 

4)   A nurse is performing a visual examination because a client has reported black dots appearing in the visual fields.  The client asks the nurse if the black dots are a sign of a serious problem. How should the nurse respond?

1)   “The black dots are known as floaters and are usually normal.”

2)   “You may have cataracts.”

3)   “You may have glaucoma.”

4)   “We need to refer you to an eye surgeon immediately.”

 

 

 

5)   A nurse is completing a health history interview on a young adult.  What question will provide information about the client’s health behaviours related to eye health?

1)   “Do bright lights bother you?”

2)   “Do you routinely wear sunglasses during the summer?”

3)   “Have you ever been bothered by spots in front of your eyes?”

4)   “Does anyone in your immediate family have diabetes?”

 

6)   A nurse is preparing to use an ophthalmoscope to examine a client with an emmetropic eye. How should the nurse position the diopter wheel?

1)   Minus numbers

2)   Zero

3)   Positive numbers

4)   Really does not matter

 

 

7)   A nurse is assessing the visual fields of a 38-year-old female who reports recent changes in visual abilities.  What statement by the nurse would be appropriate?

1)   “The changes could be related to increased pressure within the eye.”

2)   “These changes are probably related to your age.”

3)   “These changes require a prescription for glasses.”

4)   “It is possible you have taken narcotics recently?”

 

 

 

8)   A nurse is performing the cover test and notes inward turning of the eye.  What is the correct term to use to document this finding?

  • Nystagmus
  • Emmetropia
  • Esophoria
  • Exophoria

 

 

 

9)   A nurse is performing a vision test with a client. With a Rosenbaum chart in place the nurse asks the client to read the letters from top to bottom.  How will the nurse position the client to ensure the accuracy of this examination?

1)   Must be exactly 6 m from the chart

2)   Seated at eye level 0.5 to 1 m from the nurse

3)   Should be 35.5 cm from the chart

4)   Ensure one eye is covered while reading the chart

 

 

10) When assessing the eyes of a client, the nurse notes severe redness of the iris and cornea.  The client reports pain in the eye as well.  What term should the nurse use to document this finding?

  • Blepharitis
  • Iritis
  • Conjunctivitis
  • Mydriasis

 

 

 

11) A nurse is assessing the eyes of an 82-year-old client.  What age related physiologic change should the nurse anticipate?

1)   Thin, yellow lens

2)   Larger size pupils

3)   Quicker pupillary light reflexes

4)   Decrease in lacrimal secretions

 

 

12) A nurse will be giving a distance visual acuity test to a 3- year-old child. What type of chart will be required for this examination?

  • Rhinne
  • Rosenbaum
  • Snellen E
  • Webber

 

 

13) Doug and Tyler, student nurses, are studying for a midterm. Tyler asks Doug to explain Adie’s pupil. What would be the best answer?

1)   Both pupils are small, irregular, and nonreactive to light.

2)   Unequal papillary size than may be normal or may indicate disease.

3)   Fixed and dilated pupils due to central nervous system damage.

4)   Unilateral sluggish pupillary response also known as a tonic pupil.

 

 

14) A nurse is caring for a client recovering from an occipital lobe stroke who is demonstrating vision changes. The client’s spouse asks the nurse what has caused the vision changes. How should the nurse respond?

1)   “An eye specialist needs to consult on the cause of the vision changes”

2)   “The visual changes were probably present before the stroke occurred.”

3)   “The stroke was in the occipital area of the brain, which is responsible for vision.”

4)   “I think another stroke is occurring I need to do an immediate assessment.”

 

 

15) What type of vitamin deficiency can cause night blindness?

1)   A

2)   B

3)   D

4)   E

 

16) A nurse is interviewing the mother of a three-week-old infant.  What statement by the mother would require teaching by the nurse?

1)   “My baby’s eyes will stay blue.”

2)   “I can get my baby to follow bright objects.”

3)   “I know that my baby’s crossed eyes won’t be permanent.”

4)   “My baby should not have tears.”

 

 

 

17) A nurse would like to assess the fusion reflex in a client. What assessment technique should the nurse use?

1)   Corneal light reflex

2)   Cover test

3)   Testing by confrontation

4)   Cardinal Fields of Gaze

 

 

18) A nurse is going to perform the cover test on a client? How should the client be prepared for this examination?

1)   Seated approximately 0.5 to 1 m away from the examiner

2)   Explain to the client when the light is first seen to say “now” or “yes”.

3)   Tell the client that the testing will take place in a darken room.

4)   Look at a fixed point while covering one eye and then repeat with the other eye.

 

 

19) During an eye examination, the nurse finds a client is able to read all lines on the Snellen chart without

difficulty. How should the nurse document this finding?

1)   Reading vision normal

2)   Vision 20/20

3)   Distance vision normal

4)   Vision 14/14

 

 

20) A client is found to need corrective lenses for myopia.  How should the nurse explain the purpose of the lenses to the client?

1)   “Your glasses will help you to see things that are close to you better.”

2)   “Your glasses will help you to see things that are farther away better.”

3)   “Your glasses will help you to read small print better.”

4)   “Your glasses will help you to improve your eyes’ ability to focus.”

 

 

21) A nurse is assessing a client’s visual fields by confrontation. What instructions should the nurse provide the client in preparation for this eye test?

1)   “Follow the pen light with your eyes only.”

2)   “Keep both eyes uncovered and focus on the examiners forehead.”

3)   “Cover one eye with the card.”

4)   “Say no when you can no longer see the light.”

 

 

 

22) A nurse is assessing an infant and notes the left eye deviates inward while focusing on an object. How should the nurse document this finding?

1)   Strabismus

2)   Myopia

3)   Hyperopia

4)   Presbyopia

 

23) A client being assessed by a nurse is found to have a poor consensual light response. How should the nurse interpret this finding?

1)   A potential abnormality of cranial nerve III

2)   Evidence of retinal degeneration

3    An indication of macular degeneration

4)   Evidence of Horner’s Syndrome

 

 

24) During a physical assessment the nurse suspects the client has entropion. What did the nurse observe?

1)   Eversion of the lower eyelid

2)   Firm, nontender nodule on the eyelid

3)   Swollen, red hair follicles

4)   Inversion of the lid and eyelashes

 

 

25) During a physical assessment the nurse suspects the client has ptosis. What did the nurse observe?

1)   Eversion of the lower eyelid

2)   Swollen and puffy eyelids

3)   Drooping of the eyelid

4)   Redness of the iris and cornea

 

 

SHORT ANSWER.  Write the word or phrase that best completes each statement or answers the question.

 

26) A nurse is caring for a client who is 30 weeks pregnant.  The client has various visual complaints and asks the nurse whether the changes are permanent.  What signs and symptoms are usually normal in this stage of pregnancy and should disappear after delivery?  (Select all that apply.)

1)   Edema of eyelids

2)   Blurred vision

3)   Visual changes

4)   Intolerance of contact lenses

5)   Eye dryness

 

 

27) What structure(s) in the eye are responsible for refraction?  (Select all that apply.)

1)   Aqueous humor

2)   Sclera

3)   Iris

4)   Crystalline lens

5)   Cornea

 

 

 

Chapter 14

 

MULTIPLE CHOICE.  Choose the one alternative that best completes the statement or answers the question.

 

1)   A nurse notes in the physical exam done by the physician that the client has a positive Romberg.  What should the nurse do to help the client meet elimination needs?

1)   Provide a bedside commode

2)   Allow the client to walk independently

3)   Obtain an order for a catheter

4)   Limit fluid intake

 

2)   Mr. Jarvis works with heavy machinery and until recently was not required to use hearing protection. He tells the nurse that he has experienced a gradual change in his hearing over the past 5 years. What finding would the nurse anticipate when performing the Rinne test?

1)   Shorter bone conduction of sound

2)   Longer air conduction of sound

3)   Shorter air conduction of sound

4)   Sound lateralization of one ear

 

3)   What assessment techniques are used to assess the ears, nose, mouth and throat?

1)   Transillumination and palpation

2)   Auscultation and percussion

3)   Transillumination and conduction

4)   Conduction and percussion

 

4)   A nurse is assessing the tympanic membrane of a client in the emergency room and notes the presence of a bluish colour.  What should the nurse suspect in this situation?

1)   Previous tympanostomy tubes

2)   Use of a hearing aid

3)   Diagnosis of gout

4)   Head trauma

 

 

5)   Ms. Jarvis, 41 years old, states she suffers from headaches and malaise. The nurse completes an assessment and finds that Ms. Jarvis has severe pain across the bridge of her nose, on the forehead, and beneath both eyes when these areas are palpated.  What disorder should the nurse suspect?

1)   Sinusitis

2)   Acute allergies

3)   Migraines

4)   Rhinitis

 

 

 

6)   A nurse is presenting a class to high-school teenagers about the risks of chewing tobacco.  What early sign of oral cancer should the nurse include in the presentation??

1)   Excessive salivation

2)   Ulcerations on the lip or tongue

3)   Sore throat

4)   Bleeding gums

 

7)   A client arrives in the emergency room with complaints of intermittent nosebleeds for the past two days.  What assessment would be a priority for the nurse is this situation?

1)   Obtain a blood pressure

2)   Check for deviated septum

3)   Check stools for blood

4)   Obtain nasal cultures

 

 

8)   A nurse is assessing the oral mucosa of a pregnant female and notes enlargement of the gums. The client states that she brushes and flosses her teeth three times a day and does not understand why they are swollen and bleed.  How should the nurse respond?

1)   “You are experiencing a normal change during pregnancy.”

2)   “You may have oral cancer.”

3)   “You need to increase the frequency of your oral hygiene.”

4)   “You need a dental referral for gingivitis.”

 

 

9)   Tamara, 20 months old, is being discharged following treatment of an ear infection and fever.  What should the nurse include in the discharge teaching to the parents?

1)   “It is important to not prop the baby’s bottle at bedtime.”

2)   “You should use water at bedtime instead of milk.”

3)   “You must rinse the baby’s mouth out at night.”

4)   “You must perform oral hygiene more often.”

 

 

10) A nurse is performing an otoscopic examination on an adult client and is unable to visualize the tympanic membrane.  What should the nurse do first to better visualize this structure?

1)   Pull down and back on the pinna, then reinsert the otoscope

2)   Reposition the otoscope while still in the auricle until the tympanic membrane can be seen

3)   Remove the otoscope, reposition the auricle, then reinsert the otoscope

4)   Defer the examination for this client to the physician and document rationale

 

11) A nurse is examining a 14-month-old child when the mother tells the nurse that the child cries frequently, has a fever, and is pulling at both ears.  The child has no cough, congestion, or drainage from the ears and the temperature is normal.  What conclusion would the nurse make from these findings?

1)   Respiratory infection

2)   Otitis externa

3)   Strep throat

4)   Otitis media

 

12) A nurse is triaging a client and notes pallor and cyanosis of the oral cavity and lips.  What action should the nurse take first?

1)   Administer oxygen

2)   Provide a warm drink

3)   Type and cross for blood

4)   Administer IV fluids

 

13) A nurse is examining a client’s ears and notes that the right ear is occluded with wax.  How should the nurse remove the earwax?

1)   A cerumen spoon to remove the wax

2)   Irrigation with warm sudsy water

3)   A cotton swab soaked in warm mineral oil

4)   Irrigation with a cold solution

 

14) A nurse assessing the nasal passages of client notes the presence of watery discharge.  The client mentions sneezing and nasal congestion.  What condition`would the nurse suspect?

1)   Rhinitis

2)   Previous epistaxis

3)   Sinusitis

4)   Nasal polyps

 

15) A nurse is assessing the oral cavity of a client and notes a blackish coating over the tongue.  What questions should the nurse ask the client?

1)   “Have you ever had this happen before?”

2)   “Have you eaten licorice lately?”

3)   “Are you taking anti-seizure medication?”

4)   “How often do you brush your tongue?”

 

 

 

 

16) A client with a sore throat is also having difficulty hearing.  What disorder might the client be experiencing?

1)   Infected tonsils

2)   Sinus infection

3)   Inner ear infection

4)   Middle ear infection

 

17) During a Weber test, a client is found to have increased hearing in the right ear. What does this finding indicate?

1)   Conductive hearing loss in the left ear

2)   Perforated left eardrum

3)   Cerumen or otitis media in the right ear

4)   Normal aging

 

18) A nurse is assessing a client and finds small raised lesions on the rim of the ear. What would contribute to this finding?

1)   Hypertension

2)   Gout

3)   Kidney failure

4)   Heart disease

 

19) Mrs. Ming, 78 years old, says “I can’t seem to hear as well as I used to.” What should the nurse suspect is contributing to the hearing loss?

1)   Cochlea atrophy

2)   Otitis externa

3)   Presbycusis

4)   Otitis media

 

 

20)  Mr. Webster, 31 years old, is having his ears assessed with an otoscope. What should the nurse do first?

  • Turn the light on
  • Ask the client to tilt head forward
  • Explain the procedure
  • Pull the pinna down

 

 

 

21)  What is the purpose of the tragus?

  • Equalized ear pressure
  • Hold receptors necessary for hearing
  • Protects the anterior meatus of the auditory canal
  • Attaches the tongue to the floor of the mouth

 

22)  What is the normal finding for a Rinne Test?

  • Equal sound to both ears
  • Maintain position without swaying
  • Sound heard twice as long by air conduction
  • Correctly repeat phrases whispered by the nurse

 

 

23)  A nurse is assessing a client and notices an ammonia-like mouth odour. What may cause this finding?

1)  Poor dental hygiene

2)  Oral cancer

3)  Kidney disease

4)  Diabetic acidosis

 

 

24)  Jenny, 8 years old, has been admitted following a bicycle accident. The nurse notes her tympanic membrane has a bluish tinge. How should the nurse document this finding?

1)  Scarred tympanic membrane

2)  Normal colour for a child

3)  Tophi present

4)  Hemotympanum

 

25)  How should a nurse assess for a perforated nasal septum?

1)  Ask the client

2)  Use a nasal speculum

3)  Shine a penlight up into one naris

4)  Palpate the nose

 

 

SHORT ANSWER.  Write the word or phrase that best completes each statement or answers the question.

 

26) A client is having difficulty maintaining equilibrium. The nurse realizes the portion of the ear involved with this symptom would be the ________________.

 

 

 

27) The nurse is assessing the ears of an Asian client and notes that the cerumen is very dark in colour.  The nurse would document this finding as ______________.

 

=============================================================

 

 

Chapter 15

 

MULTIPLE CHOICE.  Choose the one alternative that best completes the statement or answers the question.

 

  • A nurse is preforming auscultation on a client who has significant atelectasis in the right lower lung field. What would the nurse anticipate hearing in this area of the lung?
  • Sonorous wheeze
  • Increased whisper pectoriloquy
  • Decreased breath sounds
  • Lack of tactile fremitus

 

 

2)   A nurse is performing a respiratory assessment on a pregnant client at term. She finds that her breathing pattern is faster at rest than her normal, non-pregnancy state. The client also states that she has dyspnea. How should the nurse interpret these findings?

1)   Expected for third trimester of pregnancy.

2)   Evidence of chronic pulmonary disease.

3)   Abnormal findings that require reporting.

4)   Abnormal findings, but not significant.

 

 

3)   A nurse is percussing the anterior chest of an elderly client.  What would the nurse expect to find in this client?

1)   Tympany

2)   Flatness

3)   Dullness

4)   Hyperresonance

 

 

4)   A nurse is assessing an infant’s respiratory rate and sees that the infant is primarily using abdominal muscles. How should the nurse interpret this finding?

1)   An indicator of respiratory dysfunction.

2)   Accessory muscles are assisting with breathing.

3)   A normal pattern.

4)   A slightly irregular pattern.

 

 

 

5) Bob presents to the street nurse, with a persistent cough that is productive for rust coloured mucus. What health issue does Bob likely have based on this finding?

  • Pneumonia
  • Asthma
  • Tuberculosis
  • Pleural effusion

 

 

6)   A nurse is monitoring a client’s respiratory rate. What is the most accurate method for the nurse to use in assessing respiratory rate?

1)   Count only the respirations that are audible.

2)   Ask the client not to talk while you listen to his respirations.

3)   Lay a hand on the client’s chest to count.

4)   Count without the client knowing what is happening.

 

 

7)   While palpating respiratory expansion the nurse notes unilateral chest movement. What health issue is most likely to cause this alteration?

