Sample Chapter

Nursing Health Assessment A Best Practice Approach 1st edition by Jensen -Test Bank
Sample  Question           


1. What is one of the broad goals within nursing?
A) To prevent mental health C) To promote self-care
B) To form broad nursing diagnoses D) To treat human responses


2. What do nursing activities that promote health and prevent disease accomplish? (Select all that apply.)
A) Reduce the risk of disease
B) Maintain optimal functioning
C) Reinforce good habits
D) Optimize self-care abilities
E) Create home care safety


3. The purpose of a health assessment includes what? (Select all that apply.)
A) Identifying the patient’s major disease process
B) Collecting information about the health status of the patient
C) Clarifying the patient’s ability to pay for health care
D) Evaluating patient outcomes
E) Synthesizing collected data


4. The nurse is conducting a physical assessment. The data the nurse would collect vary depending on what?
A) How much time the nurse has C) The patient’s cooperation
B) The patient’s acuity D) Onset of current symptoms


5. A nursing instructor is discussing the purposes of health assessment. What is one purpose of health assessment?
A) To establish a database against which subsequent assessments can be measured
B) To establish rapport with the patient and family
C) To gather information for specialists to whom the patient might be referred
D) To quantify the degree of pain a patient may be experiencing


6. How do nurses facilitate the achievement of high-level wellness with a patient?
A) Encouraging the patient to keep appointments
B) Providing information on alternative treatments
C) Promoting health
D) Providing good patient care


7. The nurse is caring for a patient who, on the continuum between wellness and illness, is moving toward illness and premature death. How would the nurse know this to be true?
A) The patient stops doing wellness-promoting activities
B) The patient develops signs and symptoms
C) The patient begins exercising
D) The patient verbalizes anxiety over the cost of medications


8. A nursing instructor is discussing the health belief model with students. What elements would the instructor explain as part of the health belief model? (Select all that apply.)
A) Vector
B) Chronicity
C) Host
D) Agent
E) Environment


9. A nurse is writing a care plan for a newly admitted patient. When formulating the diagnostic statements in the care plan, what would the nurse use?
A) Rationale C) Physical assessment skills
B) ANA recommendations D) Diagnostic reasoning


10. A nurse is caring for three patients whose care involves complex situations and multiple responsibilities. What is the key to resolving problems for this nurse?
A) Diagnostic reasoning C) Critical thinking
B) Physical assessment D) Nursing care plan


11. A community health nurse is planning individualized care for a community. What does the nurse use as a framework for this plan?
A) Nursing process C) Critical thinking
B) Diagnostic reasoning D) Community care map


12. What are the types of nursing assessments? (Select all that apply.)
A) Physical
B) Focused
C) Mental
D) Emergency
E) Comprehensive


13. A nurse performs a comprehensive assessment on a patient. What is included in this assessment?
A) Circulatory assessment C) Complete health history
B) Assessment of the airway D) Disability assessment


14. The nurse is admitting a patient to the clinic and performs a focused assessment. What makes a focused assessment different from a comprehensive assessment?
A) Covers the body head to toe C) Involves all body systems
B) Occurs only in the clinic area D) Is more in-depth on specific issues


15. A nurse is admitting a patient, has completed the health history, and is now doing a physical assessment. The physical assessment will provide what type of data?
A)  Concrete    B)  Subjective    C)  Realistic    D)  Objective


16. The nurse is performing a health assessment on a new patient. While taking the detailed history, the nurse knows to include what?
A) Functional status
B) Only data involving the patient complaint
C) A focused assessment of the patient complaint
D) Family history for the past three generations


17. What does the Health Insurance Portability and Accountability Act (HIPAA, 2002) regulate?
A) Who empties the hospital waste
B) Privacy of information
C) How insurance information is obtained
D) Where a chart can be stored


18. The nursing instructor is teaching about health assessment and explains to students how to assess the roles and relationships of the patient. The students know that this type of information is assessed in what type of assessment?
A)  Body systems    B)  Head to toe    C)  Functional    D)  Comprehensive


19. A clinical instructor is teaching a group about organizing data when documenting and communicating findings. The clinical instructor knows that the method she is teaching promotes critical thinking and clustering of similar data. The instructor is teaching about which type of assessment?
A)  Body systems    B)  Comprehensive    C)  Head to toe    D)  Functional


20. A 26-year-old male nurse is assessing a 14-year-old girl newly admitted to the pediatric unit. The nurse knows that an efficient assessment framework that provides additional modesty for the patient is what?
A)  Body systems    B)  Functional    C)  Focused    D)  Head to toe
1. During the interview process, the nurse obtains what type of data from the patient?
A)  Primary    B)  Secondary    C)  Objective    D)  Oral


2. The nurse is admitting a new patient to the unit. While reviewing old records of this patient, the nurse knows that the data being gathered are what kind of data?
A)  Primary    B)  Secondary    C)  Subjective    D)  Objective


3. The nursing instructor is discussing with students different types of health histories. A student asks when it would be appropriate to take a comprehensive health history. What would be the instructor’s best answer? (Select all that apply.)
A) During a hospital admission
B) At a clinic visit for a fall
C) In the emergency department after a car accident
D) During an annual physical examination
E) At a screening for sports participation


4. Student nurses are practicing taking comprehensive health histories from one another. What components should be included in a comprehensive health history? (Select all that apply.)
A) When coughing began
B) Pain location
C) Pain duration
D) Pain intensity
E) What was eaten for breakfast


5. The nurse is gathering a complete history of the patient’s present illness. The nurse knows that the most appropriate way to begin to gather this information is what?
A) Assessing the patient’s vital signs
B) Gathering a complete list of the patient’s medications
C) Asking open-ended questions
D) Asking focused questions


6. A clinical instructor is discussing with a clinical group how to take a history of the patient’s present illness. A student asks how to best guide the interview. What would be the instructor’s most appropriate answer?
A) Follow the cues of the patient during the interview
B) Use a written checklist to make sure you cover all necessary areas
C) Use a head-to-toe approach to make sure you do not miss anything
D) Use a focused approach, asking only about symptoms of the present illness


7. A genogram is developed to visually show what?
A) Family tree C) Family relationships
B) Family health patterns D) Nationalities of family members


8. A group of student nurses is presenting information on Gordon’s framework for assessing a patient. What type of assessment would they be talking about?
A)  Comprehensive    B)  Focused    C)  Functional    D)  Emergency


9. When using Gordon’s framework for a functional health assessment, the nurse asks a patient, “Have you made any changes in your environment because of vision, hearing, or memory decrease?” What functional health pattern is the nurse assessing?
A)  Vision    B)  Hearing    C)  Coping    D)  Cognition


10. The nurse is caring for a 77-year-old woman who has been admitted with a fractured hip. While doing the admission assessment, the patient states, “I tripped over the small rug we have in front of the sink.” What subject would this report indicate that needs teaching during this patient’s hospital stay?
A) The need to eliminate rugs on the patient’s floors
B) The need to have wall-to-wall carpeting throughout the patient’s house
C) The need for the patient to use a walker when she goes into the kitchen
D) The need for the patient to be in a wheelchair


11. After completing the interview process, the nurse analyzes the data collected in order to?
A) Establish a baseline from which to start interviewing the family
B) Develop nursing interventions
C) Communicate information to the physician
D) Communicate information to other staff members


12. The nursing instructor is explaining to students the difference between the language used when a nurse talks to the patient and the language used when documenting in the medical record. What would the instructor tell the students about documenting in the medical record?
A) Document according to the orders of the physician
B) Talk to the patient and document exactly the same
C) Use medical terminology when documenting in the medical record
D) Document exactly as the patient talks


13. The nurse is caring for an 82-year-old man and is reviewing information obtained in the health history assessment. The nurse knows that it is important to identify the pattern of illnesses and recognize how they might be related because this patient is what?
A)  In the hospital    B)  Stoic    C)  An older adult    D)  Chronically ill


14. Through what process do the patient and the nurse work together to develop a plan of care?
A) Functional assessment C) Therapeutic communication
B) Use of subjective and objective data D) Use of Gordon’s framework


15. A nurse is assessing a patient and collecting only the most important information. What type of assessment is the nurse doing?
A)  Functional    B)  Emergency    C)  Comprehensive    D)  Focused