1)   Acute bronchitis

2)   Pneumothorax

3)   Abdominal pain

4)   Pneumonia

 

8)   A nurse auscultates low-pitched, continuous respiratory sounds that have a snoring quality. How should the nurse document this finding?

1)   Rhonchi

2)   Rales

3)   Crackles

4)   Wheezes

 

 

9)   A client is 1 day post-operative for a left lower lobectomy. The nurse is palpating around the chest tube insertion site and notes crepitus. What has caused the crepitus?

  • Mucus plug in the left bronchus.
  • Air leaking into subcutaneous tissue.
  • Increase fremitus from fluid in the lung on the surgical side
  • Consolidation of the alveoli in the affected lung

 

 

10) A nursing instructor is observing a student during the respiratory assessment of a client. How will the student demonstrate proper technique for auscultating the posterior thorax?

1)   Base to apices of the lungs

2)   Side to side moving toward the bases

3)   First down one side of the thorax, then the other

4)   Midaxillary line to bases then to the apex of the lungs

 

 

11) A nurse is percussing the posterior thorax of a client with emphysema. What sound does the nurse anticipate hearing?

  • Resonance
  • Hyperresonance
  • Fremitus
  • Bronchial

 

 

12) During auscultation where are vesicular breath sounds heard on the thorax?

  • Over the lung fields
  • Over the trachea
  • Next to the trachea
  • Between the scapula

 

 

13) Jordan, 3 years old, has an obstructed airway. The nurse hears a loud high pitched crowing on inspiration. What is the medical term used to document this finding?

  • Rhonchi
  • Sibilant wheeze
  • Stridor
  • Friction rub

 

 

14) A nurse is assessing a client’s respiratory pattern and notes periods of deep breathing alternating with periods of apnea.  What term should be used to document this assessment finding?

1)   Hypoventilation

2)   Cheyne-Stokes

3)   Orthopnea

4)   Eupnea

 

 

15) A student nurse is asked to describe how to assess for bronchophony. What instructions should the student give the client during the assessment?

  • “Say “E” each time I put the stethoscope on your chest.”
  • “Whisper 1, 2, 3 when directed to do so.”
  • “Say ninety-nine when I place the stethoscope on your chest.”
  • “Take slow deep breathes in and out when directed to do so.”

 

 

16) Amrita, is 36 week pregnant and reports having shortness of breath.

How should the nurse respond to Amrita’s concern?

1)   “This is due to a decrease in oxygen demand.”

2)   “You must be having Braxton Hicks contractions.”

3)   “This is common at this point in the pregnancy.”

4)   “The enlarged uterus can decrease lung expansion.”

 

 

17) What is the landmark used to locate the angle of Louis?

1)   Manubrium

2)   First rib

3)   Clavicle

4)   Xiphoid process

 

18) During auscultation where are bronchial breath sounds heard on the thorax?

  • Over the lung fields
  • Over the trachea
  • Next to the trachea
  • Between the scapula

 

 

19) What landmarks are used to auscultate the bronchi?

  • From below the scapula down to the 6th intercostal space (ICS)
  • Above the suprasternal notch on each side
  • At the 2nd and 3rd ICS on either side of the sternal border
  • At the 5th ICS, at the midclavicular line

 

 

20) During a health history interview the nurse wants to know more about a client’s health behaviours. What question would elicit information on health behaviours?

  • “Do you have a cough?”
  • “Is there a family history of allergies?”
  • “Do you get the seasonal flu shot?”
  • “Are you exposed to respiratory irritants in the workplace?”

 

 

21) A client, 45 years old, with emphysema is being assessed by the nurse.  What physical finding would the nurse expect to find in this client?

1)   Pectus excavatum

2)   Barrel chest

3)   Scoliosis

4)   Pigeon chest

 

 

 

22) The nurse is examining a client who is diagnosed with a fracture of a floating rib. Which rib is fractured?

1)   9

2)   5

3)   1

4)   12

 

 

23) During auscultation where are bronchovesicular breath sounds heard on the posterior thorax?

  • Over the lung fields
  • Over the trachea
  • Next to the trachea
  • Between the scapula

 

 

24) A student nurse is practicing auscultation on a classmate and is concerned that the voice sounds were muffled. How should the instructor respond to this concern?

  • “This is an expected finding in areas of lung consolidation.”
  • “This is an anticipated finding in the normal lung.”
  • “The voice sounds should be loud and clear.”
  • “The voice sounds should be absent in this situation.”

 

 

25) A nurse notes a client’s respirations are less than 10 breaths per minute. What is the appropriate terminology to use in documenting this finding?

1)   Bradypnea

2)   Tachypnea

3)   Apnea

4)   Atelectasis

 

 

26) A nurse is preparing to percuss a client’s chest. How should the nurse position the client for this assessment?

  • Ask the client to lean forward and round the shoulders.
  • Have the client raise his arms over his head and sit up straight.
  • Have the client stand for this portion of the examination.
  • Ask the client to flex the neck and extend arms on a bedside table.

 

 

SHORT ANSWER.  Write the word or phrase that best completes each statement or answers the question.

 

27) A nurse is preparing to interview a client with asthma.  What topics should the nurse include during this interview to determine triggering factors?  (Select all that apply.)

_______ Workplace environment

_______ Presence of pets

_______ Age of onset

_______ Diet preferences

 

 

 

28) Draw an arrow to the area where tracheal breath sounds would be heard:

 

 

 

 

 

 

 

Chapter 16

 

 

MULTIPLE CHOICE.  Choose the one alternative that best completes the statement or answers the question.

 

1)   A nurse is performing an assessment on a newborn and notes a thin, milky discharge from the infant’s nipple.  What should the nurse document?

1)   Common finding in newborns

2)   Highly irregular finding

3)   Congenital anomaly

4)   Specimen sent for culture

 

 

 

2)   A female client is hospitalized with tissue destruction of the left pectoralis major and serratus anterior muscles due to motor vehicle accident.  What should the nurse include in the discharge teaching for the immediate post-hospitalization period?

1)   Plastic surgery

2)   Support bras

3)   Physical therapy

4)   Prosthetic device

 

 

3)   A nurse is using inspection to assess the breasts of a female client.  What finding might the nurse obtain using this assessment technique?

1)   Symmetry

2)   Skin thickening

3)   Tenderness

4)   Hard nodules

 

 

4)   A nurse is taking a history of her client. What should alert the nurse to possible increased risk for breast cancer?

1)   Menarche at age 14

2)   Drinking a glass of wine each night

3)   Having unprotected sexual contact with unknown partners

4)   Smoking two packs of cigarettes daily for four years

 

 

 

5)   A nurse is performing a clinical breast examination on a client and asks her to raise her arms over her head.  The client asks the nurse why this is necessary.  How should the nurse respond?

1)   “It is the only way to look for nipple retraction.”

2)   “It allows any masses to bulge forward and be seen.”

3)   “This is the best position to look for skin dimpling.”

4)   “This is the only position to detect Paget’s disease.”

 

 

6)   What causes galactorrhea?

1)   Endocrine disorders

2)   Breast malignancy

3)   Breastfeeding

4)   Breast infection

 

 

7)   A nurse is examining a client with a history of fibrocystic breast disease. What would the nurse expect to find during this assessment?

1)   Yellow discharge from the nipples

2)   Hard, fixed nodes

3)   Bloody discharge from the nipples

4)   Nipple retraction

 

 

8)   A nurse is teaching a client with fibrocystic breast disease.  What should the nurse teach about symptom relief?

1)   Limit salt intake

2)   Avoid fat in the diet

3)   Wear a loose fitting bra

4)   Drink tea instead of coffee

 

 

9)   A nurse is teaching a group of high school males about breast health.  What statement would indicate the teaching was effective?

1)   “I only need to be concerned if I have pain in my chest.”

2)   “I’ll be able to know about problems if I see changes in my chest.”

3)   “I know that I need to have regular breast examinations as my mother has breast cancer.”

4)   “Breast cancer is not something I have to worry about.”

 

10) Millie, 16 years old, expresses concern about breast tenderness and darkening of the nipples and areolae. She tells the nurse that her breast feel bigger. How should the nurse respond?

1)   Ask Millie if she might be pregnant.

2)   Tell Millie this is normal during adolescence.

3)   Recommend Millie see her physician immediately.

4)   Refer Millie for a mammogram.

 

 

11) Mrs. Dunlop, 40 years old, is being interviewed by the nurse about breast cancer risks.  Which comment would indicate Mrs. Dunlop understands the risks associated with breast cancer?

1)   “My family history is negative so I do not need to worry.”

2)   “I will have a clinical breast examination every three years.”

3)   “I know my risk for breast cancer increases with age.”

4)   “A mammogram every year is my goal.”

 

 

 

12) A nurse is compiling statistics for a breast cancer awareness presentation for a group of women.  What fact about breast cancer should the nurse include?

1) Monthly self-breast examination reduces the mortality rate

2) Incidence of breast cancer is declining

3) Late menarche increases the risk for breast cancer

4) Having children before age 30 decreases the risk of breast cancer

 

13) Why should the nurse palpate for the Tail of Spence?

1)   It can show the difference between fibrocystic disease and fibroadenomas.

2)   Peau d’orange may occur here over other areas of the breast.

3)   Breast cancer occurs more frequently in this area.

4)   It does not contain any lymph nodes.

 

 

14) A menopausal woman comes to the clinic with a history of thin, watery nipple discharge with blood present.  What breast disorder should the nurse suspect?

1)   Intraductal papillomas

2)   Fibrocystic disease

3)   Breast malignancy

4)   Mammary duct ectasia

 

15) A nurse is teaching a prenatal class about lactation when one of the clients asks how milk is produced.  What structure in the breast is responsible for milk production?

1)   Lactiferous ducts

2)   Montgomery’s glands

3)   Acini cells

4)   Areola

 

 

16) During a client’s breast examination, the nurse palpates a small, subclavicular node on the right side of the client’s chest. What should the nurse do next?

1)   Call in a physician

2)   Document the location of the node

3)   Schedule a mammogram for the next available appointment

4)   Continue with the exam

 

 

 

17) Mrs. Beliveau, 42 years old, has fibrocystic breast disease. She asks the nurse if this disorder will lead to cancer.  How should the nurse respond?

1)   “There is not a link between this disease and cancer incidence.”

2)   “Why are you so worried about this?”

3)   “You will need to ask the physician that question.”

4)   “This disease is a form of cancer.”

17

 

 

18) A nurse working in a First Nations community is teaching breast health to a group of 50 to 70 year old women. What information should the nurse include in her teaching?

1)   High alcohol consumption by aboriginal women places them at higher risk than Caucasian women.

2)   Clinical breast examinations are recommended every 5 years after age 50.

3)   Aboriginal women should have a yearly mammogram.

4)   Annual clinical breast examination in recommended.

 

 

19)  What suspensory ligaments provide the breast with their contour?

1)  Cowper’s

2)  Pectoralis

3)  Serratus

4)  Cooper’s

 

 

20)  What hormone contributes to breast development in girls at puberty?

  1. Progesterone
  2. Growth hormone
  3. Prostaglandin
  4. Placental lactogen

 

 

21) Mr. James, 52 years old, weighs 65 kg and has enlarged breast tissue. How should the nurse document this finding?

1) Mr. James is obese

2) Gynecomastia

3) Fibroadenoma

4) Galactorrhea

 

22)  What should the nurse include in a health history before doing a breast examination?

1) Number of sexual partners the woman has had

2) Age of menarche

3) The woman’s bra size

4) Age of her first sexual experience

 

23) What equipment does the nurse require to perform a clinical breast examination?

1) Sterile gloves

2) Metric ruler

3) Large pillow

4) Stethoscope

 

 

24) Mrs. Milne, 28 years old, requires a breast examination. She tells the nurse that she will not expose herself. What should the nurse do?

1) Do the examination as quickly as possible to minimize exposure

2) Have Mrs. Milne do the examination herself

3) Palpate Mrs. Milne’s breasts through the gown

4) Explore with Mrs. Milne her rationale for this decision

 

 

25) What is a normal finding when inspecting the breasts?

1) Nipples pointing upward and inward

2) 15 to 20 lobes per breast radiating from the nipple

3) Areola is specked with small papillae

4) Lumpiness of the breasts that disappears with menstruation

 

26) Mrs. Singh, 81 years old, is having a clinical breast examination.  What is a normal finding in a woman this age?

1) A decrease in adipose breast tissue

2) Increased breast firmness

3) Nipples are smaller

4) Areola is more darkly pigmented

 

 

27) Miranda, 16 years old, asks the nurse about a ‘mammary ridge’. What information should the nurse include in her answer?

1) A line from right to left axilla over the nipples

2) A ridge of breast tissue from the axilla to the umbilicus

3) The presence of breast tissue in the axilla

4) A ridge of breast tissue from the axilla to the groin

 

 

 

SHORT ANSWER.  Write the word or phrase that best completes each statement or answers the question.

 

28) A nurse is conducting a breast health workshop for a group of women.  What would the nurse include in this workshop when outlining environmental risk factors for breast cancer?  (Select all that apply.)

________Caucasian race

________Positive family history

________Low socioeconomic status

________Hormone replacement therapy

________Reaching age 35-40

 

 

 

29)  A nurse is preparing a poster on self breast examination and is labeling the anatomical structures of the breast.  Identify the area that the nurse should label as the Tail of Spence.

 

 

 

 

 

 

30) A nurse is examining the breasts of a female client.  What assessment techniques will the nurse use during this examination?  (Select all that apply.)

_______Inspection

_______Palpation

_______Percussion

_______Auscultation

 

 

====================================

 

Chapter 17

 

MULTIPLE CHOICE.  Choose the one alternative that best completes the statement or answers the question.

 

1)   What is the correct landmark for locating the point of maximal impulse?

1)   Second intercostal space, right sternal border

2)   Second intercostal space, left sternal border

3)   Third intercostal space, left sternal border

4)   Fifth intercostal space, midclavicular line

 

 

 

2)   A nurse is conducting a cardiac assessment on a healthy older adult.  What age related physiologic change would the nurse anticipate with this client?

1)   Increased resting heart rate

2)   Decreased cardiac output

3)   S4 heart sound

4)   Decreased stroke volume

 

 

3)   A client, 39 years old, has increasing fatigue with a history of rheumatic fever as a child.   The nurse hears a diastolic murmur at the apex with the client in the left lateral recumbent position.  The murmur is described as rumbling without radiation.  What condition is present?

1)   Tricuspid regurgitation

2)   Mitral regurgitation

3)   Mitral stenosis

4)   Pulmonic stenosis

 

 

4)   A nurse is assessing a client with atrial fibrillation.  What finding would the nurse anticipate?

1)   Heart rate of 58

2)   Irregular heart rhythm

3)   Elevated blood pressure

4)   Increased urine output

 

 

 

5)   A student nurse is calculating the cardiac output for a 30-year-old client. The client’s resting heart rate is 70 beats per minute with a stroke volume of 75 mls. How should the student interpret this finding?

  • The low cardiac output is consistent with an athlete.
  • This is too high for a client of this age.
  • This is expected in a healthy adult.
  • The result indicates cardiac pathology.

 

 

6)   A student nurse noted that a client had up and down head bobbing in time with the apical pulse. The student asks the instructor to explain this assessment finding. How should the instructor respond?

1)   “Bobbing is created by pulsatile waves of regurgitated blood that echo upward toward the head.”

2)   “This is the classic head bob associated with Parkinson’s disease due to a deficiency in dopamine.”

  • “A ventricular septal defect can result in a holosystolic murmur that presents as a head bob.”
  • “The abnormal pulsations occur due to a weakening of the aorta indicating an abdominal aneurysm.”

 

 

 

7)   A nurse is reviewing the history and physical for a 69-year-old client admitted with hypertension. The nurse notes the apical impulse is 2 cm in diameter and is displaced laterally.  What health issue should the nurse suspect?

1)   Left ventricular hypertrophy

2)   Ventricular tachycardia

3)   Pulmonary hypertension

4)   Myocardial infarction

 

 

8)   During a cardiac assessment of a 78-year-old client with no history of cardiovascular disease the nurse hears a soft sound directly before S1, at the apex of the heart with the bell of the stethoscope.   There is no change in this sound with position or respirations.  What should the nurse do?