16. A student is working with a floor nurse who is admitting a new patient to the unit. The nurse asks the patient if he has traveled outside the United States in the past 12 months. The student knows that this information is part of what area of the comprehensive health history?
A) Activities C) Demographical data
B) Present illness D) History of illnesses


17. Why is it important for the nurse to reconcile all the hospitalized patient’s medication lists with the medication that the patient regularly takes at home?
A) So the physician can order the correct drugs for the hospitalized patient
B) So the patient’s medication record correlates with the patient’s medication history
C) So the patient continues taking the correct drugs
D) So the physician can make sure to change the patient’s drugs


18. The nursing instructor explains that sometimes a nurse uses a mnemonic, such as OLDCARTS, as he or she does the assessment. The instructor explains that the use of the mnemonic is to?
A) Remember the elements that are important to assess for
B) Remember the parts of a focused assessment
C) Remember the order of the assessment
D) Remember how to document assessment findings


19. While admitting a patient to the unit, the patient states, “I am allergic to sulfa drugs.” How would the nurse verify this information?
A) Ask family members
B) Ask the physician
C) Ask the patient about the response to the allergen
D) Compare against the patient’s legal records


20. A new patient is admitted to the clinic. The nurse assesses how the effects of health or illness affect the patient’s quality of life. What type of assessment is this nurse performing?
A)  Comprehensive    B)  Functional    C)  Emergency    D)  Focused


1. The medical record serves many purposes. What are they? (Select all that apply.)
A) Framework for medical information
B) Means for financial reimbursement
C) Research
D) Care planning
E) Information for the family


2. A court trial is being conducted over an incident in the operating room. How would the medical record best be used in this instance?
A) To provide a record of the nurse’s activities
B) To provide a record of the actual events
C) To provide a record of how the patient was harmed
D) To provide a record of the physician’s activities


3. Students are learning about the many uses of the medical record. One of these uses is to perform an internal audit. What is the goal of an internal audit?
A) The evaluation of financial reimbursement
B) The evaluation of patient nutrition
C) The evaluation of care for continual improvement
D) The evaluation of timely documentation of pain


4. Why do nursing students review medical records? (Select all that apply.)
A) To enhance clinical learning
B) To compare nursing care provided to patients
C) To evaluate the plan of care for a specific patient
D) To verify that laboratory results are accurate
E) To better understand complex clinical situations


5. The implementation of computerized charting systems is a nationwide event. What has research shown about the use of computerized systems?
A) Safety among patient populations decreases
B) Pharmacy orders are electronically verified
C) Physician notes are more secure
D) Patient safety increases


6. A clinical instructor is discussing with students the care provided to a patient. The instructor asks the student why it is important to make timely entries into the medical record. What would be the student’s best answer?
A) To have up-to-date information on which to base clinical decisions
B) To be able to verify what care has been given
C) To communicate with other health care providers
D) To be able to update the plan of care


7. The Joint Commission, in 2006, developed a National Patient Safety Goal. What is a requirement of this goal?
A) Health care agencies need to standardize their charting
B) Health care agencies need to develop a standardized approach to hand off communications
C) Health care agencies need to conform to Joint Commission communication templates
D) Health care agencies need to computerize medical records


8. One of the goals of nursing is to provide care that is safe to patients. What is the best way for nurses to realize this goal?
A) By accurately charting patient care
B) By continually assessing patient laboratory values
C) By continual communication with all members of the health care team
D) By giving patient care conferences including all members of the health care team


9. A new graduate nurse has just started working. The new nurse asks a more experienced nurse to explain SOAP charting. What would the second nurse explain that the A in SOAP stands for?
A) Analysis of data to identify a problem
B) Assessment of subjective data
C) Assessment of objective data
D) Articulation of the plan of treatment


10. When an agency has policies that require nurses to write focus notes, the nursing documentation can include what?
A) Areas of personal accomplishments C) Social networks
B) Areas of personal weakness D) Family concerns


11. When a nurse works in a health care agency that charts by exception (CBE), he or she knows that the patient assessment is structured by what?
A) Medical diagnoses C) Standardized norms
B) Patient needs D) Joint Commission standards


12. When charting by exception is used in a health care agency, the most important aspect of this method is what?
A) Organizing new forms for the nursing staff
B) Identifying the standards and norms for the institution
C) Training new nurses in writing CBE notes
D) Pulling together a group of experts to teach agency staff


13. Nursing students are learning about different methods of charting in the clinical laboratory. What method would they learn that is a shared mental model for improving communication between and among clinicians?
A)  SBAR    B)  CBE    C)  SOAP    D)  PIE


14. The nursing instructor is explaining SBAR documentation to students before taking them into the clinical area. What would the instructor explain that the situation, background, and assessment are based on in SBAR charting?
A) The patient’s background
B) Information that the nurse obtains from the family
C) Complete and accurate assessment data
D) Data in old records


15. What is the most common use of SBAR?
A) Contacting a provider regarding a patient issue
B) Structuring communications during handoff
C) Delegating care to nursing assistants
D) Expressing concern about a patient’s condition to the charge nurse


16. A nurse has assessed that a patient’s condition is worsening. The nurse is telephoning the primary care provider and providing an SBAR report about the patient and her condition. What would be important for the nurse to document? (Select all that apply.)
A) The time
B) Information from the previous shift
C) The information received
D) Specialists to whom the patient is referred
E) The name of the provider


17. A nurse has been called to testify in a lawsuit brought by a patient against his employer. This institution uses charting by exception (CBE). What type of legal problems does CBE pose?
A) The charting format is not ethical
B) Details are often missing
C) Subjective information is often missing
D) It reflects poor assessment skills on the part of the nurse


18. How does computerized documentation enhance communication? (Select all that apply.)
A) It is more complete than handwritten charting
B) It is legible and time dated
C) It permits multiple simultaneous users
D) It increases compliance
E) It verifies telephone communication


19. To make a legal entry into the medical record, the nurse must document what?
A) Laboratory tests ordered C) Time of the assessment
B) Attending physician D) Nature of the assessment


20. HIPAA gives patients greater control over their medical records. What else does HIPAA provide?
A) Copying of medical records
B) Education of lay people about medical records
C) Patient recourse if privacy protections are violated
D) Legal use of medical records


1. What is the most commonly accepted theory of pain?
A) Pain stimulus theory C) Pain transmission theory
B) Gate control theory D) Gatekeeper theory


2. On what does current research on pain focus?
A) Elements that can affect the intensity of pain
B) Stopping the cause of pain
C) Elements that can affect pain inhibition
D) Stopping the sensation of pain


3. The element of pain transmission that causes nociceptors to perceive a nerve impulse is what?
A)  Transduction    B)  Transmission    C)  Perception    D)  Modulation


4. Both the peripheral and the central nervous systems are involved in the transmission of a pain stimulus. When there is continued input from the peripheral nervous system, what can develop?
A) Fibromyalgia
B) A peripherally mediated pain syndrome
C) Neuronal plasticity
D) A centrally mediated pain syndrome


5. The nursing instructor is discussing the different types of pain with the nursing class. What type of pain would the instructor explain to the students that originates from a specific site, yet the patient feels the pain at another site?
A)  Chronic pain    B)  Cutaneous pain    C)  Referred pain    D)  Somatic pain


6. A nurse is caring for a patient who reports constant pain. The nurse knows that constant pain can lead to the modification of the function of the nervous system, which can, in turn, lead to what?
A) Neuronal windup C) Neuronal plasticity
B) Peripheral sensitization D) Chronic pain


7. Pain is often untreated or undertreated; when this occurs, chronic pain may result. What can be the outcome?
A) Chronic sensitization syndrome C) Complex regional pain syndrome
B) Peripheral sensitization syndrome D) Fibromyalgia pain syndrome


8. What is an excitatory process caused by pain stimuli that involves the spinal nerves and can persist when there is no longer stimulation?
A) Central sensitization C) Peripheral sensitization
B) Neuronal windup D) Neuronal plasticity


9. A 52-year-old woman comes to the clinic reporting pain in her right lower quadrant. When assessing the patient’s pain, what elements would the nurse include? (Mark all that apply.)
A) Aggressiveness
B) Intensity
C) Quality
D) Functional goal
E) Quantity