1)   Notify the physician immediately because this is always an abnormal finding

2)   Document the finding as normal in older adults

3)   Obtain a 12 lead ECG as this is consistent with dysrhythmias

4)   Monitor fluid status closely due to ventricular volume overload

 

9)   A nurse is percussing a client’s heart and notes a dull sound that extends into the midaxillary region of the thorax.  What does this finding indicate?

1)   A normal finding

2)   Heart enlargement

3)   Pulmonary hypertension

4)   Aneurysm

 

 

10) What cardiac assessment finding may be present in a healthy pregnant woman at 35 weeks gestation?

1)   Atrial gallop

2)   Ejection click

3)   S3

4)   Bruit

 

 

 

11) A nurse is listening to heart sounds on a 19-year-old client. The nurse notes a splitting of S2 at the end of inspiration. How should the nurse interpret this assessment finding?

1)   A normal finding caused by the semilunar valves closing at slightly different times.

2)   An unusual finding and the physician must be notified of this result.

3)   This is also called an atrial gallop and is heard in well-conditioned athletes.

4)   This is abnormal and indicates a damaged pulmonic valve.

 

 

12) During a health history interview the nurse wants to know more about a client’s health behaviours. What question would elicit information on health behaviours?

  • “Do you experience activity intolerance?”
  • “Does your heart disease affect your ability to carry out activities of daily living?”
  • “How would you describe your personality?”
  • “Describe your weekly physical activity?”

 

 

13) A nurse is assessing a client who is 7 months pregnant.  What assessment finding would be normal for this client?

1)   Increased systolic and diastolic blood pressures when standing

2)   Apical impulse is pushed laterally and to the left

3)   Irregular heart rate

4)   Diastolic murmur

 

14) Jackson, 2 weeks old, has been diagnosed with Coarctation of the Aorta. His mother asks the nurse to explain what has happened to her son. What is the most appropriate response by the nurse?

  • “This is an opening between the aorta and the pulmonary artery that should have closed 48 hours after Jackson’s birth.”
  • “This is a complicated congenital heart defect that involves four different areas of the heart that can be fixed surgically.”
  • “This is a condition results in a narrowed artery restricting blood flow out of the left ventricle into the systemic circulation.”
  • “Jackson has a heart defect that results in oxygenated and deoxygenated blood to mix together.”

 

 

15) A client asks the nursing student to explain the purpose of the bundle branches. How should the student respond?

1)   “These fibers receive an electrical impulse from the sinoatrial (SA) node.”

2)   “Also known as the Purkinje fibers, this tissue penetrates into the heart to facilitate conduction.”

3)   “Has an intrinsic rate of 60 to100 per minute and will fire if the atrioventricular (AV) node fails.”

4)   “Are like expressways of conducting fibers that spread the electrical current to the ventricles.”

 

16) A nurse is reviewing the history on a 72-year-old client and notes the following findings:  peripheral edema, jugular venous pulsations of 6 cm above sternal angle at 45 degrees, and an enlarged liver.  What health condition is most likely present based on these assessment findings?

1)   Pulmonary edema

2)   Left-sided heart failure

3)   Myocardial infarction

4)   Right-sided heart failure

 

 

17) The cardiac auscultation on a 16-year-old reveals a splitting of the second heart sound.  The intensity varies with respirations and is only audible in the supine position.  What is the best explanation for the cause for this extra sound?

1)   Pulmonary stenosis

2)   Inspiration causes the aortic valve to close slightly faster than the pulmonic valve

  • Increased blood volume causes the mitral valve to close more forcefully

4)   Delayed ventricular contraction

 

 

18) A nurse is assessing a client with left-sided weakness and notes a loud, blowing sound over the right carotid artery.  What term should be used to document this finding?

1)   Atrial kick

2)   Thrill

3)   Cardiac index

4)   Bruit

 

19) During a cardiac assessment the nurse notes a heave across the third and fourth intercostal space at the left sternal border.  What health issue is most likely present based on this assessment finding?

1)   Left ventricular hypertrophy

2)   Right ventricular hypertrophy

3)   A normal heart

4)   Aortic regurgitation

 

 

20) A nurse is assessing a full-term newborn, 18 hours old.  What would the nurse expect to find?

1)   Heart rate of 175-180 beats per minute

2)   Heart rate of 115-120 beats per minute

3)   Blood pressure of 60/40 mm Hg

4)   Blood pressure of 100/60 mm Hg

 

21) A nurse is teaching the student nurse about heart sounds when the student asks what causes the S1 heart sound.  What is the correct response?

1)   “It results from closure of the semilunar valves.”

2)   “You hear it when there is ejection of blood from the atria.”

3)   “It results from the closure of the atrioventricular (AV) valves.”

4)   “It is due to the onset of atrial relaxation.”

 

 

22) A student nurse is inspecting a client’s chest for pulsations. How should the client be positioned to best complete this inspection?

  • Orthopneic
  • Sim’s
  • Lying prone
  • Low to mid-Fowler’s

 

 

23) What assessment technique should the nurse use to best assess a thrill?

1)   Inspection

2)   Palpation

3)   Percussion

4)   Auscultation

 

 

24) What is the correct landmark for hearing S1 the loudest?

1)   Left sternal border at 4th intercostal space

2)   Left sternal border at 2nd intercostal space

3)   Right sternal border at 2nd intercostal space

4)   Erb’s point

 

25) What is the correct landmark for hearing S2 the loudest?

1)   Left sternal border  (LSB) at fifth intercostal space

2)   Left midclavicular line at fifth intercostal space

3)   Right midclavicular line at third intercostal space

4)   Right sternal border at second intercostal space

 

 

26) A nurse has completed a cardiovascular assessment and is going to document that a ringlike structure was noted in the margin of the client’s cornea. What term should the nurse use to document this finding?

1)   Xanthelasma

2)   Arcus

3)   Noonan syndrome

4)   Presbyopia

 

 

 

27) A nurse has just completed a cardiac assessment and noted that the apical pulse was greater than the carotid pulse.  What action should the nurse take?

1)   No action required as this is a normal finding

2)   Document this as a pulse deficit

3)   Notify the physician immediately

4)   Apply a cardiac monitor

 

28) A nurse is assessing a 20-year-old client and notes the presence of bilateral earlobe creases.  What should the nurse do?

1)   Refer the client to a plastic surgeon

2)   Document this finding as normal

3)   Document the finding and alert the physician

4)   Ask the client if this is a result of piercings

 

 

29) A nurse is interviewing a client with congestive heart failure and wants to determine any recent changes in the client’s condition.  What question would the nurse ask to obtain this data?

1)   “Have you noticed an increased need to urinate at night?”

2)   “Is there any change in your usual bowel elimination?”

3)   “Are you still smoking?”

4)   “Have you experienced chest pain in the last week?”

 

 

SHORT ANSWER.  Write the word or phrase that best completes each statement or answers the question.

 

30) What assessment techniques would the nurse include in a cardiovascular examination?  (Select all that apply.)

1)   Inspection

2)   Palpation

3)   Percussion

4)   Auscultation

 

 

 

Chapter 18

 

MULTIPLE CHOICE.  Choose the one alternative that best completes the statement or answers the question.

 

1) A nurse is assessing the pulse behind the client’s knee.  What is the name of this pulse?

1)   Brachial

2)   Dorsalis pedis

3)   Popliteal

4)   Posterior tibial

 

 

2)   A nursing student is assessing the carotid pulses of a client.  What action by the student would cause the instructor to intervene?

1)   Asks the client to turn the head slightly.

2)   Pushes firmly into the side of the neck.

3)   Palpates both pulses simultaneously.

4)   Notes the rate, rhythm, and amplitude.

 

3)   A nursing student is learning blood pressure technique and asks the instructor why it is necessary to palpate the systolic pressure prior to the procedure.  How should the instructor respond?

1)   “You can record this if you cannot hear the blood pressure well.”

2)   “Only do it when your client is bradycardic.”

3)   “It helps to avoid inaccuracy when obtaining the blood pressure.”

4)   “It can tell you if there is a variance between arms.”

 

4)   While a nursing student is assessing a client’s blood pressure the client asks the nursing student what is a normal blood pressure reading.  How should the student respond?

1)   “That depends on the individual.”

2)   “A normal reading is 140/80.”

3)   “Ask the nurse looking after you.”

4)   “Normal is considered less than 120/80.”

 

 

5)   A nurse is taking the blood pressure of a client and obtains a difference of 15 mm Hg in the systolic readings between the arms.  How should the nurse interpret this finding?

1)   Inaccurate technique

2)   Arterial obstruction

3)   Client anxiety

4)   Normal findings

 

 

6)   In the assessment of a female client who is seven months pregnant, the nurse notes mild peripheral edema.  The remainder of the examination is normal.  What is the most appropriate nursing action?

1)   Notify the physician immediately

2)   Obtain an order for a diuretic

3)   Document the findings

4)   Ask the client to limit sodium intake

 

 

 

7)   A nurse is calculating a client’s ankle-brachial index (ABI). The systolic blood pressure for the dorsalis pedis is 135 mm Hg and the brachial blood pressure is 150 mm Hg. How should the nurse interpret this finding?

1)   Within normal limits

2)   Mild arterial disease

3)   Moderate arterial blockage

4)   Severe arterial disease

 

 

8)   What is the landmark for locating the epitrochlear lymph node?

1)   Behind the elbow to the groove between the bicep and tricep muscles

2)   Locate the anterior border of the axilla

3)   Palpate along the inferior and medial aspect to the inguinal ligament

4)   Posterior border of the axilla below the scapulae

 

 

9)   What equipment is required to perform the Trendelenburg test?

1)   Sphygmomanometer

2)   Doppler

3)   Stethoscope

4)   Tourniquet

 

 

10) A nurse is assessing a client admitted to the hospital for congestive heart failure and notes nonpitting edema of the left arm, as well as bilateral 1+ ankle edema.  The client’s history is positive for a myocardial infarction and left mastectomy.  What is the likely cause for the edema in the left arm?

1)   Impaired lymphatic drainage

2)   Noncompliance with medication regimen

3)   Right sided heart failure

4)   Excessive intake of sodium

 

 

 

11) A nurse is caring for an immobile client and is planning care to prevent vascular complications that may occur.  What would the nurse include in the plan of care?

1)   Meticulous skin care

2)   Turn, cough, deep breath

3)   Physical therapy for tolerated activity

4)   Increased protein intake

 

 

12) During an assessment of a client’s hand the nurse observes: flattening of the angle of the nails, rounding of the fingertips, and spongy nails with a bluish coloured nail bed.  What condition would the nurse suspect?

1)   Raynaud’s disease

2)   Nutritional deficit

3)   Venous insufficiency

4)   Chronic hypoxia

 

 

13) A nurse is caring for a client requiring arterial pressure monitoring.  The physician is preparing to place a catheter into the client’s radial artery.  Prior to this procedure, what assessment must the nurse do?

1)   Allen test

2)   Homans’ sign

3)   Corrigan’s pulse

4)   Compression test

 

 

 

14) A female client being examined by the nurse exhibits severe swelling in one entire arm, while the remaining arm is normal in size.  What question would the nurse ask the client?

1)   “How much salt do you have in your diet?”

2)   “Does the other arm swell also?”

3)   “Tell me about your past surgical procedures.”

4)   “Tell me if you feel self-conscious about your arm.”

 

 

 

15) During a health history interview the nurse wants to know more about a client’s health

behaviours. What statement would elicit information on health behaviours?

  • “Tell when you first became aware of the ankle ulcer.”
  • “Have you experienced any difficulty in achieving an erection?”
  • “Are you experiencing any side effects related to the medication?”
  • “Describe your exercise routine.”

 

 

 

16) A nurse will be auscultating Mrs. Murray’s carotid arteries. How should the nurse prepare the client for this assessment?

1)   Have the client sit on the examination table

2)   Ask the client to hold her breath for a few seconds

3)   Have the client turn her head toward the side being examined

4)   Adjust the head of the examination table to be at a 45 degree angle

 

17) During the assessment of a client with a laceration of the left third finger, the nurse notes inflammation and swelling of the finger.  What additional assessment data would the nurse anticipate finding?

1)   1cm, tender, soft, fixed, right brachial node

2)   1cm, tender, soft, mobile right brachial node

3)   2 cm, tender, firm, mobile right epitrochlear node

4)   2 cm, tender, firm, mobile right ulnar node

 

18) A nurse notes that Mrs. Wu, 45 years old, has bilateral varicose veins. What information in the client’s health history supports the nurse’s observation?

1)   Asian descent

2)   Employed as hairdresser

3)   Marathon runner

4)   Nulliparous

 

 

19) During the assessment of a client’s lower extremities, the nurse notes slight pitting edema. How should the nurse document this finding?

1)   1+

2)   2+

3)   3+

4)   4+

 

 

 

20) A nurse is assessing an elderly client with atherosclerosis.  What assessment findings would the nurse anticipate in this client?

1)   Pitting edema

2)   Carotid bruit

3)   Blood pressure of 112/58 mm Hg

4)   Peripheral pulses 4+

 

 

21) The arm blood pressures of a 4-year-old client are 108/65 left and 110/66 right.  The nurse obtains a thigh pressure of 88/48.   What condition would the nurse would suspect?

1)   Normal in young children

2)   Coarctation of the aorta

3)   Atherosclerosis

4)   Peripheral vascular disease

 

 

 

22) A client is examined for concerns of bluish discolouration of the hands and fingers.  The client states that spasms occur and the hands change colour from very red to blue.  What situation would the nurse suspect?

1)   Lymphedema

2)   Raynaud’s Disease

3)   Arterial insufficiency

4)   Venous insufficiency

 

23) A client presents with an enlargement of the inguinal lymph nodes and asks the nurse what these structures do for the body.  How should the nurse respond?

1)   “Your lymph nodes filter blood for your body.”

2)   “They are responsible for the break down of old red blood cells.”

3)   “They make antibodies for you.”

4)   “Your lymph nodes help to remove infectious organisms.”

 

 

24) A nurse is assessing capillary refill on a client and notes colour return takes 4 seconds on each great toe. How should the nurse document this finding?

1)   Normal

2)   Brisk

3)   Sluggish

4)   Absent

 

 

 

25) A nurse has just completed a peripheral vascular assessment on Mr. McKenzie, who is several days post-operative for a fractured wrist. All assessment findings are normal except the capillary refill is delayed. This is a change from the previous assessment completed two hours ago. What should the nurse do next?

  • Notify the physician immediately
  • Ask the client if he just had a smoke
  • Reassess the client in 1 hour
  • Do nothing because all other assessments are normal

 

 

SHORT ANSWER.  Write the word or phrase that best completes each statement or answers the question.

 

 

26) A client is being evaluated for lower extremity arterial insufficiency.  What assessment findings would the nurse expect to observe in this client?  (Select all that apply.)

1)   Diminished pulses

2)   Shiny skin

3)   Redness on elevation

4)   Pallor when dependent

5)   Pain

 

 

 

27) A client is being evaluated for venous insufficiency.  What assessment findings would the nurse expect to note in this client?  (Select all that apply.)

1)   Cool skin temperature

2)   Edema

3)   Thick and darkened skin

4)   Pain with rest

 

 

28) A nurse is preparing to assess a client’s peripheral vascular system. The nurse would use which of the following assessment techniques during this examination?  (Select all that apply.)

1)   Inspection

2)   Palpation

3)   Percussion

4)   Auscultation

 

 

29) What are the risk factors for the development of varicose veins?  (Select all that apply.)

1)   Polish descent

2)   Sedentary lifestyle

3)   Multiple pregnancies

4)   Obesity

 

 

 

Chapter 19

MULTIPLE CHOICE.  Choose the one alternative that best completes the statement or answers the question.

 

1)   What is the correct pattern for auscultating abdominal vascular sounds?

1)   Begin in the right lower quadrant and then move to the other quadrants

2)   Start midline below the xiphoid process and then side to side

3)   The starting point is not important as long as the whole abdomen is assessed

4)   Initiate the assessment from the right hypochondriac region

 

 

2)   A nurse is preparing to test a client for costovertebral tenderness. How should the nurse position the client for this assessment?

1)   Place in supine position with the nurse’s hand at a 90-degree angle to the abdominal wall

2)   Position on either the right or left side while the nurse percusses the abdomen

3)   Have the client raise the leg to cause flexion of the hip

4)   Have the client seated while the nurse gently taps the area

 

 

 

3)   A nurse is performing an abdominal assessment on a client.  While palpating the liver the client indicates a sharp pain in the abdomen.  What term should be used to document this finding?

1)   Blumberg’s sign

2)   Rovsing’s sign

3)   Murphy’s sign

4)   Psoas sign

 

 

4)   A nurse is assessing a client’s abdomen and notes dullness when percussing over the left lower quadrant. What would be the most appropriate question to ask the client?

1)   “Do you take fiber tablets?”

2)   “Do you have pain after eating?”

3)   “When was your last bowel movement?”

4)   “Have you ever had splenomegaly?”

 

 

 

5)   A nurse is percussing the liver and notes that the liver span is approximately 7 cm.  How should the nurse document this finding?

1)   Liver enlargement

2)   Normal

3)   Ascites

4)   Liver displacement

 

 

6)   A nurse is completing an abdominal assessment and is percussing over the stomach.  What would the nurse expect to find?

1)   Dullness

2)   Flatness

3)   Tympany

4)   Resonance

 

 

7)   What is the landmark for McBurney’s point?

1)   Midline below the xiphoid process

2)   3cm lateral to the right hypochondriac region

3)   Midaxillary line between the sixth and tenth intercostal spaces

4)   2.5 to 5 cm above the anterosuperior iliac spine

 

8)   During a health history interview the nurse wants to know more about a client’s health behaviours. What question would elicit information on health behaviours?

1)   “How much coffee do you consume in a 24-hour period?”

2)   “Have you recently travelled to a developing country?”

3)   “Have you experienced a change in bowel habits?”

4)   “Does your illness affect your ability to carry out activities of daily living?”

 

 

9)  A nurse is preparing to assess a client’s abdomen. What assessment technique should be used last during this examination?

1)   Inspection

2)   Percussion

3)   Palpation

4)   Auscultation

 

 

10) During the auscultation of a client’s abdomen the nurse notes a loud, long, consistent sound followed with several seconds of rumbling. What is the most accurate way to document this finding?

1)   Borborygmi

2)   Cheilosis

3)   Bruit

4)   Normal bowel sounds

 

 

11) A nurse places a client with advanced metastatic cancer in the lateral position to begin percussion of the abdomen. What finding would the nurse expect in this situation?

1)   Tympany at the superior level and dullness at lower levels

2)   Tympany throughout the abdomen

3)   Dullness over all abdominal organs

4)   Dullness at superior level and tympany at lower levels

 

 

12) A nurse is teaching a pregnant client how to reduce nausea and vomiting.  What information should be included in the teaching plan?

1)   Eat fewer, small meals of vegetable soup

2)   Limit intake of raw fruits and vegetables

3)   Increase intake of dairy products

4)   Eat frequent, small meals of dry foods

 

 

13) During the auscultation of a client’s abdomen the client states “something must be wrong — you’ve been listening for an extremely long time!” How should the nurse respond?

1)   “Shhhh, I am trying to listen.”

2)   “I’m not sure what I’m listening to.”

3)   “Now I have to start counting all over again.”

4)   “I need to listen over all the major areas of your stomach area.”

 

 

14) A nurse is conducting a health history on a client recently diagnosed with Hepatitis E (HEV).  What piece of client health history is congruent with the diagnosis of HEV?

1)   Intravenous drug use

2)   Travel throughout Africa

3)   Unprotected sexual intercourse

4)   Numerous tattoos

 

 

15) A nurse is palpating the spleen of a young adult male with infectious mononucleosis.  How should the nurse approach this assessment?

1)   Palpate under the lower portion of the eleven and twelve ribs

2)   Must be done with light followed by deep palpation

3)   Must be performed with the client’s breath held

4)   This should be done carefully

 

 

 

16) A nurse palpates the abdominal aorta of an adult client and finds that it measures approximately 5 cm in diameter. What should the nurse do next?

1)   Discontinue palpation

2)   Apply deep palpation inferiorly

3)   Continue to palpate just under the xiphoid process

4)   Auscultate for bruits

 

 

17) A nurse is auscultating a client’s abdomen for bowel sounds, and no sounds have been detected for at least 2 minutes. What action should the nurse take?

1)   Give the client something to eat or drink

2)   Document bowel sounds as absent

3)   Continue listening for an additional 3 minutes

4)   Document this finding as normal

 

 

18) A nurse is assessing a client who reports a sudden onset of right lower quadrant pain.  The nurse obtains a positive psoas sign. What condition should the nurse suspect based on this data?

1)   Constipation

2)   Appendicitis

3)   Cholecystitis

4)   Bowel obstruction

 

19) A client asks the nurse, “What’s the purpose of my pancreas?”  How should the nurse respond?

1)   “You can’t live without one.”

2)   “It increases your blood sugar when needed.”

3)   “It produces digestive enzymes.”

4)   “I am not sure.”

 

 

20) A nurse is conducting an educational session for a group of well seniors.  What information would be appropriate to promote digestive health in this population?

1)   Eating only soft foods

2)   Decrease roughage

  • Increasing protein intake
  • Include daily exercise

 

 

21) A nurse is assessing an infant and notes a bulging area in the umbilicus.  What condition would the nurse suspect?

1)   Infection

2)   Umbilical hernia

3)   Ventral hernia

4)   Hiatal hernias

 

 

22) A nurse is assessing a client’s abdomen and notes loud, high-pitched, rushing, bowel sounds with auscultation.  How should the nurse document these bowel sounds?

1)   Hyperactive

2)   Bruits

3)   Boborygmi

4)   Normal

 

 

 

23) A nurse is caring for a client in the first trimester of pregnancy. The client asks the nurse why she is experiencing nausea and vomiting.  What is the most appropriate response by the nurse?

1)   “You must not be eating correctly.”

2)   “Your hormonal levels are changing.”

3)   “The baby is pushing up on your stomach.”

4)   “You need to ask your obstetrician.”

 

 

24) A nurse is auscultating the abdomen of a client and notes a continuous hum around the umbilicus and epigastric area.  What would the nurse suspect as the causative factor of this hum?

1)   Gastroenteritis

2)   Paralytic ileus

3)   Portal hypertension

4)   Aortic stenosis

 

 

25) A nurse is interviewing a client who reports abdominal pain and belching at bedtime. What priority question should the nurse ask in the interview?

1)   “Do you eat fatty foods?”

2)   “Do you take antacids?”

3)   “How soon after eating do you go to bed?”

4)   “Are you ever constipated at night?”

 

 

26) A nurse is performing an abdominal assessment and notes ascites.  What should the nurse do next?

1)   Obtain a stool specimen for occult blood

2)   Measure abdominal girth

3)   Document

4)   Notify the physician

 

 

 

27) A nurse is assessing a toddler when the mother asks if the child’s abdomen should be so round and large.  How should the nurse respond?

1)   “There is no reason for you to be concerned.”

2)   “How often does the child have a bowel movement?”

3)   “What do your other children look like?”

4)   “This is normal for children of this age.”

 

 

28) Ms. Blomvist has esophageal cancer and reports pain with swallowing. How should the nurse document this information?

  • Dysphagia
  • Dysphasia
  • Odynophagia
  • Oligodactyly

 

 

SHORT ANSWER.  Write the word or phrase that best completes each statement or answers the question.

 

29) A nurse is completing discharge instructions on a client admitted with esophagitis.  What are the triggers for esophagitis?  (Select all that apply.)

__________Smoking

__________Alcohol

__________Hot and cold fluids

__________High fat foods

 

 

30) A nurse is planning an abdominal assessment for a client.  Rank these assessment steps in the order the nurse would perform them. (Use numbers 1 through 5.)

_________ Percuss over the solid organs

_________ Auscultate for hyper or hypoactive bowel sounds

_________ Auscultate for bruits

_________ Visualize the abdominal quadrants

_________ Shine a light across the abdomen assessing for hernias

 

 

31) A nurse is palpating the right upper quadrant of a client’s abdomen.  What structures would the nurse examine?  (Select all that apply.)

_________Liver

_________Gallbladder

_________Sigmoid colon

_________Stomach

_________Tail of pancreas

 

 

32) A nurse is mapping the client’s abdomen into four quadrants.  What are the landmarks the nurse would use to perform this assessment?  (Select all that apply.)

__________Xiphoid process

__________Umbilicus

__________Lower border of the left ribs

__________Lower border of the right ribs

 

 

 

Chapter 20

 

MULTIPLE CHOICE.  Choose the one alternative that best completes the statement or answers the question.

 

1)   A nurse is interviewing an elderly client who reports having incontinence. Numerous attempts have been made in the recent past to help control the problem, with no success. What is a priority nursing diagnosis to consider for this client?

1)   Skin integrity impairment

2)   Self-care deficit

3)   Self-esteem, low

4)   Infection

 

 

2)   A nurse is collecting a urine specimen from a client and notes the urine is cloudy and has a strong odor. What situation would the nurse suspect?

1)   Kidney stones

2)   Renal failure

3)   Urinary tract infection

4)   Liver disease

 

 

3)   A nurse is caring for an infant recently diagnosed with renal disease.  What other body part will need to be evaluated?

1)   Ears

2)   Heart

3)   Lungs

4)   Joints

 

 

4)   A nurse is admitting a client who has constant, severe flank pain, spasms, nausea and vomiting, and oliguria. The client states that the pain was initially intermittent and radiated from the low back to the lower quadrants of the abdomen. What should the nurse do next?

1)   Administer pain medication

2)   Notify the physician immediately

3)   Obtain a urine specimen for culture

4)   Give an antiemetic

 

 

 

5)   A nurse is palpating the flank area and feels a sharp edge with clearly delineated margins.  What is the nurse palpating?

1)   Spleen

2)   Kidney

3)   Colon

4)   Bladder

 

 

6)   A nurse is assessing a client and needs to palpate the bladder. What instructions should the nurse provide the client?

1)   “Please do not void prior to the examination.”

2)   “Take a deep breath and hold it during the exam.”

3)   “Inhale and exhale throughout the exam.”

4)   “Please be sure to urinate prior to the examination.”

 

 

7)   A nurse is percussing over the client’s bladder and notes a dull tone. How should the nurse interpret this data?

1)   An empty bladder

2)   A full bladder

3)   A bladder tumor

4)   Air trapped in the intestines

 

 

8)   A client has a spinal cord injury with paralysis at C5 level. When completing discharge teaching, what client statement would prompt the nurse to do further teaching?

1)   “I need to perform self-catheterization three times daily.”

2)   “I know I cannot look to see if my bladder is full.”

3)   “I need to avoid bladder distension.”

4)   “I’ll drink adequate amounts of liquids.”

 

 

9)   A nurse is interviewing the parents of a toddler who state they are concerned about the child’s bedwetting. What is the best response by the nurse?

1)   “Take your child to the bathroom once during the night.”

2)   “Don’t worry; all children wet the bed.”

3)   “We’ll run a specimen to check for a urinary tract infection.”

4)   “This problem will be gone at the age of 4.”

 

 

10) During the assessment of a client with multiple injuries, the nurse notices a large hematoma located at the left costovertebral angle. What is the first body structure the nurse would assess?

1)   Kidney

2)   Ribs

3)   Intestines

4)   Bladder

 

 

 

11) A nurse is caring for a client admitted with an infection of the ureters. What other structure could be involved with this infection?

1)   Capsule

2)   Cortex

3)   Medulla

4)   Pelvis

 

 

 

 

12) A client has been diagnosed with azotemia. What assessment finding will the nurse anticipate being present?

1)   Hematuria

2)   Confusion

3)   Increase urine output

4)   Decreased sensation of thirst

 

 

 

13) A nurse is assessing an infant and notices that the urinary meatus is located on the top side of the penis. What term will the nurse use to document this finding?

1)   Exstrophy

2)   Epispadias

3)   Hypospadias

4)   Cryptorchidism

 

 

14) What is a common urinary system change for postmenopausal women?

1)   Decreased alkalinity of the urinary tract

2)   Less urinary tract infections

3)   Increase in nighttime urination

4)   Increased urine leakage

 

 

15) A nurse is teaching a client in a bladder retraining program about the capacity of the bladder. How many milliliters of urine would the cause the bladder to rise above the symphysis pubis?

1)   100

2)   250

3)   375

4)   550

 

16) A nurse is preparing to catheterize a client after the client just independently voided. What is the purpose of this catheterization?

1)   Serve as a urine output baseline.

2)   Support the diagnosis of kidney stones.

3)   Evaluate the ability of the bladder to empty urine.

4)   Evaluate renal function.

 

 

 

17) Anne, 15 years old, visits the school nurse to ask why she is getting frequent urinary tract infections. What question would the nurse ask the client during this visit?

1)   “Are you bathing enough?”

2)   “Do you drink a lot of cokes?”

3)   “Does the water in your area have a high mineral content?”

4)   “What direction do you wipe after a bowel movement?”

 

18) A postpartum client who had a difficult vaginal delivery 36 hours ago tells the nurse she has not needed to void much since delivery.  How should the nurse respond?

1)   “Your bladder is swollen, which makes you feel like you don’t have to urinate.”

2)   “You must be overdoing it with your activity level so soon after delivery.”

3)   “I need to catheterize you immediately.”

4)   “The baby is no longer pressing on the bladder and thus it can hold more urine.”

 

 

19) A nurse is educating a group of older adults on urinary health. What information would be important to provide to the participants?

1)   Drink fluids even if you are not thirsty

2)   Limit fluids throughout the day

3)   Increase medication dosages

4)   Eat foods high in potassium

 

20) During the assessment of a client’s urinary system, the nurse learns the client has painful urination. How should this information be documented?

1)   Dysuria

2)   Hematuria

3)   Oliguria

4)   Polyuria

 

21) A nurse is interviewing Mrs. Davis, who states she has urinary incontinence with coughing and sneezing.  How should the nurse document this type of incontinence?

1)   Functional

2)   Reflex

3)   Stress

4)   Urge

 

22) What is the landmark for palpating the kidneys through the abdominal wall?

1)   Costoverterbral angle

2)   Symphysis pubis

3)   Iliac crests

4)   Rectus abdominis

 

 

23) A nurse is auscultating the renal arteries on a 15-year-old client and hears a “whooshing.” How should the nurse interpret this finding?

1)   Nothing is abnormal

2)   Polycystic kidney disease

3)   Chronic renal failure

4)   Renal artery stenosis

 

 

24) During the assessment of a client’s renal system, the nurse is unable to palpate the kidneys. How would the nurse document this finding?

1)   Inflammation

2)   Acute renal disease

3)   Normal

4)   Polycystic kidney disease

 

 

25) A nurse is assessing a client after a motor vehicle accident and notes the presence of ecchymosis in the left flank area.  How should the nurse interpret this finding?

1)   Positive Grey Turner’s sign

2)   Costovertebral angle tenderness

3)   Possible clotting dysfunction

4)   Precursor to hematuria

 

 

 

SHORT ANSWER.  Write the word or phrase that best completes each statement or answers the question.

 

26) A nurse is interviewing a client regarding urinary health. Which questions would the nurse include during the collection of subjective data? (Select all that apply.)

________ “Do you have difficulty starting your stream of urine?”

________ “After you urinate, does your bladder feel full or empty?”

________ “Do you ever have an accident or wet yourself when you sneeze?”

________ “Do you have to hurry to the bathroom when you have to urinate?”

 

 

27) A nurse is assessing a client admitted for oliguria of unknown origin.  What factors affect urine output?  (Select all that apply.)

_______Bladder size

_______Bowel patterns

_______Medications

_______Anxiety

_______Fluid intake

 

 

 

 

28) A client presents with a medical diagnosis of uremia. What symptoms would the nurse anticipate finding? (Select all that apply.)

_______ Itching

_______ Weight loss

_______ Altered mental status

_______ Fluid retention

_______ Hyperkalemia

_______ Insomnia

 

 

29) A nurse is preparing to assess the urinary system of a client.  What assessment techniques would the nurse use in this examination?  (Select all that apply.)

_______Inspection

_______Palpation

_______Percussion

_______Auscultation

 

 

 

30) An elderly female client is demonstrating signs of bladder dysfunction. What are the characteristics of age-related bladder changes? (Select all that apply.)