10. The nurse is assessing a 17-year-old boy with a history of drug addiction. What will be helpful in determining interventions that will be most beneficial for providing adequate pain relief to this patient?
A) Gathering information that the patient wants to share about his pain
B) Using in-depth questions to collect salient data about the patient’s pain
C) Collecting objective data that the patient chooses to share
D) Collecting subjective data that the nurse notes during assessment


11. A pediatric nurse is assessing a 4-week-old boy who has just been admitted to the pediatric unit with a diagnosis of possible pyloric stenosis. When assessing this patient, what behavior would indicate pain in this newborn to the nurse?
A)  Closed lips    B)  Extended fingers    C)  Nasolabial fold    D)  Eye widening


12. A 5-year-old girl is admitted to the postanesthesia care unit after the repair of her fractured femur. What activities would best indicate pain in this child according to the FLACC scale? (Mark all that apply.)
A) Leg movement
B) Arched back
C) Sleep
D) Eye widening
E) Difficulty consoling


13. A nurse in the emergency department is caring for a patient who is nonverbal following a traumatic injury. What would be the best way for the nurse to assess this patient’s level of pain?
A) Ask the patient to draw a picture of the pain
B) Ask the paramedics what they think is the patient’s pain level
C) Ask the patient to describe the pain
D) Ask the family if they have noticed any changes in the patient’s behavior


14. When a patient with opioid tolerance has an altered physiologic response to pain stimuli, he or she develops a form of pain sensitivity called what?
A) Opioid hyperalgesia C) Opioid hypoalgesia
B) Pain hyperactivity D) Pain hypoactivity


15. What are the steps for pain transmission in the gate control theory? (Mark all that apply.)
A) Unrelieved painful stimulus on a peripheral neuron causes the “gate” to open
B) The gate opens through repolarization of the nerve fiber
C) The brain stem recognizes the stimulus as pain
D) The pain stimulus passes down the afferent pathway
E) The pain stimulus crosses the dorsal horn of the spine to the limbic system


16. The Joint Commission mandates that nurses assess and reassess a patient’s pain level. A nurse’s institution mandates pain reassessment at 30 minutes for any drug given intravenously. This mandate is based on what?
A) Research that shows that it takes half as long for IV pain medication to work than oral medication
B) The time it takes a pain medication to decrease pain intensity
C) The time it takes a pain medication to block pain in a patient
D) The median half-life of an intravenous pain medication


17. What is the best description of the pain phenomena felt in rheumatoid arthritis and osteoarthritis?
A) Neuronal windup C) Peripheral sensitization
B) Neuronal plasticity D) Central sensitization


18. The nurse is assessing the pain of an 86-year-old man who is recovering from a right hip open reduction procedure. What element would the nurse know it is important to review to best understand the patient’s pain?
A) Sleep patterns C) Genetic history
B) Family history D) Elimination pattern


19. A 78-year-old patient is admitted to the unit with abdominal pain. The nurse doing the admission assessment knows what about pain in older adults?
A) Older adults have fewer nerve fibers; therefore, they feel less pain
B) Older adults may be reluctant to report pain
C) Older adults are always in chronic pain
D) Older adults are stoic and expect to be in pain
1. What term is this quote describing? “__________ encompasses the evolutionary development which has made man the teaching, instituting, and learning animal.”
A)  Ego integrity    B)  Despair    C)  Generativity    D)  Stagnation


2. Piaget differentiates young adulthood from middle adulthood by the use of what?
A)  Expertise    B)  Fluid intelligence    C)  Wisdom    D)  Cognitive pragmatics


3. Wisdom, as defined by Piaget, has many characteristics. What are they? (Select all that apply.)
A) Focuses on important and moderately easy matters
B) Involves superior knowledge, judgment, and advice
C) Applies only to nonspecific situations
D) Is easily recognized by most people
E) Is employed for personal well-being


4. What is egocentrism?
A) Internalized sets of actions that permit children to do mentally what they once did physically
B) Centering attention on one aspect of a problem and failing to consider other dimensions
C) The belief that inanimate objects are capable of action and have lifelike qualities
D) The inability to distinguish one’s own perspective from another person’s


5. A nurse is caring for a 75-year-old man who reports that he is becoming “forgetful.” The nurse explains that some parts of memory decrease with aging, and some do not. What would the nurse identify happens with aging to the type of memory that corresponds with the retrieval of facts, vocabulary, and general knowledge?
A) Decreases minimally
B) Decreases, but may be from slower processing speed
C) Decreases, but the patient may use better strategies to minimize the effects
D) Shows slight or no decrease


6. The nurse is presenting a class for new mothers and explains that from ages 4 to 8 months infants perform secondary circular reactions. This occurs when
A) The infant reproduces an event that initially happened by chance
B) The infant coordinates schemes and intentionality
C) The infant becomes more object-oriented, moving beyond being preoccupied with the body
D) The infant experiments with new behavior


7. Erikson theorizes that the school-aged child faces the task of industry vs. inferiority. What is the danger in this stage of development?
A) The child will separate himself or herself from others to avoid commitment to intimacy
B) The child will not be able to learn to use adult tools
C) The child will struggle to choose an occupational identity
D) The child will overmanipulate self and work to repossess the environment in a repetitive fashion


8. A married patient who lives in a rural area is 8 months pregnant and reports to the nurse that her house is “rather primitive.” The couple cooks and heats using propane, does not have indoor plumbing, and lives along the bank of a stream. What would be the most appropriate nursing intervention for this family?
A) Baby-proof the house
B) Teach the patient to avoid using the stove or heater without ventilation
C) Screen for genetically transmitted diseases
D) Encourage timely immunizations


9. If A is greater than B, and B is greater than C, then it must be true that A is greater than C. This is called what?
A) Transitivity C) Formality
B) Seriation D) Hypothetical-deductive reasoning


10. A nurse is presenting an educational event for a local community group. What intelligence would the nurse tell the group is learned and influenced by the individual person’s culture?
A) Pragmatic mechanics C) Fluid intelligence
B) Cognitive mechanics D) Crystallized intelligence


11. A young adult couple adopts an 8-month-old boy. The clinic nurse writes a care plan that includes the diagnosis of risk for delayed child development related to recent adoption. What would be an appropriate nursing intervention for this patient/family?
A) Consider visits by a home health nurse to assess the environment for safety and comfort
B) Teach parents to discipline the infant
C) Teach parents to stimulate the child as needed
D) Consider a visit by a home health nurse to assess parenting skills


12. In the Hispanic culture, a common rite of passage for a female child is called what?
A)  Bar Mitzvah    B)  Confirmation    C)  Quinceanera    D)  Menstruation


13. In some countries, the transition to adulthood is a long process. Why is this?
A) These countries value parenting more than in other countries
B) These countries have no rites of passage
C) These countries have higher education opportunities
D) These countries do not value independence


14. When Erikson published his theory in1963, he postulated that the end of childhood was what?
A) End of grammar school
B) Puberty
C) When the person gets his or her first job
D) Teenage years


15. Uri Bronfenbrenner postulated that development was continuous. What else did he postulate?
A) Development stagnates if the individual does not complete tasks associated with stages
B) Development stops cognitively at older adulthood
C) Development is important at all ages
D) Development does not involve interaction with the environment


16. In what life stage, defined by Erikson, is group identity important?
A)  Early adulthood    B)  School age    C)  Adolescence    D)  Young adult


17. In Bronfenbrenner’s theory, development is what?
A)  A series of tasks    B)  Divided into eight stages    C)  Continuous    D)  Passive


1. What was the primary reason that the American Nurses Association and other accrediting agencies developed the National Standards for Culturally and Linguistically Appropriate Services in Health Care?
A) The composition of the United States is multicultural
B) Ethnicity in nursing is part of the holistic process
C) Unless cultural differences are addressed, many patients do not respond well to nurses
D) Nurses need to understand every aspect of various cultures to provide good care to all patients


2. A nursing student is caring for a 77-year-old Hispanic woman. The nurse’s preceptor asks the student what would be an important assessment to make to provide quality nursing care for this client. What would be the student’s most appropriate response?
A) Transcultural assessment C) Mobility assessment
B) Respiratory assessment D) Family assessment


3. A nurse is performing a community assessment on a small town 30 miles from the nurse’s home. How might the nurse best begin the assessment process for this town?
A) Assess the relationship between the community’s social support and incidence of acute illness
B) Assess the relationship between the community’s level of education and rates of chronic illness
C) Assess the relationship between the community’s living conditions and divorce rate
D) Assess the relationship between the community’s median family income and rate of high school graduation


4. What is included in Anderson and McFarlane’s Community as Partner Assessment Model?
A) Transcultural assessment of community allies
B) Social assessment of community leaders as individuals
C) Systemic evaluation to identify the effects of interventions
D) Community evaluation to identify interventions in communities


5. A shared, learned, and symbolic system of values, beliefs, and attitudes that shape and influence how people see and behave in the world is a definition of what?
A)  Society    B)  Community    C)  System    D)  Culture


6. A new graduate nurse is attending orientation at her new institution of employment. The staff educator gives a pre-lecture quiz and asks what the goals of a cultural assessment include. What would be the graduate nurse’s best answer?
A) Developing and implementing a culturally congruent plan of care
B) Comparing social care needs of the specific person
C) Acquiring knowledge about the community’s cultural beliefs and practices
D) Comparing social and health beliefs of public health agencies


7. Madeline Leininger has identified attributes and behaviors that a nurse practicing effective care across cultures must have. What attribute does Leininger cite?
A) Understanding that the nurse’s own beliefs always interfere with cultural sensitive care
B) Active listening
C) Awareness of meanings behind the patient’s social communications
D) Awareness of cultural differences


8. A nurse is caring for a 58-year-old Southeast Asian man. The nurse knows that, most importantly, incorporating the patient’s health beliefs and practices into nursing care will
A) Enhance his social system
B) Enhance cultural connectedness
C) Improve his health outcomes
D) Improve communication with him and his family


9. Matters of the human soul are referred to as what?
A)  Culture    B)  Ethnicity    C)  Values and beliefs    D)  Spirituality


10. A hospice nurse is admitting a new patient who states that she is not religious but considers herself spiritual. What might happen with this patient if her illness progresses?
A) Religious activities may lose importance
B) Religious activities may take a central position in her life
C) Religious activities may blend with national identity
D) Religious activities may become formalized


11. A nursing student is helping with a group presentation on social assessment. What would be most important for the student to include in the group presentation?
A) Social assessment emphasizes the interconnectedness of physical, physiologic, and educational dimensions of health
B) Social assessment emphasizes the interconnectedness of physical, family, and social dimensions of health
C) Social assessment emphasizes the interconnectedness of physical, spiritual, and psychic dimensions of health
D) Social assessment emphasizes the interconnectedness of physical, psychosocial, and spiritual dimensions of health


12. The nurse is participating in a group assignment on performing a social assessment on the Hmong society. What would be important to include in this assessment?
A) Societal trends and relationships C) Individuals in the society
B) Spiritual architecture D) Occupational relationships


13. A 35-year-old Afghani woman is admitted to the obstetric unit. While doing a transcultural assessment, how would the nurse individualize questions for this patient?
A) Ascertain if the patient speaks and understands English
B) Remember that 35-year-old Afghani women were not allowed an education in their home country
C) Get a translator
D) Speak only with the patient’s husband


14. Madeline Leininger formulated a theory that highlights what?
A) Social behaviors in a community
B) Nursing behaviors necessary to carry out an effective cultural assessment
C) Nursing behaviors that compare personal philosophies of life and spiritual beliefs
D) Behaviors and skills necessary to carry out a community social assessment


15. The nurse is caring for a hospitalized patient from a culture that believes that a diet low in fruit and vegetables and high in fat is healthiest. While writing the plan of care for this patient, it would be important to include which of the following nursing diagnoses?
A) Emotional distress related to hospital diet
B) Spiritual distress related to distance from family
C) Nutritional deficiency related to beliefs in societal diet
D) Nutritional excess related to societal diet


16. When performing a systematic community assessment, a nurse chooses to use Kretzmann and McKnight’s framework. What would the nurse be doing in this case?
A) Forming a partner assessment C) Asset mapping
B) Generating a holistic picture D) Core element diagramming


1. A burn victim of a house fire is brought to the emergency department. The burn is classified as dermal. The nurse knows that the structures destroyed by the burn are what? (Select all that apply.)
A) Lymphatic vessels
B) Connective tissue
C) Vernix
D) Blood vessels
E) Sweat glands


2. The physiology instructor is discussing the function of sebaceous glands in the body. What would the teacher explain as the purpose of sebum to the students?
A) Assists in keeping the skin intact C) Assists in protection from infection
B) Assists in friction protection D) Assists in keeping skin dry


3. A patient has been prescribed tetracycline for acne. What is the most important point the nurse should make in patient teaching about this medication?
A) The patient may experience phototoxicity
B) The medication may interfere with the menstrual cycle
C) The patient may experience photosensitivity
D) The medication may be inactivated by antacids


4. A 17-year-old Hispanic teen comes to the clinic reporting excessive hair growth. She tells the nurse that she is teased a lot because of hair growing on her shoulders and back; the patient also reports that hair is growing on her upper inner thighs. What would the nurse suspect?
A) Endocrine disorder C) Hepatic dysfunction
B) Ovarian dysfunction D) Chronic nephrosis


5. The nurse in the dermatology clinic is assessing a 39-year-old woman who has presented at the clinic with a lesion on her left inner thigh. The patient tells the nurse that she discovered the lesion one month ago and has noticed no changes in the color or size of the lesion. What would be the most appropriate teaching subject for this patient?
A) Skin self-examination
B) Signs and symptoms of melanoma
C) Recognizing different types of lesions
D) Protection from sun damage


6. A first-time mother calls the clinic to talk to the nurse. The mother is very upset, saying that her newborn’s fingernails dip in the middle, appearing spoon-like. What would be the nurse’s best response?
A) “Take the baby to the emergency room to be evaluated.”
B) “Bring your baby to the clinic immediately.”
C) “This may be normal in infants.”
D) “This is a sign of a nutritional deficiency. What are you feeding your infant?”


7. A pediatric nurse is doing her initial shift assessments on assigned patients. One of the patient’s is a toddler with pneumonia. How would the nurse assess this patient’s skin turgor?
A) Pinch a fold of skin on the patient’s abdomen
B) Pinch a fold of skin on the patient’s cheek
C) Pinch a fold of skin on the patient’s upper thigh
D) Pinch a fold of skin on the patient’s forearm


8. When inspecting the hair, what would the nurse note? (Select all that apply.)
A) Color
B) Condition of hair shaft
C) Length of hair
D) Hair breakage of more than 6 hairs
E) Hair shafts that are shiny


9. The nurse is performing a generalized assessment of a 79-year-old man who has come to the clinic for his annual physical examination. The nurse notes that the patient’s skin is thin and rough with abrasions. The patient tells the nurse that it seems to take “forever” for scratches to heal, “a lot longer than when I was younger.” When asked if he has any other problems, the patient says that he always seems to be cold. How would the nurse note these findings in the patient’s medical record?
A) The patient has abnormal thinning of skin
B) The patient’s integumentary system is within normal limits
C) The patient states that wounds are taking longer to heal
D) The patient has an abnormal inability to maintain temperature


10. A 6-year-old girl is brought to the pediatric clinic by her mother, who tells the APRN that her daughter has a sore on her leg that “just keeps getting bigger.” On examination, the APRN notes an area of vesicles and bulla, some of which have ruptured and are oozing serous fluid. A honey-colored crust covers the area. What would the APRN tell the mother the lesion is?
A)  Varicella    B)  Scabies    C)  Impetigo    D)  Rubella


11. A newborn has a hemangioma on the face. What would be important for the nurse to include in patient teaching?
A) Will need surgery to remove
B) Will become smaller over the first year of life
C) Is made of epithelial cells that form caverns and fill with blood
D) Will usually resolve by age 9 years


12. A 63-year-old patient hospitalized with pancreatitis is having problems performing ADLs. The nurse’s aide brushes the patient’s hair and tells the nurse that the patient is losing an excessive amount of hair. The hair has the hair bulb intact. What might this indicate to the nurse?
A) Abnormal endocrine function C) Abnormal hepatic function
B) Abnormal ovarian function D) Abnormal integumentary function


13. An 81-year-old man presents at the clinic with a painful ulcer on the left big toe. The patient states that the ulcer is very painful and never seems to heal. An assessment of the ulcer shows a lesion with well-defined wound edges. When dependent, the base of the lesion is ruddy in appearance and exhibits signs of infection. What would the nurse suspect?
A) Infected spider bite C) Infected tick bite
B) Arterial ulcer D) Venous ulcer