1)   Decreased blood flow

2)   Urinary retention is more common

3)   Increase in urinary frequency

4)   Increased risk of hyponatremia

 

 

 

Chapter 21

 

MULTIPLE CHOICE.  Choose the one alternative that best completes the statement or answers the question.

 

1)   A nurse has completed testicular self-examination teaching for a male client.  Which statement if made by the client would indicate the need for further instruction?

1)   “I should feel hardened areas where the testicles and epididymis are located.”

2)   “I should perform this examination monthly.”

3)   “I should be in a warm room or the shower to perform this exam.”

4)   “I should apply gentle pressure to each testicle to feel the area.”

 

 

 

2)   A nurse is assessing a male infant and notes only one testis.  The mother asks what effect this will have on the child.  What would be a correct response by the nurse?

1)   “There will be a need for testosterone replacement therapy.”

2)   “He will be unable to father children.”

3)   “He will do fine and have no problems”.

4)   “There will be a normal level of sperm production.”

 

3)   A nurse is assessing a male client who has epididymitis.  How should the nurse explain the diagnosis to the client?

1)   “You will have a decrease in testosterone production.”

2)   “Your sperm maturity may be affected.”

3)   “There will be a decrease in blood flow to your penis.”

4)   “There may be erectile difficulties.”

 

 

4)   During the examination of an elderly male the nurse notes thin, gray pubic hairs and a scrotal sac that hangs significantly lower than the penis.  What action should the nurse take?

1)   Document the findings as normal

2)   Inform the client that he is no longer fertile

3)   Notify the physician of the findings

4)   Ask the client about his sexual practices

 

5)   During the routine assessment on a two-year-old male the nurse notes that the testes are not descended.  What action should the nurse take?

1)   Report the finding to the physician

2)   Ask the parents if the child plays with his genitals

3)   Proceed with palpation of the scrotum

4)   Inquire about the child’s voiding patterns

 

 

6)   During the examination of a male client’s scrotum the nurse detects a hardened area in the right side of the scrotal sac.  What should the nurse do next?

1)   Ask the client about voiding patterns

2)   Notify the physician of this finding

3)   Use a light to perform transillumination

4)   Ask the client about a history of sexually transmitted infections

 

7)   During the examination of a male client who has not been circumcised, the nurse attempts to retract the foreskin of the penis, but the skin is very tight and cannot be retracted.  How should the nurse document this finding?

1)   Urethral stricture

2)   Paraphimosis

3)   Urethritis

4)   Phimosis

 

 

 

8)   During the examination of a male child the nurse notes that the urinary meatus appears on the under side of the glans penis about 5 mm from the tip.  How would the nurse document this finding?

1)   Hypospadias

2)   Normal finding

3)   Epispadias

4)   Paraphimosis

 

 

 

9)   During the examination of a male client, the nurse detects a bulge in the right inguinal area as the client is bearing down.  How should the nurse interpret these findings?

1)   Varicocele

2)   Prostatitis

3)   Cremasteric reflex

4)   Hernia

 

 

 

10) A nurse is interviewing a male client who states “I feel like I have a bag of worms in my scrotum.”  What conclusion can the nurse draw from this statement?

1)   Orchitis

2)   Varicocele

3)   Epididymitis

4)   Hernia

 

 

11) Mr. Barton, 52 years old, is scheduled for a prostatectomy. What assessment finding might the nurse observe in Mr. Barton?

1)   Enlargement of the scrotal sac

2)   Decrease in prostatic specific antigen (PSA)

3)   Lower back pain

4)   Difficulty in initiating urine stream

 

 

12) The mother of a toddler expresses concern over her son “constantly playing with his penis and scrotum.”  How should the nurse address the mother’s concern?

1)   “These practices are normal for a toddler.”

2)   “He has likely seen someone else doing this.”

3)   “Does he know what it means to be a boy or a girl?”

4)   “These bahaviours will go away once he gets older.”

 

 

 

13) An elderly client tells the nurse that he has no desire to have sex.  What should be the nurse’s initial response?

1)   “What medications are you taking?”

2)   “Are you happily married?”

3)   “How often would you like to have sex?”

4)   “Tell me how you view a satisfying sexual relationship.”

 

 

 

14) During the examination of an adult male the nurse notes thick, curly hair over the pubis area, a pear-shaped scrotum, and slightly darkened skin on the penis.  What action should the nurse take?

1)   Ask the client about childhood illnesses

2)   Inquire about the client’s sexual practices

3)   Notify the physician of the findings

4)   Document the findings as normal

 

 

 

15) While performing prostate palpation, the nurse notes that the client expresses severe tenderness and discomfort during the procedure.  What condition should the nurse suspect based on these findings?

1)   Prostate cancer

2)   Prostatitis

3)   Enlargement of the prostate

4)   Urinary tract infection

 

 

 

16) A couple is seeking infertility information from the nurse.  What statement made by the couple would indicate the need for intervention by the nurse?

1)   “We have been to two doctors already.”

2)   “We have intercourse at least three times a week.”

3)   “We are using temperature tracking for ovulation prediction.”

4)   “We have been trying to conceive for a year.”

 

 

17) A nurse is examining a male client’s genitalia and notices the scrotum is asymmetric, with the left side hanging lower than the right side.  What action should the nurse take?

1)   Reassess after increasing the temperature in the room

2)   Report the finding to the physician

3)   Proceed with palpation of the scrotum

4)   Ask if the client has sustained an injury to the scrotum

 

 

 

18) Mr. VanBeek, 28 years old, tells the nurse he has decreased libido. The nurse tells him that the results of a semen analysis show a diminished sperm count.  What question should the nurse ask Mr. VanBeek?

1)   “How often do you masturbate?”

2)   “Do you smoke?”

3)   “How old is your present house?”

4)   “Are you married?”

 

 

19) A nurse is interviewing a male client with an elevated prostate specific antigen level (PSA).What are the risk factors for prostate cancer?

1)   A positive family history for prostate cancer

2)   Masturbation

3)   Frequent sexual intercourse

4)   Drinking beer

 

 

 

20) During the health history, a male client describes his erection and ejaculate in terms that are less than professional. What should the nurse do?

1)   Ask the client to refrain from using offensive language.

2)   Ask the client to define the terms.

3)   Document the client’s responses in the terms used.

4)   Find another nurse to complete the assessment.

 

 

21) A nurse is preparing to examine a male client’s reproductive organs. What should the nurse do in preparation for this examination?

1)    Use clean hands for the examination

2)   Ask the client to lie down on the examination table

3)   Ensure the room’s temperature is cool and comfortable

4)   Ask the client to empty his bladder

 

 

22) A nurse is examining a male client and notes small clusters of vesicular lesions on the glans penis.  The client states the area is painful and often reddened.  How should the nurse interpret these findings?

1)   Carcinoma

2)   Genital warts

3)   Syphilis

4)   Genital herpes

 

 

 

23) A nurse is examining a male adolescent with suspected spermatic cord torsion.  What would be the nurse’s priority intervention?

1)   Administer an analgesic as ordered

2)   Prepare for surgery

3)   Elevate the scrotum

4)   Administer anti-inflammatory medication, if ordered

 

 

24) A nurse is conducting a health history on an 18-year-old male. What would be an appropriate question for the nurse to ask?

1)  “Do you and your girlfriend use birth control?”

2)  “Are you sexually active?”

3)  “Have you ever had measles?”

4)  “What is you sexual relationship with your girlfriend?”

 

 

25)  The mother of a 5-month-old male infant asks the nurse how to retract her son’s foreskin. What should the nurse tell the mother?

1)  Demonstrate the procedure to the mother.

2)  Explain the procedure to the mother as she retracts the foreskin.

3)  Tell the mother it is too soon to retract the foreskin.

4)  Suggest to the mother to have her husband do this.

 

 

26)  Simon, 7 years old, is developing pubic hair. His parents are concerned and ask the nurse for advice. How should the nurse respond?

1)  “Some boys develop earlier than others.”

2)  “Make an appointment with your physician as soon as possible.”

3)  “Have you talked to your son about his sexual development.”

4)  “How do his friends feel about these changes?”

 

 

 

27)  A nurse taught a group of adolescent males about sexually transmitted infections (STI). What response would indicate that additional teaching is required?

1)  “I guess I better start using condoms.”

2)  “So I just need to remember who I had sex with for the past month.”

3)  “Gee, I have to wait another week to have sex after I finish being treated.”

4)  “I guess I can’t double the dose of the medication to get better faster.”

 

 

28)  What should be inspected in an assessment of the male reproductive system?

1)  Epididymis

2)  Bulbourethral Gland

3)  Prostate Gland

4)  Inguinal region

 

 

29)  What equipment is normally required to assess the male reproductive system?

1)  Sterile gloves

2)  Flashlight

3)  Measuring tape

4)  Pubic hair comb

 

 

30)  What is the landmark for palpating the spermatic cord?

1)  Posterior side of each testicle

2)  Anterior side of each testicle

3)  Above each testicle

4)  Between the base of the scrotal sac and the testicle

 

 

SHORT ANSWER.  Write the word or phrase that best completes each statement or answers the question.

 

 

31) The nurse is preparing a presentation on testicular cancer and wishes to target the age group most frequently affected.  Which group (s) should the nurse schedule for this presentation? (Select all that apply.)

1)   Elementary schools

2)   Post-secondary institutions

3)   Senior Action Centers

4)   High schools

 

 

 

32) What assessment techniques would the nurse use to examine the male reproductive system?  (Select all that apply.)

1)   Inspection

2)   Palpation

3)   Percussion

4)   Transillumination

 

 

 

Chapter 22

 

 

MULTIPLE CHOICE.  Choose the one alternative that best completes the statement or answers the question.

 

1)   A nurse is examining the external genitalia of a female client and notes raised, cauliflower-shaped papules.  What conclusion can the nurse make based on these findings?

1)   Genital warts

2)   Herpes infection

3)   Bartholin’s abscess

4)   Contact dermatitis

 

 

 

2)   A nurse suspects a gonorrheal infection in a client during an examination.  What is the priority nursing action?

1)   Counsel regarding safe sex practices

2)   Obtain history of sexual contacts

3)   Take a swab for culture and sensitivity

4)   Document the findings

 

 

3)   A nurse is providing education on menopause to a group of female clients.  What statement made by a client would indicate the need for further instruction?

1)   “I will have gone through menopause once I have not had a period for 2 years.”

2)   “Night sweats and hot flashes are commonly experienced.”

3)   “My mood changes are a normal part of menopause.”

4)   “I should consider using a vaginal lubricant.”

 

4)   While examining a female client, a nurse notes reddened areas on the labia and a discharge that is white and curd-like in the vaginal canal.  What should the nurse suspect based on these findings?

1)   Chlamydia

2)   Candidiasis

3)   Herpes infection

4)   Trichomoniasis

5)   What statement made by an elderly client would require intervention by the nurse?

1)   “I use a lubricant for sex to help with dryness.”

2)   “I take hormone pills to help with my hot flashes.”

3)   “At times it hurts when I have intercourse.”

4)   “I don’t have a desire for sex very often, but neither does my partner.”

 

 

6)   A nurse reads in the client’s history and physical the presence of a nontender protrusion into the anterior vaginal wall.  What condition would the nurse suspect?

1)   Skene’s infection

2)   Prolapsed uterus

3)   Rectocele

4)   Cystocele

 

 

7)   During an inspection of the perineum the nurse notices a protrusion from the vagina.  What conclusion can the nurse make from this observation?

1)   Uterine prolapse

2)   Bartholin’s gland infection

3)   Cystocele

4)   Rectocele

 

 

 

8)   A female client reports a grayish discharge with a fishy odor.  What condition should the nurse suspect?

1)   Bacterial vaginosis

2)   Chlamydia

3)   Genital warts

4)   Gonorrhea

 

 

 

9)   Annette, 17 years old, tells the nurse that she has a frothy, yellow-green discharge.  What condition should the nurse suspect?

1)   Vaginitis

2)   Trichomoniasis

3)   Gonorrhea

4)   Chlamydia

 

 

 

10) A nurse is performing a bimanual examination on an extremely obese client and is unable to palpate the uterus.  What action should the nurse take?

1)   Defer the examination

2)   Ask another nurse to perform the examination.

3)   Discuss obtaining an ultrasound with the physician

4)   Ask the client if they have had recent problems

 

 

11) A nurse is examining the external genitalia of a female client and notes small vesicular lesions that are painful.  What conclusion should the nurse make from these findings?

1)   Genital warts

2)   Herpes infection

3)   Bartholin’s abscess

4)   Contact dermatitis

 

 

 

12) A nurse is examining the external genitalia of a female client and notes a nontender papule.  The nurse would suspect which condition in this situation?

1)   Human papillomavirus

2)   Syphilitic lesion

3)   Herpes infection

4)   Contact dermatitis

 

 

 

13) Ms. LaRosa, 28 years old, reports a greenish discharge with a foul odor.  She is guarding her abdomen.  What condition should the nurse suspect in Ms. LaRosa?

1)   Trichomoniasis

2)   Herpes infection

3)   Gonorrhea

4)   Bacterial vaginosis

 

 

 

14) A nurse notes a forward tilted uterus with a downward tilted cervix when examining a female client.  What term should the nurse use to document this finding?

1)   Anteflexion

2)   Retroflexion

3)   Anteversion

4)   Uterine descensus

 

 

 

15) Ms. Horton, 35 years old, tells the nurse that she has a very heavy flow during her menses. She also states she has urinary frequency. Upon examination the nurse finds that the uterus is slightly enlarged.  What conclusion should the nurse draw from these findings?

1)   Pregnancy

2)   Bladder infection

3)   Fibroids

4)   Ovarian cancer

 

 

 

16) A nurse is examining an elderly client and palpates a mobile, smooth, round-shaped area in the left lower abdominal quadrant.  What action should the nurse do next?

1)   Ask the client if she is menstruating

2)   Report the findings to the physician

3)   Re-examine the area using a vaginal speculum

4)   Ask the client if she could be pregnant

 

17) Aime, 15 years old, is having a physical examination. The nurse notes Aime has no pubic hair. What should the nurse do first?

1)   Ask Aime if she is taking the birth control pill

2)   Examine the client for breast buds

3)   Report the findings to the physician

4)   Document the findings

 

 

 

18) A nurse is examining an adult female and notes thick, course, pubic hair covering the pubis and extending to the thighs.  What action should the nurse take?

1)   Ask the client if she has started menstruation

2)   Report the findings to the physician

3)   Document the findings as normal

4)   Ask the client if she is sexually active

 

 

 

19) A nurse is examining a pregnant client and notes the cervix is soft in texture and nontender.  How would the nurse document this finding?

1)   Nabothian cyst

2)   Chadwick’s sign

3)   Cervical cancer

4)   Goodell’s sign

 

 

20) What landmark should the nurse use when assessing the Skene’s glands?

1)   Posterior to the urethra

2)   Beside the vaginal opening

3)   Between the clitoris and urethra

4)   Posterior to the vaginal opening

 

 

 

21) A nurse is performing a gynecological examination and is ready to insert the speculum into the vagina.  How should the nurse insert the speculum?

1)   90 degree angle

2)   45 degree angle

3)   Straight down

4)   Straight up

 

 

22) A nurse is performing a vaginal examination, which includes a cervical scrape, on a client who has had a hysterectomy.  What should the nurse do in this situation?

1)   Inform the client cervical scrapes will no longer be required

2)   Scrape the vaginal wall to obtain a specimen

3)   Tell the client she will not need a vaginal examination in the future

4)   Use the surgical stump for the cervical scrape

 

 

23)  What factor may increase a woman’s risk for cervical cancer?

1)  Obesity

2)  Family history of cancer

3)  History of gonorrhea

4)  Having only 6 to 10 sexual partners in a lifetime

 

 

24)  A nurse is teaching a women’s group about ovarian cancer. What risk factor should the nurse include in the presentation?

1)  Having more than 2 children

2)  History of birth control use

3)  Using baby powder in the perineal area

4)  Having cervical cancer

 

 

25)  Ms. O’Hara, 26 years old, is to have her first Papanicolaou test (Pap test) in the morning. What should the nurse tell Ms. O’Hara to help her prepare for the test?

1)  Ask Ms. O’Hara to douche before going to bed

2)  A gel like lubricant will be used to make insertion easier

3)  Teach relaxation exercises to help Ms. O’Hara deal with the pain

4)  Ask Ms. O’Hara if her vagina is inflamed

 

 

 

26)  Kaitlyn, 17 years old, is having a vaginal examination. The nurse notes that the cervix is soft and the cervix and vagina has a bluish discolouration. What should the nurse do next?

1)  Take a culture for sexually transmitted infections

2)  Ask Kaitlyn if she has had rough sexual relations in the past 24 hours

3)  Discuss with Kaitlyn the possibility of pregnancy

4)  Inquire whether Kaitlyn’s mother used diethylstilbestrol when pregnant

 

 

27)  A nurse is asked to teach a group of women about Pelvic Inflammatory Disease (PID). What risk factors for PID should the nurse include in her presentation?

1)  Use of condoms

2)  Frequent douching

3)  Limiting the number of partners.

4)  Using the birth control pill

 

 

28)  A nurse is completing a health history on a 21-year-old female client. What is the best question to ask about health practices and health behaviours?

1)  “Do you use birth control?”

2)  “Have you ever been forced to have sexual relations?”

3)  “How do you protect yourself from sexual transmitted infections?”

4)  “Do you drink or use drugs?”

 

 

 

SHORT ANSWER.  Write the word or phrase that best completes each statement or answers the question.

 

29) A nurse is preparing to assess a female client’s external genitalia. What structures would be included in this examination? (Select all that apply.)

1)   Vagina

2)   Cervix

3)   Clitoris

4)   Labia majora

5)   Labia minora

 

 

 

30) A nurse is preparing to examine the reproductive system of a female client.  The nurse would anticipate using which assessment techniques?  (Select all that apply.)

1)   Inspection

2)   Palpation

3)   Percussion

4)   Auscultation

 

 

31) A nurse is preparing to perform an endocervical swab. What equipment will the nurse require to collect this specimen.  (Select all that apply.)

1)   Microscopic slides

2)   Saline

3)   Cytobrush

4)   Cotton applicator

 

 

 

Chapter 23

 

MULTIPLE CHOICE.  Choose the one alternative that best completes the statement or answers the question.

 

1)   Ms. Delmonte, 30 years old, tells the nurse she has a non-painful lump on her left wrist. The nurse notes a round mass on the back of the wrist.  What condition should the nurse suspect?

1)   Rheumatoid arthritis

2)   Osteoarthritis

3)   Ganglion

4)   Carpal tunnel syndrome

 

 

2)   What technique is used in assessing the musculoskeletal system?

1)   Inspection

2)   Conduction

3)   Percussion

4)   Transillumination

 

 

 

3)   Jeremy, 17 years old, is admitted with a dislocated shoulder.  He asks the nurse what this diagnosis means.  How should the nurse respond?

1)   “I cannot tell you without your doctor’s permission.”

2)   “You have a muscle tear at the shoulder.”

3)   “Your shoulder bone has come apart from the shoulder joint.”

4)   “Your shoulder is fractured and separated from the joint.”

 

4)   What instruction should the nurse provide the client in order to perform this assessment?

1)   Sit down, then stand as the nurse looks from the front of the client

2)   Stand, bend forward slowly, then to the right and left while the nurse looks from the back

3)   Bend over, stand tall, and stretch arms over the head

4)   Lie down on the abdomen so the nurse can look at the back more carefully

 

5)   A nurse assesses a client and finds that a grating sound is present when a joint is bent and straightened.  How should the nurse document this finding?

1)   Grating

2)   Grinding

3)   Crepitation

4)   Joint noise

 

 

6)   A nurse notes a child sitting in reverse tailor position during a well-child examination.  What action should the nurse take?

1)   Notify the physician so that x-rays can be obtained

2)   Explain to the parent that this can cause joint stress

3)   Continue with the examination

4)   Ask the child if this is a comfortable position

 

7)   A 38-week pregnant client is complaining of lower back pain.  The nurse notes a slight lordosis.  What action should the nurse take?

1)   Tell the client to go on bedrest

2)   Notify the physician

3)   Document the finding as normal

4)   Ask the client if she has been lifting

 

8)   What musculoskeletal change would a nurse expect in an elderly client?

1)   Difficulty with dexterity

2)   Increased bone production

3)   Risk for fractures

4)   Pain when ambulating

 

 

 

9)   The client’s chief complaint is numbness and tingling in the hands when interviewed by the nurse.  The nurse performs a Phalen’s test which is positive for pain and numbness. What would the nurse conclude from these findings?

1)   Arthritis of the wrists

2)   Carpal tunnel syndrome

3)   Crepitus of the wrists

4)   Dupuytren’s contracture

 

10) A nurse notes a grating sound when examining the knee joint.  How should the nurse correctly document this finding?

1)   Crepitus

2)   Limited motion

3)   Knee deformity

4)   Atrophy

 

 

11) A nurse notes full range of motion against gravity with full resistance when assessing muscle strength of the upper extremities in a client.  How should the nurse document this finding?

1)   Poor

2)   Normal

3)   Fair

4)   Good

 

 

12) A nurse notes swelling and tenderness of the olecranon process during palpation.  The client’s chief complaint is pain upon movement of the forearm and wrist.  What conclusion can the nurse draw from these findings?

1)   Arthritis

2)   Bursitis

3)   Epicondylitis

4)   Crepitus

 

 

13) A nurse is palpating the knee of a client and uses firm pressure to stroke the medial aspect of the knee upward while applying pressure to the lateral side and observing the medial side.  The client has expressed pain and immobility in the area.  What test has the nurse performed?

1)   Inspection

2)   Ballottement

3)   Bulge sign

4)   McMurray

 

 

14) The client’s chief complaint is pain in the foot.  The nurse notes a deviation of the great toe from the midline and crowding of the remaining toes.  There is enlargement and inflammation noted in the area.  What conclusion can the nurse make from these findings?

1)   Pes planus

2)   Gouty arthritis

3)   Hammertoe

4)   Hallux valgus

 

 

15) A nurse asks the client to pull the toes up towards the nose during an examination of the lower extremities.  What movement is the nurse assessing?

1)   Inversion

2)   Plantar flexion

3)   Eversion

4)   Dorsiflexion

 

 

16) A nurse notes an exaggerated lumbar curve while inspecting the spine of a client.  How would the nurse document this finding?

1)   Lordosis

2)   Spinal list

3)   Kyphosis

4)   Flattened curve

 

17) A nurse notes asymmetry of the iliac crests and gluteal folds while inspecting the spine of a client.  The client’s spine has a slight curvature to the right, but denies complaints of pain.  How should the nurse document these findings?

1)   Compression fracture

2)   Scoliosis

3)   Spinal list

4)   Kyphosis

 

 

18) A nurse asks the client to touch the chest with the chin during the examination.  What movement is the nurse assessing?

1)   Flexion

2)   Hyperextension

3)   Lateral flexion

4)   Rotation

 

 

19) What type of bone is the ilium?

1)   Short

2)   Hollow

3)   Flat

4)   Irregular

 

 

 

20) What bone changes might occur in the elderly client?

1)   No bone changes should be noted

2)   Increased osteoblastic activity

3)   Decreased calcium absorption

4)   Increase in bone density

 

 

 

21) A client tells the nurse of pain in the right great toe.  The nurse notes hardened nodules on the lateral aspect of the toe, as well as redness and swelling.  What conclusion can the nurse make from these findings?

1)   Bunion

2)   Synovitis

3)   Hammertoe

4)   Gout

 

 

22) What type of joint is the knee?

1)   Saddle

2)   Hinge

3)   Pivot

4)   Plane

 

 

23) Mr. Grassie tells the nurse he is unable to move his fourth and fifth fingers.  The nurse notes severe flexion in both of the affected fingers but there are no complaints of pain from Mr. Grassie.  What condition might the nurse suspect based on these findings?

1)   Dupuytren’s contracture

2)   Carpel tunnel syndrome

3)   Bursitis

4)   Osteoarthritis

 

 

24) Upon inspection of a client’s knee, the nurse notes swelling, heat, and redness of the anterior aspect of the knee.  The client reports pain in the area.  What condition might the nurse suspect?

1)   Degenerative disease

2)   Torn meniscus

3)   Osteoarthritis

4)   Prepatellar bursitis

 

 

25) A nurse is completing a health history on a client. What question relates to health behaviours?

1)   “Have you ever broken your arm?”

2)   “Have you gained any weight in the last year?”

3)   “Are you lactose intolerant?”

4)   “How many hours a day do you spend on the computer?”

 

 

26) A nurse is assessing shoulder movement of a client expressing pain.  The nurse notes that the client is unable to abduct the right arm without lifting the shoulder.  The deltoid muscle of the affected arm appears smaller than that of the other arm.  What conclusion can the nurse draw from these findings?

1)   Shoulder strain

2)   Bursitis

3)   Tendinitis

4)   Rotator cuff injury

 

 

27) A nurse is assessing a client who is experiencing wrist pain.  Upon examination the pain occurs when resistance is produced against the wrist.  What condition can the nurse suspect based on these findings?

1)   Rheumatoid arthritis

2)   Bursitis

3)   Medial epicondylitis

4)   Crepitus

 

 

28) Daniel, 16 years old, has a possible fractured femur. What finding would support this diagnosis?

1)   External rotation of the lower leg and foot

2)   Internal rotation of the lower leg and foot

3)   Limited hip internal rotation

4)   Limited hip external rotation

 

 

 

29) A nurse is assessing a client with complaints of back pain, possibly related to sciatic nerve involvement.  When would the client experience pain with this diagnosis?

1)   Sitting

2)   Leg raises

3)   Abduction

4)   Adduction

 

 

30) A nurse is assessing the musculoskeletal system of a client and notes hard knots along the back muscles bilaterally.  What would the nurse suspect?

1)   Spasmodic torticollis

2)   Muscle spasms

3)   Scoliosis

4)   Compression fracture

 

 

31)   Maddox, 1 week old, is assessed by the nurse. What is a normal finding in Maddox?

1)  Forefeet are turned outward

2)  Positive Ortolani’s sign

3)  Arches in both feet

4)  Tibial torsion

 

 

32)  What landmark is used to assess the hips?

1)  Lesser trochanter

2)  Anterior inferior iliac spine

3)  Symphysis pubis

4)  Ischial tuberosity

 

SHORT ANSWER.  Write the word or phrase that best completes each statement or answers the question.

 

33) A nurse is preparing to examine the musculoskeletal system of a client.  In what order would the nurse conduct this assessment properly?

  • Assess joints for deformities or pain
  • Inspect and palpate the bones
  • Compare the extremities for length and circumference
  • Assess gait and posture

 

 

34) A nurse is assessing a client with suspected rheumatoid arthritis.  What musculoskeletal changes would contribute to a positive diagnosis?  (Select all that apply.)

1)   Ulnar deviation

2)   Bouchard’s nodes

3)   Heberden’s nodes

4)   Swan-Neck deformity

 

 

 

35) What should be included in the teaching plan for a client with osteoarthritis?  (Select all that apply.)

1)   Obesity increases the risks of bone, muscle, and joint disorders

2)   Musculoskeletal health is influenced by the diet

3)   Exercise is important in the prevention of osteoarthritis

4)   Smoking and alcohol contribute to the development of osteoarthritis

 

 

36) What is the function of the skeletal muscles?  (Select all that apply.)

1)   Provide a body framework

2)   Provide movement

3)   Maintain posture

4)   Generate heat

 

 

 

Chapter 24

 

MULTIPLE CHOICE.  Choose the one alternative that best completes the statement or answers the question.

 

1)   A nurse is assessing a client with Parkinson’s disease.  What type of tremors would the nurse observe?

1)   Fasciculations

2)   Chorea

3)   Rhythmic shaking

4)   Athetoid movements

 

 

2)   A nurse notes that a client has difficulty with ambulation due to an unsteady gait.  The client uses a wide base to walk, has uneven steps, and tends to sway. What is the correct term to document this finding?

1)   Steppage

2)   Scissors

  • Festination

4)   Ataxia

 

 

3)   A nurse is performing the Romberg test on a client. The nurse notes the findings are normal.  What client response occurred in this situation?

1)   Swayed from side to side

2)   Had minimal swaying

3)   Gait is smooth

4)   Complete loss of balance

 

4)   A nurse is performing a neurological assessment and needs to test cranial nerves.  The nurse asks Mr. Li to close both eyes and to report when he feels a wisp of cotton touch his face.  What cranial nerve is the nurse assessing?

1)   Trigeminal,V

2)   Abducens, VI

3)   Facial, VII

4)   Optic, II

 

5)   A client reports that he has hearing loss. A nurse suspects that the client has conductive hearing dysfunction.  What test is required?

1)   Otoscopy

2)   Weber test

3)   Rinne test

4)   Audiometry

 

 

6)   A nurse is examining a client experiencing vertigo and wants to perform the Romberg test.   What instructions should the nurse provide the client?

1)   “Touch your finger to your nose alternating hands.”

2)   “Walk across the room by placing one foot in front of the other, heel to toes.”

3)   “Walk on your toes, then on your heels, then on your toes again.”

4)   “Stand with your feet together, arms at sides, and eyes open.”

 

 

7)   A nurse is reviewing the history and physical on a client and notes a history of syncope.  What intervention would the nurse implement for this client?

1)   Soft diet

2)   Seizure precautions

3)   Fall precautions

  • Move from lying to standing slowly

 

 

8)   A nurse is interviewing a client with suspected Lyme disease.  What question would be a priority in this situation?

1)   “When was your last seizure?”

2)   “Have you been hiking or camping lately?”

3)   “What has your temperature been running?”

4)   “Do you have an appetite?”

 

 

9)   A nurse is admitting a client with suspected meningitis.  During the assessment, the nurse asks the client to flex the chin down towards the chest.  The client verbalizes pain and stiffness during this action.  How would the nurse document this finding?

1)   Positive Brudzinski’s sign

2)   Neck strain

3)   Nuchal rigidity

4)   Decorticate posturing

 

 

10) A nurse needs to conduct an interview to assess the cognitive status of a client. What would be the most appropriate assessment tool to use?

1)   Addenbrooke’s Cognitive Examination

2)   Dementia Signs and Symptoms Scale

3)   Confusion Assessment Method

4)   Mini-Mental State Examination

 

 

11) A nurse is assessing the patellar reflex on a client and obtains no reflexive activity.  The client is alert and oriented.  What should the nurse do first?

1)   Document the findings as normal

2)   Notify the physician immediately

3)   Look at the medication records for central nervous system depressants

4)   Retest the reflex but use a distraction technique with the client

 

 

12) A nurse is interviewing Ms. Davis, who states that she does not have any feeling on the right side of her body.  After confirmation of this subjective data, how should the nurse document this finding?

1)   Anaesthesia

2)   Analgesia

3)   Hypalgesia

4)   Hypoesthesia

 

 

13) A nurse is performing a neurological assessment on a client and needs to use stereognosis.  What instructions should the nurse provide the client?

1)   “Tell me if you feel one or two objects touching you with your eyes closed.”

2)   “Identify the object in your hand with your eyes closed.”

3)   “Identify the number being traced in your hand with your eyes closed.”

4)   “Open and close your hand each time I tell you to.”

 

 

14) A nurse performing reflex testing on a client uses the reflex hammer to gently strike the forearm about five centimeters above the wrist.  What reflex is being tested?

1)   Brachioradialis

2)   Biceps

3)   Triceps

4)   Achilles

 

15) A nurse has assessed a client and notes diminished reflexes.  How should the nurse document this finding?

1)   4+

2)   3+

3)   2+

4)   1+

 

 

16) A nurse notes fanning of the toes when the sole of the foot is stimulated during assessment of the plantar reflex.  What is the correct way to chart this finding?

1)   Hyperreflexia

2)   Babinski response

3)   Brudzinski’s sign

4)   Nuchal rigidity

 

 

17) A nurse is interviewing a client that reports a loss of smell.  How should the nurse document this information?

1)   Nystagmus

2)   Presbyopia

3)   Anosmia

4)   Polyneuritis

 

18) A nurse is performing a neurological assessment on a client experiencing anosmia.  What cranial nerve is involved in this problem?

1)   Trochlear, IV

2)   Trigeminal, V

3)   Olfactory, I

4)   Oculomotor, III

 

 

19) A nurse is interviewing a client and notes that the left eyelid is drooping.  What term should be used to document this finding?