14. Parents bring a child to the clinic and report a “rash” on her knee. On assessment, the APRN notes the area to be a reddish-pink lesion covered with silvery scales. What would the APRN chart?
A)  Seborrhea    B)  Contact dermatitis    C)  Eczema    D)  Psoriasis


15. The ICU nurse is caring for a trauma victim whose status is critical. On assessment, the nurse notes uremic frost along the patient’s hairline. What would this indicate to the nurse?
A) Renal failure C) Hepatic failure
B) Cardiovascular failure D) Respiratory failure


16. The nurse is caring for a patient with a nursing diagnosis of impaired skin integrity related to a stage III decubitus ulcer. What would be the most important outcome for this patient?
A) The patient exhibits no signs or symptoms of infection
B) The patient changes position every 2 hours
C) The patient keeps the area clean and dry
D) The patient knows prevention measures for decubitus


17. An obese 34-year-old man is undergoing a preoperative examination prior to having bariatric surgery. The patient tells the nurse that he has a red sore in his groin area that appears to be spreading. The nurse assesses the lesion and finds a macular erythematous lesion with satellite pustules. What would the nurse suspect?
A)  Roseola    B)  Candida    C)  Pityriasis rosea    D)  Herpes simplex


18. An 84-year-old woman is admitted to the hospital with pneumonia. While performing the admission assessment, the nurse finds a reddened area on the patient’s coccyx. What would the nurse include about this finding in notes? (Mark all that apply.)
A) Depth
B) Location
C) Other lesions on body
D) Size
E) Texture


19. As a pediatric nurse, it is important to assess each child for bruising. What might be indicated by ecchymoses in various areas of the body on a toddler or preschool-aged child? (Select all that apply.)
A) Osteomyelitis
B) A hematologic problem
C) Certain infections
D) Inappropriate play companions
E) A coagulopathy


20. A woman and her 14-year-old boy have come to the clinic. The boy has acne lesions and says that he cannot control them. The mother asks the nurse what causes acne. What would be the nurse’s best response?
A) Acne is caused by the apocrine glands
B) Acne is caused by decreased activity of the sebaceous glands
C) Acne is caused by the impedance of sebum secretion onto the skin’s surface
D) Acne is caused by enlarged epocrine glands
1. The open space between the eyelids is called what?
A) The palpebral fissure C) The lacrimal fissure
B) The limbus D) The eyeball


2. The anatomy and physiology instructor is discussing the eye with the prenursing students. What would the instructor cite as part of the lacrimal apparatus? (Select all that apply.)
A) Punctum
B) Palpebral fissure
C) Lacrimal gland
D) Limbus
E) Nasolacrimal duct


3. During an anatomy class on the eye, a student asks the instructor what blood vessels go to the eye. What would be the instructor’s best answer?
A)  The optic vein    B)  The optic plexus    C)  The choroids    D)  The coronal vein


4. The nurse is caring for a 15-year-old boy with an eye injury. The patient asks about the eye, and the nurse explains its structures and functions. What would the nurse tell the patient is the largest chamber of the eye?
A)  Anterior    B)  Posterior    C)  Corneal    D)  Vitreous


5. The nursing instructor is discussing glaucoma with clinical students. What would be important to tell the students about mydriatic drops in regard to glaucoma?
A) Mydriatic drops do not affect patients with glaucoma
B) Mydriatic drops may precipitate acute angle-closure glaucoma
C) Mydriatic drops constrict the pupils in patients with glaucoma
D) Mydriatic drops may cause a crisis in patients with open-angle glaucoma


6. The nurse is assessing the peripheral vision of a 55-year-old patient. What test would the nurse use to assess the boundaries of the patient’s peripheral vision?
A)  Static confrontation    B)  Allen    C)  Kinetic confrontation    D)  Cover


7. When assessing risk factors for eye and vision problems, the nurse knows that genetics can play a role. What major eye problem are patients most likely at increased risk for if a first-degree relative has it?
A)  Retinoblastoma    B)  Strabismus    C)  Retinitis pigmentosa    D)  Glaucoma


8. A 13-year-old girl is brought to the clinic for a sports physical examination. The patient states that she is going to play goalie on the community soccer team. What is the most important teaching opportunity presented for this patient?
A) Use of safety equipment C) Prevention of head injuries
B) Prevention of knee injuries D) Use of correct foot gear


9. A patient tells the nurse that his eyes “aren’t working right.” When the nurse asks what the patient means, the patient states, “It is like one eye is moving faster than the other.” What test would be most appropriate for the nurse to use to assess this patient?
A) Cover C) Cardinal fields
B) Kinetic confrontation D) Static confrontation


10. The cup-disc ratio is assessed by the use of the ophthalmoscope. What would the APRN know about the cup-disc ratio? (Select all that apply.)
A) It should be 1:1
B) It occurs only in females
C) It is genetically determined
D) It is equal in both eyes
E) It is found only in older adults


11. The APRN is assessing the eyes of a patient with long-standing uncontrolled hypertension. What might the APRN visualize during an assessment with an ophthalmoscope?
A)  AV nicking    B)  Dilated veins    C)  Dilated arteries    D)  Brass wiring


12. A 45-year-old professional fisherman presents at the ophthalmologist’s office after being referred by his family physician. The referral was made after a benign growth of the conjunctiva was found growing from the nasal side of the sclera to the limbus in the patient’s right eye. The patient asks the nurse what this growth is. What is the best answer the nurse can give?
A) “It is called hypertrophied conjunctiva.”
B) “It is called a pterygium.”
C) “It is called hypertrophied sclera.”
D) “It is called a pterygota.”


13. When assessing visual acuity in children, what would be the expected normal vision in a toddler?
A) 20/50 bilaterally C) 20/150 bilaterally
B) 20/100 bilaterally D) 20/200 bilaterally


14. What puts a child at increased risk for visual impairments?
A) Hearing problems C) Down’s syndrome
B) Hispanic ethnicity D) Motor problems


15. A mother brings her 2-year-old child to the clinic stating that the child is cross-eyed. What test would the nurse perform to test for strabismus?
A)  Corneal light reflex    B)  Cover    C)  Allen    D)  Static


16. A patient presents at the clinic with painful eyes, blurred vision, and headaches from using the computer all day at work. After a generalized assessment with no abnormal findings, the nurse would note what in reference to the eyes?
A)  Presbyopia    B)  Asthenopia    C)  Myopia    D)  Hyperopia


17. Normal movement of the eye involves what cranial nerves? (Mark all that apply.)
D) V


18. The nurse is performing visual acuity testing on a 70-year-old woman who has fallen and fractured her femur. What finding would be considered normal for this older adult? (Select all that apply.)
A) Arcus senilis
B) Increased tear production
C) Cataract
D) Decreased tear production
E) Increased pupillary response


19. A nursing student is helping to test vision and hearing at the local elementary school. Each child needs to have vision tested and documented. The students are standing with their heels on a line 10 feet from the eye chart. How would the nurse document “normal vision” for these students?
A) 20/20
B) 10/20
C) 10/40
D) 10/80
1. A student nurse is taking an anatomy test and is asked a question about the columella. What is the best description of the term columella?
A) The structure that divides the nares
B) The lining of the nares
C) The lining of lymphatic ducts
D) The mound of tissue just posterior to the eustachian tube


2. An oncology nurse is caring for a patient newly diagnosed with an occult nasopharyngeal malignancy. Where would the nurse expect this malignancy to be?
A) Osteomeatal complex C) Kiesselbach’s plexus
B) Rosenmuller’s fossa D) Wharton’s ducts


3. A nurse is providing patient teaching to the parents of a 3-year-old girl who experiences chronic epistaxis. What would the nurse identify as the area where most nosebleeds originate?
A) Rosenmuller’s fossa C) Kiesselbach’s plexus
B) Wharton’s ducts D) Stensen’s duct


4. A group of nursing students is making an oral presentation on the upper respiratory system. What would the group identify as the age when the frontal and sphenoid sinuses emerge in a child?
A)  6 years    B)  5 years    C)  4 years    D)  3 years