1)   Ptosis

2)   Nystagmus

3)   Strabismus

4)   Myopia

 

20) A nurse is assessing a 3-month-old infant and performs the Babinski reflex. The result was dorsiflexion of the great toe and fanning of other toes. What should the nurse do?

1)   Nothing this is a normal response until around 2 years of age

2)   Call the physician to report this finding

3)   Document that the infant has a Babinski reflex

4)   Retest the reflex because this is an abnormal result in a healthy infant

 

 

21) A nurse is assessing cranial nerve XI (accessory).  What instructions should the nurse provide the client?

1)   “Shrug your shoulders and turn your head against my hand.”

2)   “Stick out your tongue and move it from side to side.”

3)   “Taste these foods and decide which is sweet and which is sour.”

4)   “Smell these items and identify what they are.”

 

 

22) What piece of equipment is required to assess the abdominal reflexes?

1)   Reflex hammer

2)   Tongue blade

3)   Tuning fork

4)   Safety pin

 

 

23) A nurse instructs a client to walk heel-to-toe, then on toes, and finally on the heels.  What area of the brain is the nurse assessing?

1)   Cerebellum

2)   Cerebrum

3)   Midbrain

4)   Brainstem

 

 

24) A nurse is completing a health history on an older adult and wants to gather information on health behaviours. What question would elicit this information?

1)   “What factors seem to precipitate your headaches?”

2)   “Do you require more time to perform tasks today than perhaps 2 years ago?”

3)   “Do you use or have you ever used recreational drugs?”

4)   “When were you diagnosed with Parkinson’s disease?”

 

 

25) A nurse is observing a client’s ambulation abilities and notes a scissors gait.  What disorder should the nurse suspect based on this gait?

1)   Parkinson’s disease

2)   Multiple sclerosis

3)   Alcoholic neuritis

4)   Muscular dystrophy

 

 

SHORT ANSWER.  Write the word or phrase that best completes each statement or answers the question.

 

26) A nurse is interviewing a client with dysphagia after a recent cerebral vascular accident. How would the nurse assess the function of cranial nerves IX and X?  (Select all that apply).

1)   Ask client to protrude the tongue

2)   Use tongue blade to depress tongue

3)   Test gag reflex

4)   Observe voice for hoarseness

 

 

27) A nurse is assessing a client that experienced a head injury and assigns a Glasgow Coma Scale rating of 3.  What would be the client responses to have a score of 3?  (Select all that apply.)

1)   No response to eye opening

2)   No verbal response

3)   Pupil response sluggish

4)   No motor movement

 

28) A nurse is caring for an elderly client and has performed a neurological assessment.  What age related physiologic change(s) would the nurse anticipate with this client?  (Select all that apply.)

1)   Total loss of coordination

2)   Diminished reflexes

3)   Slower movements

4)   Decrease in sense of touch

 

 

29) A nurse is preparing a seminar on Alzheimer’s disease for a group of seniors.  What information should be included in this session?  (Select all that apply.)

1)   Incidence increases with age

2)   Causes memory loss and disorientation

3)   Occurs more commonly in men

4)   May be caused by a virus

 

30) A nurse is interviewing a client with a history of seizures.  What subjective data would the nurse collect about the origin of the seizures? (Select all that apply.)

1)   Alcohol withdrawal

2)   Traumatic injury

3)   Cerebral vascular accident

4)   Infections

 

 

 

 

Chapter 25

 

MULTIPLE CHOICE.  Choose the one alternative that best completes the statement or answers the question.

 

1)   A nurse is preparing to examine a 13-year-old client brought in by the mother.  The child appears uncomfortable throughout the interview and the mother intermittently answers questions directed at the child.  What should the nurse do?

1)   Ask the child if they would prefer to be examined without the mother present

2)   Request the mother to refrain from answering the questions

3)   Complete the examination with the mother present

4)   Insist that the mother leave the room during the exam

 

 

2)   The mother of a 5-year-old child reports “lumps in the child’s neck.”  The nurse notes enlarged, non-tender, cervical lymph nodes.  What action should the nurse take?

1)   Obtain a temperature to see if the child is febrile

2)   Take a throat culture

3)    Explain to the mother this is normal

4)   Ask the child if the throat is sore

 

 

 

 

3)   A nurse needs to assess a child’s gait and range of motion of extremities.  What should the nurse ask the child to do?

1)   “Would you please do some jumping jacks for me?”

2)   “Please hop across the room on one foot, then come back by hopping on the other foot.”

3)   “I need you to be a duck; squat and move forward while flapping your arms.”

4)   “Let me see you jump in place on both feet.”

 

 

4)   A nurse is assessing a newborn and notes that there are six fingers on the left hand.  What term would the nurse use to document this?

1)   Syndactyly

2)   Arachnodactyly

3)   Polydactyly

4)   Brachydactyly

 

 

5)   A nurse is assessing a newborn and abducts the hips and palpates the greater and lesser trochanter while flexing the hips and knees at a 90-degree angle.  What manoeuvre is the nurse performing?

1)   Barlow’s

2)   Gower’s

3)   Galeazzi’s

4)   Ortolani’s

 

6)   A nurse is examining a newborn and notes that the lateral edges of the eyes are below the level of the ear tops.  What action should the nurse take?

1)   Perform an otoscopic exam

2)   Complete an opthalmoscopic exam

3)   Obtain a plastic surgery referral

4)   Document and report the findings

 

 

7)   A nurse is assessing a newborn when the mother asks about the tiny white areas on the forehead and nose.  How should the nurse respond?

1)   “That is a Morbilliform rash.”

2)   “Those are Mongolian spots.”

3)   “Those are salmon patches.”

4)   “Those are milia.”

 

 

 

8)   A nurse notes a bluish discolouration of the hands and feet when examining a newborn infant.  What should the nurse do first?

1)   Assess the oral mucosa

2)   Assess capillary refill

3)   Applying a warm blanket

4)   Obtain a temperature

 

 

9)   The mother of a five-year-old child states that the child has to urinate at least twice during a ten-hour night of sleep.  What response should the nurse give the mother?

1)   “Does the child complain about any urinary discomfort?”

2)   “As long as the bed stays dry, don’t worry about it.”

3)   “Does the child wear pull-ups, and is the bed padded?”

4)   “A five-year-old’s bladder can only hold 90 mL to 210 mL.”

 

 

10) A nurse is interviewing the mother of a healthy six-month-old.  The mother reports a continuous watery drainage from the outer aspect of the left eye.  How would the nurse document this?

1)   Nystagmus

2)   Dacryostenosis

3)   Strabismus

4)   Esotropia

 

 

11) A nurse is performing an otoscopic examination of a three-year-old child.  What technique would the nurse use while inserting the otoscope?

1)   Pull the auricle down and back

2)   Pull the tragus down and back

3)   Pull the auricle up and back

4)   Pull the tragus up and back

 

 

12) A nurse is performing an otoscopic examination in a child and notes the child expressing pain when the tragus is pulled.  What should the nurse suspect?

1)   Ruptured tympanic membrane

2)   Otitis media

3)   Otitis media with effusion

4)   Otitis externa

 

 

 

 

13) A nurse is examining a child and notes an erythematous, edematous pharynx, tonsillar exudate, and a reddened tongue with prominent taste buds.  There are also petechial hemorrhages on the soft palate.  What order should the nurse anticipate?

1)   Saline mouth rinses

2)   Dental referral

3)   Throat culture

4)   Aspirin for pain

 

 

14) A nurse is assessing a child when the mother points out a depression in the lower part of the sternum.  How would the nurse correctly document this finding?

1)   Pectus carinatum

2)   Pectus excavatum

3)   Barrel chest

4)   Normal sternal border

 

 

15) A nurse is assessing heart sounds in a three-year-old child and notes a split S2 sound throughout the cardiac cycle.  What action should the nurse take?

1)   Auscultate for a bruit

2)   Document the findings as normal

3)   Palpate the point of maximal impulse

4)   Notify the physician

 

 

16) When discussing the current growth and development expectations with the mother of a 6-month-old infant, the mother states:  “We have bought him toys to push and walk behind so it will help him walk sooner.”  What should the nurse include in her response?

1)   Children develop fine motor skills prior to developing gross motor skills.

2)   Children who are encouraged with toys are usually able to walk earlier than expected.

3)   Language skills are going to develop prior to physical abilities.

4)   Physical abilities follow an expected pattern of growth and development.

 

 

17) A nurse determines that nutritional teaching is needed with a family of an 8-month- old infant after the history reveals:  the infant is drinking whole milk 3 times a day from a bottle, has table food such as hot dogs with the 2-year-old sibling, and is allowed chunks of fresh unpeeled apple as a reward for good behaviour.  Which part of the data would the nurse be able to support as being correct for a child of this age?

1)   Eating the same foods as the sibling.

2)   Consumption of whole milk.

3)   Is rewarded for good behaviour.

4)   Drinking from a bottle.

 

 

 

18) A 13-month-old child is brought to the well-child clinic for a routine exam.  After the height and weight are measured, the nurse documents the findings on a growth chart.  The child is at the 25th percentile for height and weight.  The nurse shares the findings with the mother who asks what treatments are needed for her child.  How should the nurse respond?

1)   “I will need to look at your child’s height and weight since birth before we can decide if any treatment is needed. “

2)   “Each child needs to be assessed to see if they are growing like everyone else their age.”

3)   “When a child’s information is plotted on these charts, we are able to see if they have any nutritional problems.”

4)   “We like to measure children at this clinic to see if they have specific health needs.”

 

19) The parents of a 3-year-old with a history of otitis media ask the nurse why their child continues to have this issue.  How should the nurse respond to the parent’s concerns?

1)   Children of this age have more frequent colds and upper respiratory infections.

2)   The Eustachian tube is longer at this age.

3)   This child needs further evaluation of a hearing problem that is causing this.

4)   Children of this age often put things in their ears.

 

 

 

20) A 2-month-old infant is hospitalized for a severe viral upper respiratory infection.  The pulse oximeter is reading 85% and the child is pale. While the nurse is suctioning the nose of the infant with a bulb syringe, the father enters the hospital room and states:  “You need to stop that!  You are just making him upset!”  What information should the nurse discuss with the father?

1)   Suctioning nasally will keep the infant from coughing and sneezing as much.

2)   The infant should be suctioned nasally and then orally before each feeding.

3)   Infants of this age only breathe through their nose, so it must be free of blockage.

4)   The infant is in need of oxygen therapy and the nose needs to be free of any discharge.

 

 

 

21) A nurse is performing a complete assessment on a 6-year-old child who was admitted for abdominal pain.  When asking about pain, which statement would be expected to elicit the most detailed information?

1)   “Can you tell me about your abdominal pain?”

2)   “Tell me where your tummy hurts right now.”

3)   “Can I feel your tummy and see where it hurts?”

4)   “Does your abdomen hurt anywhere right now?”

 

 

 

22) The nurse has assessed a 7-year-old female.  The child has a moderate amount of pubic and axillary hair.  The mother states:  “I just think she is going through puberty early.  I was 10 when I had these changes.”  The nurse’s best response would be:

1)   “Are her friends experiencing the same changes?”

2)   “Your daughter is very young to be having these changes.”

3)   “The doctor will probably want you to bring her back for visits every 3 months to monitor these changes.”

4)   “You are probably right, since you had these changes early.”

 

 

 

23) An 18-month-old child is brought to the emergency room with difficulty breathing.  The nurse notes the child has stridor, retractions, increased respiratory rate, drooling, and pale, hot skin.  What should the nurse do first?

1)   Perform a complete physical exam as quickly as possible.

2)   Apply oxygen by mask to ease work of breathing.

3)   Notify the physician.

4)   Apply a pulse oximeter probe to assess saturation level.

 

 

 

 

24)  Cherise, 15 years old, has been examined by the nurse. Her weight is in the 25th percentile, her teeth are eroding and she has scarring on the dorsal surface on her hands. What action should the nurse take?

1)  Ask if she is cutting her hands

2)  Inquire about her dental hygiene

3)  Ask how Cherise feels about her weight

4)  Discuss nutrition to help gain weight

 

 

25)  A nurse is teaching a group of new mothers about best practices for bottle feeding. What should the nurse include in the presentation?

1)  Sweeten the formula using honey rather than sugar

2)  Give no solids until 4 to 6 months

3)  Start cow’s milk at 9 months

4)  At 1 month start adding cereal to the bottle

 

 

 

26)  Julio, 6 months old, is having a physical examination. The nurse notes he grasps a finger when placed in his hand and he turns his head to the side his cheek is stroked on. What conclusion can the nurse make based on these findings?

1)  Normal Palmar and Moro reflexes

2)  Normal Plantar and Rooting reflexes

3)  Palmar and Rooting reflexes should have disappeared

4)  Plantar and Moro reflexes should disappear soon

 

 

27)  Tyler, 5 years old, weighs 15 kg and has a body mass index (BMI) at the 25th percentile. He has a urinary output of 45 mL over the past two hours. What can the nurse conclude from these finding?

1)   Normal output for his age

2)   Reduced urinary output

3)   Normal bladder capacity

4)   Underweight

 

 

 

SHORT ANSWER.  Write the word or phrase that best completes each statement or answers the question.

 

28) A 6-year-old child is brought to the emergency room after being in a motor vehicle accident.  What assessment data, collected in the first 5 minutes of admission to the ER, should be of concern to the nurse?  (Select all that apply)

1)   Hypotension

2)   Occasional heart murmur

3)   Bradycardia

4)   Continuous crying

 

 

 

29) A nurse who is orienting for the first week on pediatrics is ready to do a full assessment and initiation of an intravenous line on a 4-year-old child.  What interventions by the nurse would provide a positive outcome?  (Select all that apply)

1)   Asking the parents to remain with the child

2)   Allowing the child to see the intravenous catheter

3)   Leaving the child in their hospital room bed to perform the interventions

4)   Allowing the child to see the stethoscope and blood pressure cuff

 

 

 

 

Chapter 26

 

MULTIPLE CHOICE.  Choose the one alternative that best completes the statement or answers the question.

 

1)   A nurse is interviewing a primigravida client who is 14 weeks pregnant and reports she has not felt the baby move yet.  How should the nurse respond??

1)   “You need an ultrasound.”

2)   “Have you lost a baby before?”

3)   “We will listen for the heartbeat today.”

4)   “Fetal movement does not occur until the 18th week.”

 

2)   A nurse is examining a client who is 37 weeks pregnant.  What finding requires immediate intervention by the nurse?

1)   Patellar reflex +4/+4 bilaterally

2)   Weight gain of 1 kg in two months

3)   Blood pressure of 124/82 mm/Hg

4)   Mild glycosuria

 

 

 

3)   A nurse is preparing a teaching plan for a group of pregnant clients.  What should the nurse include in this teaching session?

1)   Double the daily intake of Vitamin A

2)   Do not take iron supplements due to constipation

3)   Limit salt intake

4)   Eat four servings of dairy products daily

 

 

 

4)   A nurse is interviewing a female client who reports no menstrual periods for two months and breast soreness.  What classification of signs of pregnancy would the nurse document?

1)   Objective

2)   Positive

3)   Presumptive

4)   Probable

 

 

5)   The client reports her last menstrual period (LMP) started on Sept. 28, 2011. What is the EDB using Naegele’s Rule?

1)   June 21, 2012

2)   July 28, 2012

3)   June 5, 2012

4)   July 5, 2012

 

 

 

6)   A nurse is examining a client in her third trimester.  What finding would require immediate intervention by the nurse?

1)   Blood pressure of 148/94

2)   Respiratory rate of 26 per minute

3)   Pulse of 98 beats per minute

4)   Weight gain of .75 kg in a month

 

 

7)   A nurse is monitoring a pregnant client in labour and wants to determine the length of time from the beginning of the contraction until the end of the contraction.  What is the nurse assessing?

1)   Period between contractions

2)   Contraction frequency

3)   Contraction intensity

4)   Contraction duration

 

 

8)   A nurse is interviewing a client who is 36-weeks pregnant.  What statement, if made by the client, would require immediate intervention by the nurse?

1)   “I have to use Tylenol for my backaches.”

2)   “I am leaking a yellowish fluid from my breasts.”

3)   “I have to get up during the night to void.”

4)   “I have not felt the baby move today.”

 

 

9)   A nurse is performing a pelvic examination on a client who is 20 weeks pregnant and notes a white, odourless discharge from the vagina.  What action should the nurse take?

1)   Document the findings as normal

2)   Obtain a culture of the discharge

3)   Ask the client about vaginal discomfort

4)   Inquire about recent sexual intercourse

 

 

10) A nurse is assessing a postpartum client and notes the perineal pad has whitish-yellow discharge.  How would the nurse document this?

1)   Lochia rubra

2)   Lochia serosa

3)   Lochia blanca

4)   Lochia alba

 

 

 

11) A nurse examines a client and notes the cervix is soft in texture and nontender during the pelvic examination.  What term would the nurse use to document this finding?

1)   Chadwick’s sign

2)   Piskacek’s sign

3)   Hegar’s sign

4)   Goodell’s sign

 

 

12) A nurse is assessing the fundal height of a pregnant client and notes the fundus is halfway between the symphysis pubis and the umbilicus.  How many weeks is the client pregnant?

1)   12

2)   16

3)   20

4)   24

 

 

13) A nurse is assessing a client in the third trimester of pregnancy and notes a yellowish discharge from both breasts.  What action should the nurse take?

1)   Document the findings as normal

2)   Obtain a culture of the discharge immediately

3)   Notify the physician

4)   Ask the client if she is pumping her breasts

 

 

 

14) A nurse is performing a vaginal examination on a female client and notes the cervix is a bluish-purple colour.  How should the nurse document this finding?

1)   Chadwick’s sign

2)   Hegar’s sign

3)   Goodell’s sign

4)   Leukorrhea

 

15) A postpartum client tells the nurse she has an ugly mass of red streaks all over her abdomen.  How should the nurse respond?

1)   “Over time they will become silvery in colour and be less noticeable.”

2)   “They will disappear in a few weeks.”

3)   “I am sure they are not so bad.”

4)   “That is the price you pay for having a baby.”

 

 

 

16) Alana, 15 years old, is 28 weeks gestation. She tells the nurse she is worried about gaining 6.5 kg to this point in her pregnancy.  How should the nurse respond?

1)   “I understand why you feel that way.”

2)   “Your weight gain is slightly less than recommended for this stage in your pregnancy.”

3)   “Perhaps you should begin to watch your intake more closely.”

4)   “Your weight gain is somewhat more than we recommend.”

 

 

 

17) A client, 11 weeks gestation, a hemoglobin level of 110 g/L.  What action should the nurse take?

1)   Contact the physician to assess the client’s need for additional prenatal vitamin supplements.

2)   Record the results as required by agency policy.

3)   Make a dietary consultation to provide education geared toward improving intake to meet the nutritional demands of the pregnancy.

4)   Call the client and remind her to take the prenatal vitamin supplements are prescribed.

 

 

18) While completing a health history, a pregnant client reports taking daily herbal supplements.  What initial action is indicated by the nurse?

1)   Encourage the client to speak with the physician about the herbal supplements.

2)   Record the client’s reports on the permanent medical record.

3)   Advise the client to reduce the amount of supplements taken to allot for the prescribed prenatal vitamins being taken.

4)   Instruct the client to increase the supplements to promote nutritional wellbeing.

 

 

19) A client who is 38 weeks pregnant reports she has been experiencing urinary frequency.  How should the nurse respond?

1)   “I will need to check your blood sugar as polyuria is associated with gestational diabetes.”

2)   “We will notify the physician.”

3)   “This is normal.”

4)   “You likely have a urinary tract infection.”

 

 

20)   A nurse has completed the health history of a pregnant client. The nurse documents that the client is multigravida.  What does this term mean?

  • Pregnant with twins
  • Was pregnant previously
  • Had a previous delivery
  • Pregnant for the second time

 

 

21) A client at 33 weeks gestation calls the clinic and reports she was attempting to nap when she became dizzy and felt faint.  What assessment data should be collected by the nurse first?

1)   The position the client was in during the nap period

2)   Dietary intake prior to the episode

3)   No additional data as this appears to be an isolated incident

4)   History of gestational hypertension

 

 

22) A nurse is discussing dietary recommendations with a client who has been experiencing a larger than recommended weight gain during her pregnancy.  The client reports reducing the amount of empty calories and of red meat consumed while significantly increasing intake of fish, poultry and fresh fruits and vegetables.  What action is indicated by the nurse?

1)   Notify the physician about the client’s risky dietary choices.

2)   Refer the client to a dietitian for counseling.

3)   Investigate the specific types of meats being eaten.

4)   Take no action as the client’s actions are healthful.

 

 

23)  Ms. Pasichnyk is 24 weeks pregnant. What test needs to be done in the next month?

  • 50 gm glucose test
  • Maternal serum triple screen
  • Ultrasound
  • Group B Streptococcus

 

 

 

24) A client has been diagnosed with Group B Streptococcus at 33 weeks gestation.  The client becomes tearful when the diagnosis is discussed.  She asks what will be done next.  What information should be provided to the client?

1)   IM antibiotic treatment to facilitate a rapid cure

2)   Treatment will begin after delivery

3)   Oral antibiotics to be taken over the next 7 weeks.

4)   IV antibiotics when in active labour.

 

 

25) During a prenatal counseling session a client indicates concern about her potential HIV positive status.  The client states she does not want to “jinx” the pregnancy by getting tested because if she is positive so is the baby.  How should the nurse respond?

1)   “Even if you do test HIV positive, preventative treatments have a good chance of providing protection for your baby.”

2)   “You are right to avoid the stress of finding out you are HIV positive during the pregnancy.”

3)   “As long as you do not breastfeed and have a cesarean section, your baby will be protected.”

4)   “If you are HIV positive, your baby will also have HIV.”

 

 

26) The client who is 5 weeks gestation is seen in the Emergency Room with severe abdominal and pelvic pain.  A vaginal examination reveals tenderness and a palpable mass near the uterus.  What can the nurse anticipate will take place first?

1)   The client will be sent home on bed rest.

2)   An ultrasound will be ordered.

3)   The client will be evaluated in the labour and delivery department with a nonstress test.

4)   The client will be admitted to the acute care facility for observation.

 

 

27) A nurse is completing the health history on a client who is pregnant with her second child. What question should the nurse ask about her previous pregnancy?

1)   “Was your labour over 3 hours long?”

2)   “What method of birth control have you used?”

3)   “How did you feel about your first pregnancy?”

4)   “Did your mother have problems with her blood pressure when pregnant?”

 

 

SHORT ANSWER.  Write the word or phrase that best completes each statement or answers the question.

 

28) A pregnant client reports concern about the development of reddish marks on her abdomen and breasts.  The client asks about having a cream prescribed to help them disappear.  What information should be included in the teaching provided to the client regarding this inquiry?  (Select all that apply.)

1)   The stretch marks will fade but not disappear.

2)   The marks will lighten to a silvery tone after pregnancy.

3)   Cocoa butter lotions and creams will clear the marks completely.

4)   The cream will help the skin stay supple.

 

 

29) A nurse is preparing to assist the physician perform an abdominal and fetal assessment on a client who is pregnant.  Identify in order the correct steps that will be included in the process.

  1. Assess fundal height
  2. Allow the client to void
  3. Inspect the abdomen
  4. Palpate the abdomen

 

 

30)  What are the landmarks used to determine fundal height in a pregnant client in the last trimester of pregnancy? (Select all the apply)

  • Inferior edge of the symphysis pubis
  • Fundus
  • Umbilicus
  • Superior edge of the symphysis pubis

 

 

31)  What shunts are seen in the fetus? (Select all that apply)

  1. Umbilical artery
  2. Ductus Arteriosus
  3. Foramen ovale
  4. Umbilical vein
  5. Ductus venosus
  6. Ventricular septal shunt

 

 

 

 

 

Chapter 27

 

MULTIPLE CHOICE.  Choose the one alternative that best completes the statement or answers the question.

 

1)   A nurse notes edema in bilateral knees in an elderly client.  The client has complaints of joint stiffness and pain upon awakening.  What disorder would the nurse suspect based on this data?

1)   Rheumatoid arthritis

2)   Osteoarthritis

3)   Gouty arthritis

4)   Tendonitis

 

 

2)   A nurse is assessing deep tendon reflexes in an elderly client and notes that the brachial and patellar reflexes are 2+ bilaterally on the 0 to 4+ scale.  What would the nurse do next?

1)   Document the findings as normal

2)   Perform additional neurological assessments

3)   Inquire about the client’s medication regimen

4)   Check past medical history

 

 

 

3)   A nurse is interviewing an elderly client who is concerned about “bumps on my body.”  Moist, brownish, wart-like lesions are noted on the client’s neck and chest.  What condition would the nurse suspect?

1)   Actinic keratoses

2)   Acrochordons

3)   Seborrheic keratoses

4)   Cherry angiomas

 

4)   A nurse is examining the oral cavity of an elderly client with concerns of mouth soreness.  Red, cracked skin is noted at each corner of the mouth.  How should the nurse document this finding?

1)   Periodontal disease

2)   Herpes infection

3)   Cheilitis

4)   Dehydration

 

Difficulty 1

 

 

5)   A nurse is presenting information on the wear -and -tear theory of aging to her colleagues. What statement is consistent with this theory?

  • “Longevity and healthy aging is due to the chromosomal differences between people.”
  • “Strands of DNA that should remain separate are linked together causing cell death.”
  • “Highly reactive molecules damage cellular components but antioxidants can neutralize these effects.”
  • “Healthy behaviours have a positive effect by protecting cells and allowing cells to repair themselves.”

 

 

 

6)   A nurse is interviewing Mr. Douglas, 78 years old, who reports painful sores that start on the left side of his back and cross over to the left side of his abdomen.  What condition would the nurse suspect?

1)   Ecchymoses

2)   Purpura

3)   Petechiae

4)   Herpes zoster

 

 

7)   A nurse is examining the eyes of an elderly client using the ophthalmoscope.  The vessels of the eyes are narrow and straight in appearance.  What would the nurse do next?

1)   Document the findings as normal

2)   Observe the red reflex

3)   Repeat the visual screening test

4)   Obtain an ophthalmology referral

 

 

8)   A nurse is examining the eyes of an elderly client using the ophthalmoscope.  The vessels of the eyes are narrow and tapered in appearance.  What would the nurse do next?

1)   Inquire about a history of diabetes

2)   Document the findings as normal

3)   Check for past history of hypertension

4)   Assess PERRLA

 

 

9)  The daughter of an elderly client reports that her father has a decrease in hearing ability.  The nurse suspects a conductive hearing loss due to the presence of dried cerumen in the ear canal.  How would the nurse validate this finding?

1)   Examine the external ear

2)   Perform the Weber test

3)   Perform the Rinne test

4)   Complete the whisper test

 

 

 

10) A nurse is interviewing an elderly client who reports mouth dryness and “tunnels” on the tongue.  What condition would the nurse suspect?

1)   Fungal infection

2)   Vitamin deficiency

3)   Leukoplakia

4)   Dehydration

 

11) A nurse is interviewing an elderly client and notes several soft, yellow plaques on the eyelids at the inner canthus.  What term would be used to document this finding?

1)   Xanthelasma

2)   Pterygium

3)   Presbyopia

4)   Pingueculae

 

 

12) A client, 68 years old, tells a nurse that he is experiencing erectile dysfunction since starting on a new medication. The nurse reviews the client’s medication profile. What drug classification has the most potential to cause this problem?

1)   Antidepressant

2)   Analgesic

3)   Antiarrhythmic

4)   Anti-inflammatory

 

 

13) A nurse is assessing the vital signs of an elderly client and obtains a temperature of 36 degrees celsius.  What action would the nurse take?

1)   Provide warm fluids to the client

2)   Ask the client if the room is too cold

3)   Document the finding as normal

4)   Apply warm blankets to the client

 

 

14) A nurse hears a bruit when auscultating the right carotid artery of an elderly client.  What would the nurse do next?

1)   Obtain a surgical consult

2)   Assess for jugular vein distention

3)   Document the findings as normal

4)   Auscultate the heart for murmurs

 

 

15) A nurse is assessing an elderly client who reports a chronic cough.  Upon auscultation, crackles are detected bilaterally in both lower lobes.  These sounds do not clear when asked to cough.  What condition would the nurse suspect?

1)   Pneumonia

2)   Emphysema

3)   Pulmonary fibrosis

4)   Pulmonary edema

 

 

 

16) A nurse is performing an assessment on a 70-year-old client.  The nurse notes that there is “cupping” of the optic disc and the eyeballs are rock hard. What condition would the nurse suspect?

1)   Cataracts

2)   Glaucoma

3)   Hypertension

4)   Diabetic retinopathy

 

 

17) During a health teaching session with Mrs. Samuelsson, who has no natural teeth, the nurse recommends that the client make an appointment with a dentist for a routine check up.  The client asks the nurse why this is important since she has no teeth.  What statement by the nurse is most appropriate?

1)   “It is important to assess you for mouth cancer.”

2)   “Although you do not have natural teeth, you are still at risk for disorders affecting the gums.”

3)   “You will need to be evaluated for dentures.”

4)   “You are probably right, no dental care is needed.”

 

 

18) During a routine physical examination, a 66-year-old client reports feeling tired.  She asks what is wrong with her.  What is the best initial action by the nurse?

1)   Encourage the client to alter their evening routine to reduce stressors.

2)   Encourage the client to begin to take a short nap each day.

3)   Assess the client’s sleep patterns.

4)   Ask the physician to prescribe a sleeping pill.

 

20) Mr. Basso who has a lengthy history of arthritis, reports to the physician’s office for a routine physical examination.  Mr. Basso reports his skin has become fragile and has experienced skin tears with little trauma inflicted.  Which statement by the nurse is most appropriate?

1)   “Tell me what medications you are taking.”

2)   “There is nothing you can do for this problem.”

3)   “You may not have been aware of the amount of stress the skin was under when it became injured.”

4)   “The skin changes you report are a normal part of aging.”

 

 

21) A 76-year-old client presents to the ambulatory care clinic with concerns consistent with influenza.  During the interaction, the nurse notes the client appears unkempt.  The client’s hair is uncombed and the clothing appears too large.  What would the nurse do next?

1)   Document the findings.

2)   Engage the client in a discussion regarding dietary practices.

3)   Contact social services.

4)   Report the findings to the physician.

 

 

22) A 76-year-old client, presents with a tremor associated with Parkinson’s disease. How would the nurse document this tremor?

1)   Head bobbing consistent with a senile tremor

2)   A resting tremor

3)   Dystonia

4)   A pin-rolling tremor of the hand

 

 

23) A client reports to the Emergency Room with concerns consistent with a fractured hip.  The client reports sitting down on the toilet seat and feeling the bone snap.  The client asks how this could have happened.  What information can be provided by the nurse?

1)   “You should discuss this with your physician.”

2)   “There is no good explanation for what has happened to you.”

3)   “Unfortunately, this may signal a serious underlying health problem.”

4)   “The body’s bones become increasingly brittle and lose density with aging.”

 

 

24) A client who is seen in the clinic for a routine blood pressure assessment states they have been experiencing the normal pain associated with aging.  What statement by the nurse is most therapeutic?

1)   “Normal aging can be quite painful.”

2)   “Tell me more about your pain and discomfort.”

3)   “Do you take medications for the discomfort you are experiencing?”

4)   “You must have osteoarthritis.”

 

 

25) A nurse notes a faint murmur while auscultating Mr. Carlson’s apical pulse. He is 66 years old and reports no history of heart problems.  Which statement is most correct?

1)   Mr. Carlson is presenting with the normal changes of aging

2)   The client had an underlying heart disorder

3)   The client has clinical manifestations associated with aortic calcifications

4)   The client is demonstrating mitral calcifications

 

SHORT ANSWER.  Write the word or phrase that best completes each statement or answers the question.

 

26) A nurse is discharging a client with stress incontinence.  The nurse would correctly include which of the following management techniques in the teaching plan?  (Select all that apply.)

1)   Perform pelvic muscle exercises

2)   Limit fluid intake to four glasses a day

3)   Void on a regular schedule

4)   Maintain an ideal body weight

 

 

27) A nurse is planning an educational program for new nurses regarding health care needs for the elderly.  What should be included in the nurse’s planning?  (Select all that apply.)

1)   Depression is a common problem for the elderly.

2)   Pneumonia is a significant health issue for older adults.

3)   Falls are the most common type of injuries experienced by older adults.

4)   Influenza vaccines should be given to most elderly clients.