5. A nursing instructor is discussing areas of health promotion related to the nose, sinuses, mouth, and throat. What topics would the instructor be most likely to cite? (Select all that apply.)
A) Tobacco use
B) Risks for chronic obstructive pulmonary disease (COPD)
C) Obstructive sleep apnea
D) Alcohol use
E) Oral health


6. When doing a risk assessment of the nose, sinuses, mouth, and throat, what finding might indicate allergy?
A) Low-grade fever C) Frequent childhood infections
B) History of macular rash D) Family history of diabetes


7. A mother brings her 6-month-old son to the clinic for a follow-up assessment after antibiotic treatment for recurring otitis media. What would the nurse expect to find while assessing the patient’s mouth?
A) White uvula C) White patches on the buccal mucosa
B) Red and white patches in the throat D) White coated tongue


8. The nurse is caring for a 65-year-old patient with a feeding tube ordered by the physician. The nurse notes that the patient is not a mouth breather and having no difficulty breathing. While inserting the feeding tube, the nurse encounters difficulty getting the tube through the nares. What should the nurse suspect?
A) Deviated septum C) Swollen nasal passages
B) Obstructed turbinate D) Hypertrophied adenoids


9. A patient presents at the urgent care clinic with severe pain and pressure around the eyes. The APRN suspects a sinus infection. What is considered the gold standard diagnostic technique in evaluating sinus disease?
A) Transillumination
B) Computed tomography (CT) scanning
C) Percussion of the sinus cavities
D) Magnetic resonance imaging


10. The nurse is caring for a 58-year-old man who presents at the clinic with reports of general malaise and fatigue. Physical assessment reveals that the patient’s lips are dry and cracked. What might this indicate?
A)  Heat stroke    B)  Viral infection    C)  Inadequate hydration    D)  Allergy


11. A nurse caring for a patient admitted 2 days ago following a cerebral vascular accident notes that the patient is frequently coughing, has food falling from the mouth while eating, and frequently chokes. What would be the most pertinent nursing diagnosis for this patient?
A) Impaired dentition C) Altered cerebral perfusion
B) Alteration in mobility D) Impaired swallowing


12. The nurse is conducting a comprehensive health assessment of a 55-year-old Hispanic man. Which of the following abnormal findings would be most likely in this patient?
A)  Bifid uvula    B)  Gingivitis    C)  Oral cancer    D)  Sinus infection


13. An APRN is conducting the physical assessment of a 5-year-old Caucasian girl. The patient’s mother states that it seems like her daughter always has a strep throat. For what intervention might this indicate a need?
A)  Dialysis    B)  Removal of nasal polyps    C)  Sinus surgery    D)  Tonsillectomy


14. A 35-year-old woman is recovering from sinus surgery. The patient reports that she is in “a lot” of pain. The physician has ordered morphine every 3 hours. What intervention would be most appropriate?
A) Give morphine every 3 hours
B) Reassess the patient before giving morphine as ordered
C) Use nonpharmacologic pain relief prior to giving morphine
D) Wait until the patient asks for pain medication before administering morphine


15. What is the purpose of the tongue? (Select all that apply.)
A) Provides resonance to the voice
B) Manipulates solids and liquids when eating and drinking
C) Helps with the identification of sweet, sour, salty, and bitter tastes
D) Assists in speech production
E) Aides in the production of saliva


16. The autonomic nervous system innervates the salivary glands along with which cranial nerves? (Select all that apply.)
A) X


17. A nurse is conducting an admission assessment on a 67-year-old man with an intractable oral infection. The patient tells the nurse that he cannot smell things as well as he once could. What should the nurse do?
A) Chart the information in the medical record
B) Conduct olfaction tests
C) Notify the physician immediately
D) Verify the patient’s ability to taste all flavors


18. A nurse is preparing an educational event for the parents of children with respiratory disorders. What would the nurse tell the parents about allergy?
A) If a parent has allergies, the child has a 25% chance of developing them as well
B) Children will outgrow their allergies
C) Allergy can affect any target organ in the body
D) There are few effective treatments for allergies
1. Which of the following anterior neck structures is found in the depression between the trachea and the sternomastoid muscle?
A) Internal jugular vein C) Trachea
B) External jugular vein D) Carotid artery


2. Across the lifespan, a nurse knows that the female heart
A) Is normally smaller than the male heart
B) Weighs more than a male heart
C) Is normally larger than a male heart
D) Normally beats slower than a male heart


3. The area known as Erb’s point is the third site for auscultation on the precordium. Where is it located?
A) 4th left rib space C) 4th right rib space
B) 3rd right rib space D) 3rd left rib space


4. The sternal angle at the 2nd rib space is also known as what?
A)  Erb’s point    B)  Manubrium    C)  The aortic area    D)  The PMI


5. To increase the proportion of adults who engage in vigorous physical activity that promotes the development and maintenance of cardiorespiratory fitness, what would the nurse teach a patient? (Mark all that apply.)
A) The importance of physical activity
B) To exercise vigorously 3 or more days a week
C) To “cool down” after exercise so as not to strain muscles
D) To exercise for 20 or more minutes
E) To swim, which is the best exercise


6. The nurse is caring for a patient who has an elevated cholesterol level. To reduce the mean total blood cholesterol and LDL cholesterol levels, what would be important to teach this patient?
A) Eat high-protein, low-fat meals
B) Eat low-fat, low-cholesterol meals
C) Eat high-protein, low-carbohydrate meals
D) Eat low-cholesterol, low-carbohydrate meals


7. A patient comes to the emergency department reporting a sudden onset of dyspnea. What finding is a manifestation of dyspnea?
A) Shortness of breath C) Rapid breathing
B) Painful breathing D) Inability to breathe


8. A 62-year-old woman states that she has to get up during the night to urinate. How would the nurse further assess this patient’s nocturia?
A) Ask the patient how often she thinks she should be getting up at night
B) Ask the patient “Are you tired in the morning because of this?”
C) Ask the patient whether siblings or parents had this problem
D) Ask the patient “Have you made any changes because of this?”


9. An 87-year-old woman has come to the clinic for a routine checkup. The nurse practitioner notes that the carotid artery pulse is diminished bilaterally and a systolic bruit is auscultated bilaterally. What would the NP want to have this patient assessed for by a cardiologist?
A) Stenotic aortic valve
B) Atherosclerotic pulmonic valve
C) Atherosclerotic stenotic carotid arteries
D) Congenital stenotic carotid arteries


10. Nursing students are learning how to objectively assess venous pulses. How would the nursing instructor teach the students to optimally position the patient for this procedure? (Mark all that apply.)
A) Use a bright light for better visualization
B) Sit the patient up at a 90°angle
C) Emphasize the shadows of the pulsations with lighting
D) Place the head of the bed 30° to 45°
E) Have the patient turn the head away from the side being examined


11. A 79-year-old man has come to the clinic for a routine checkup. He reports general malaise and chronic fatigue, stating “I just can’t get out and work in the garden anymore. I really miss it.” The patient has a history of cardiomegaly with a hypertrophied left ventricle. Where would the nurse expect to find the PMI?
A) Between the 4th and the 5th ICS at the MCL
B) Lateral and inferior to the 4th and 5th ICS and the MCL
C) Lateral and superior to the 4th and 5th ICS and the MCL
D) Lower left sternal border


12. The nursing instructor is discussing assessment of the heart with students. A student states that he has a patient with a rushing vibration in the precordium that the student could feel and that it was in the area of the pulmonic valve. What should the instructor explain that the student is feeling?
A)  A thrill    B)  A thrust    C)  A heave    D)  A normal finding


13. While performing an admission assessment, the nurse auscultates a high-pitched, scratching, and grating sound at the left lower sternal border. The nurse should know that this would be documented as what type of sound?
A) Paradoxical sound C) Pericardial murmur
B) Split sound D) Pericardial friction rub


14. A patient presents at the cardiology clinic for a checkup 6 months after MI. The patient is known to have a bundle branch block that delays activation of the right ventricle. What would the nurse expect to hear when auscultating heart sounds?
A)  Arrhythmia    B)  Extra sound    C)  Wide splitting    D)  Delayed S1


15. A patient has been admitted to the cardiac unit and test results are available. The nurse is writing a plan of care for this patient. On what would the nurse base interventions?
A) Patterns of subjective and objective data
B) Patterns of test results
C) Areas for care planning
D) Areas that the patient requests


16. An emergency department nurse is assessing a 62-year-old rancher who arrives at the ED with chest pain. The patient states that the pain gets worse with movement. What further assessment should the nurse make?
A) Auscultation at the 5th ICS
B) Palpation at the PMI
C) Assessment of the precordium
D) Palpation of the costochondral junction


17. The nurse performs an admission assessment on a 52-year-old woman admitted through the ED with a myocardial infarction. The nurse charts “Swooshing sound heard over right carotid artery.” How should this documentation be corrected?
A) “Murmur heard over right carotid artery”
B) “Split sound auscultated over right carotid artery”
C) “Right carotid bruit auscultated”
D) Does not need to be corrected


18. An 83-year-old woman presents at the office of her primary care physician with fatigue, heart palpitations, and a “wet” cough. What might the nurse suspect in this patient?
A) Heart failure C) Atrial hypertrophy
B) Atrial fibrillation D) Ventricular arrhythmia


19. What feature of a newborn shunts blood from the right atrium directly into the left atrium, bypassing the lungs?
A) Foramen ovale C) Placental insufficiency
B) Ductus arteriosus D) Injection fraction


1. An anatomy and physiology instructor is discussing the functions of the breasts. A student asks about the function of Montgomery’s glands. What would be the instructor’s best answer?
A) “During lactation, they secrete a protective lubricant.”
B) “They are the lactiferous ducts.”
C) “They aid in supporting breast tissue.”
D) “They are lymph nodes in the axillae.”


2. Where are the acini cells located?
A)  Nipple    B)  Lobules of the breast    C)  Lactiferous ducts    D)  Breast sinus


3. When assessing the breast and lymphatics of the axillae, where would the nurse locate the central axillary nodes?
A) Inside the upper arm
B) Along the lateral edge of the scapulae
C) High in the axillae at the top of the ribs
D) Inside the lateral axillary fold


4. When assessing the breast and axillae, the nurse remembers that most lymph drains where?
A) Bilateral axillary nodes C) Ipsilateral mammary nodes
B) Bilateral mammary nodes D) Ipsilateral axillary nodes


5. A nurse is teaching a patient about self breast examination. What would the nurse emphasize? (Mark all that apply.)
A) Inspection
B) Pain
C) Timing
D) Palpation
E) Pallor


6. Modifiable risk factors for breast cancer include what?
A)  Obesity    B)  Age    C)  Genetics    D)  Asthma


7. While assessing a 32-year-old woman new to the clinic, the nurse would perform a subjective assessment of what?
A) Onset of menstruation 13 years or after
B) Exercise
C) High-protein, low-carbohydrate diet
D) History of breast cancer in second-degree (grandmother) relatives


8. Included in the subjective assessment of the breast are the patient’s statements about what? (Mark all that apply.)
A) Breast size
B) Palpation
C) Surgeries
D) Nipple discharge
E) Personal history


9. When performing a breast assessment on a clinic patient, the nurse practitioner notes scaly lesions that begin at the nipple and move toward a lump behind the nipple well. The NP would know that further assessment for what would be necessary?
A)  Mastalgia    B)  Lipoma    C)  Fibroadenoma    D)  Paget’s disease


10. Breast self-examination is best when breasts are least congested and smallest. The nurse knows this would be what days of the menstrual cycle?
A)  1 to 3    B)  3 to 5    C)  4 to 7    D)  6 to 9


11. A 57-year-old woman reports to the nurse that she has an area on her breast that looks dimpled and “like orange peel.” What would this indicate to the nurse?
A) Early cancer C) Fibrocystic disease
B) Fibroadenoma D) Blocked lymph drainage


12. When assessing the breasts, it is important for the patient to lift the arms over the head. Why?
A) Adds tension to suspensory ligaments
B) Eventuates dimpling and retraction
C) De-emphasizes suspensory ligament retraction
D) Accentuates signs of unilateral nipple inversion


13. A 37-year-old woman is 2 days postoperative after a right breast mastectomy. Included in the discharge teaching is care of the surgical incision. What would be the most appropriate intervention for this patient?
A) Provide for a home health nurse to assist in care of the incision
B) Provide a mirror to visualize the incision
C) Make a referral to the wound care nurse
D) Teach signs and symptoms of wound infection


14. A nurse is providing patient teaching related to SBE to a 67-year-old woman. When would be the best time during the month for this patient to perform SBE?
A) First day of each month C) First two weeks of month
B) Last two weeks of month D) A convenient day of each month


15. When assessing a breast, what signs/symptoms might indicate a malignancy? (Mark all that apply.)
A) Hyperpigmentation
B) Erythema
C) Pallor
D) Peau d’orange
E) Unilateral vascular appearance


16. The nurse is caring for a 47-year-old Filipino woman, a 55-year-old African American woman, a 65-year-old Caucasian woman, and a 58-year-old Asian woman. Which patient would be at highest risk for late-stage breast cancer?
A) Filipino woman C) Caucasian woman
B) African American woman D) Asian woman


17. A man brings his 15-year-old son to the clinic because the boy is embarrassed by his tender and enlarged breasts. What would be an appropriate nursing intervention for this patient?
A) Teach the patient self-breast examination
B) Encourage the patient to verbalize feelings related to sexual identity
C) Prepare the patient for further testing
D) No intervention is needed because findings are within normal limits


18. The nurse practitioner is examining a 41-year-old patient and notes an axillary lymph node approximately 1.5 cm in size, tender, and movable. The NP also notes an erythematous 3-cm abrasion on the patient’s upper arm. The patient tells the NP that she fell in the garden while fertilizing her plants. What nursing diagnosis would the NP include in the plan of care?
A) Infectious process related to abrasions
B) Fear related to possible diagnosis of breast cancer
C) Inflammation related to abrasions
D) Anxiety related to probable diagnosis of breast cancer


19. A 32-year-old mother of three young children is newly diagnosed with breast cancer. The patient tells the nurse that she is so sad and cannot stop crying. She adds that she feels like she is less of a woman and is having trouble sleeping. When initiating the plan of care, what would be the most appropriate nursing diagnosis?
A) Altered body image C) Grieving
B) Altered self-concept D) Altered sleeping pattern


1. A 23-year-old female athlete presents at the clinic with pain in her tibiotalar joint. It is a hinge joint limited to flexion and extension. The terms used to describe these movements are what?
A) Adducting and abducting C) Supination and pronation
B) Dorsiflexion and plantar flexion D) Rotation and supination


2. For an examination in Anatomy and Physiology, students must label a diagram using the correct medical terminology. Students are placing the joints in their correct places. Where would the students place the metacarpophalangeal joint?
A) In the finger C) Between the hand and the finger
B) In the hand D) In the foot


3. A 12-year-old girl has been diagnosed with genu valgum. What is the other name for this disease?
A)  Clubfoot    B)  Flatfeet    C)  Bowlegs    D)  Knock kneed


4. On the Morse Fall Scale, a secondary diagnosis indicates an increase in the final score by how many points?
A)  25 points    B)  20 points    C)  15 points    D)  10 points


5. A 3-month-old girl has been diagnosed with congenital hip dislocation. What is a confirmatory test for this disease?
A) Trendelenburg’s test C) Bouchard’s test
B) Heberden’s test D) Phalen’s test


6. A patient is thought to have a balance problem. What would be an advanced method of assessing balance in this patient? (Mark all that apply.)
A) Walking heel to toe
B) Standing on one foot
C) Romberg’s test
D) Standing
E) Hopping on one foot


7. A patient comes to the clinic and reports a sore knee. The nurse notes popping and cracking noises when the patient attempts to bend the knee. The patient exhibits signs of pain by facial expression. The nurse knows that the popping and cracking noises should be charted as what?
A) Crepitus C) Tactile emphysema
B) Grating noise D) Popping and cracking noises


8. When assessing a patient’s strength, it is necessary to
A) Compare one side to the other
B) Assess the extremities at the same time
C) Compare upper and lower extremities
D) Assess upper and lower extremities at the same time


9. A patient is admitted to the unit. The nurse notes that the medical record for this patient lists a fall risk of 75% per the Morris Fall Risk scale. What would be an appropriate nursing intervention?
A) Assess for orthotics
B) Use environmental cues
C) Use an accessory high seat on the toilet
D) Encourage the patient to use canes bilaterally


10. Which of the following tools would an advanced practice nurse be more likely than a registered nurse to use during the performance of a musculoskeletal assessment on a patient?
A)  Flashlight    B)  Gradiometer    C)  Scale    D)  Goniometer


11. A nurse has just finished assessing a patient’s spine and neck muscles. How would the nurse document normal findings?
A) C8 and T1 spinous processes prominent. Paravertebral, sternocleidomastoid, and trapezius muscles fully developed, symmetrical, and nontender
B) All findings within normal limits
C) Neck assessment WNL
D) C7 and T1 spinous processes prominent. Paravertebral, sternocleidomastoid, and trapezius muscles fully developed, symmetrical, and nontender


12. The nurse is assessing the musculoskeletal system of a 14-year-old boy for participation in athletics. The nurse would expect to find that this patient’s bones are what as compared to a female of the same age?
A) No difference C) Longer and stronger
B) Larger and stronger D) More curved


13. Many variations related to ethnicity are visible in the musculoskeletal system. Mark all that are correct.
A) Caucasians have intermediate curves in their femurs
B) Asian Americans have denser bones than other races
C) Native Americans have an anterior curvature to their femurs
D) Polynesian Americans have a posterior curvature to their femurs
E) African Americans have straight femurs


14. The nurse is receiving report on a patient with a nursing diagnosis of activity intolerance. What would be an appropriate nursing intervention for this patient?
A) Use footwear that facilitates walking and prevents injury
B) Promote reconditioning
C) Use assistive devices
D) Ask for input on habits and preferences


15. The nurse is developing a plan of care for a patient found to have a strength problem. What would be an appropriate nursing diagnosis for this patient?
A) Activity intolerance C) Impaired physical mobility
B) Self-care deficit D) Impaired walking


16. An 87-year-old patient has been admitted to the unit. This patient has problems with fine motor movement. What would be important to do for this patient?
A) Open all packages and arrange the meal tray while communicating actions to the patient
B) Teach the patient to call for assistance when getting up to bathroom
C) Evaluate for assistance devices
D) Assess gross motor function


17. A 13-year-old boy is brought to the emergency department with an injury to his left ankle after a skateboard accident. Diagnostic films show a fracture across the epiphyses. The doctor explains that the patient may not have full ROM and that his left leg may be shorter than his right leg. The parents ask why one leg may be shorter than the other. What would be the nurse’s best answer?
A) The epiphysis is the growth plate
B) The fracture crosses the part of the bone where the bone lengthens
C) Any fracture of a bone has the potential of decreasing length in the leg bone
D) Bone growth in boys generally stops about this time


1. Where is the corona of the penis found?
A) At the base of the glans C) At the tip of the glans
B) At the root of the penis D) At the root of the corpus spongiosum


2. During health class, a student asks the school nurse about the function of the testicles. What would be the nurse’s best reply?
A) To produce smegma C) To produce estrogen
B) To produce testosterone D) To produce semen


3. Where is the rectum located in a male?
A) Inferior to the anus
B) At the junction of the sigmoid and transverse colon
C) Superior to the anus
D) Superior to the rectal ampulla


4. In men, what are located on either side of the urethra just below the prostate gland?
A) Skene’s glands C) Seminiferous glands
B) Bartholin’s glands D) Bulbourethral glands


5. One of the goals of Healthy People is to reduce the proportion of adolescents and young adults with sexually transmitted infections (STIs). What subject(s) would be most appropriate to teach this population to reduce the incidence of STIs? (Select all that apply.)
A) Use of diaphragm
B) E. coli infections
C) Modes of transmission
D) Condom use
E) Use of spermicides


6. A 47-year-old man comes to the clinic for his annual physical examination. During the nursing assessment, the nurse asks, “Do you have any current or chronic illnesses such as diabetes, hypertension, neurologic impairment, respiratory problems (asthma, COPD, chronic bronchitis), or cardiovascular disease?” Why does the nurse ask this question?
A) To assess risk for erectile dysfunction
B) To refer the patient to a pulmonologist
C) To assess risk for limited range of motion
D) To determine the need for involvement from an internist


7. The nurse is conducting an examination of a 27-year-old male’s genitalia during his annual physical examination. The patient has an erection and the nurse reassures him that this is a normal physiologic response and continues the examination. Why would the nurse continue with the examination at this time?
A) They do not; they wait until the erection is gone
B) Stopping could cause further embarrassment
C) To demonstrate to the patient that there is nothing to be embarrassed about
D) It is better to assess the penis when it is erect


8. During the examination of a 72-year-old man, the nurse practitioner (NP) notes the patient has a history of BPH. How would the NP expect the prostate gland to feel?
A)  Tender    B)  Hard, nodular    C)  Rubbery    D)  Firm, nontender


9. While preparing to conduct a rectal examination on a 67-year-old man, the nurse notes the patient has a history of cancer. The nurse should know that peritoneal metastases create what in the peritoneum?
A)  Nodularity    B)  Edema    C)  Inflammation    D)  Extreme rectal pain


10. The nurse is caring for a 72-year-old man who has had surgery on his rectum and perineum. What would be an appropriate intervention for this patient?
A) Explain the procedure to the patient
B) Teach the patient exercises to strengthen the pelvic floor
C) Begin discharge planning for this patient
D) Teach the patient how to keep the rectum clean


11. A clinic nurse is admitting a 16-year-old boy with complaints of itching and burning in his genital area. He tells you “I am sure I have an STI. This will be the third one in 3 months.” What intervention would be most appropriate with this patient?
A) Provide samples of spermicides to patient
B) Provide patient with educational material on testicular cancer
C) Assess the patient’s knowledge and understanding of safe sexual practices
D) Teach the patient correct use of condom to prevent pregnancy


12. The nurse is documenting current health concerns during the health history of a 63-year-old man. Identification of what may help most at this time?
A) Number of sexual partners C) Sexual preference
B) Number of STIs D) Previous problems


13. How often is mature sperm generated?
A)  Every 90 days    B)  Every 80 days    C)  Every 70 days    D)  Every 60 days


14. A 76-year-old man has come to the clinic for his annual physical examination. The nurse knows that the fibromuscular structures of the prostate gland in this patient have atrophied with aging. What might obscure the natural physiology?
A) Prostate nodules C) Perineal cancer
B) Benign prostatic hyperplasia (BPH) D) Penile cancer


15. An 18-year-old man has come to the emergency department with purulent drainage from an area on his penis that was pierced 48 hours ago. What would be important for the nurse to discuss with the patient? (Select all that apply.)
A) Ways to avoid infection
B) Significance of the piercing to the patient
C) Care of the piercing
D) Sensation in the area of the piercing
E) Where the piercing was done


16. A 17-year-old male patient is admitted to the emergency department with an acute scrotum. One nursing diagnosis for this patient is severe pain related to acute scrotum. What conditions cause a medical diagnosis of acute scrotum? (Select all that apply.)
A) Ruptured testicular tumor
B) Ischemia
C) Infectious conditions
D) Hydrocele
E) Orchiectomy


17. A 49-year-old man comes to the clinic complaining of awakening at night to void and voiding more than once in a 2-hour time period. The patient has a history of bladder irritation. What would be an appropriate nursing diagnosis for this patient?
A) Ineffective sexuality pattern C) Risk for urge incontinence
B) Risk for infection D) Urinary retention


18. An uncircumcised male with poorly controlled diabetes is being seen in the clinic. The patient is found to have scars and narrowing of the urethral opening. What condition would the nurse suspect?
A)  Balanoposthitis    B)  Epispadias    C)  Paraphimosis    D)  Phimosis


19. A male infant is born with the urethral meatus opening on the underside of the penis. When providing information to the parents, what is the correct terminology to use for this condition?
A)  Phimosis    B)  Hypospadias    C)  Epispadias    D)  Paraphimosis


1. While assessing a new patient, the nurse asks about a family history of genetic illnesses. The patient states that her mother has diabetes. For which of the following is this patient at increased risk?
A)  Diabetes    B)  Hypertension    C)  Twins    D)  Seizures


2. An obstetric patient has a history of psychiatric illness. Which psychiatric problems would the nurse assess for exacerbations of in a pregnant patient? (Select all that apply.)
A) Gambling addiction
B) Dementia
C) Depression
D) Anxiety
E) Eating disorders


3. By the time a woman is 36 weeks’ gestation, where would the nurse expect to find the uterus?
A) At the umbilicus
B) Halfway between the umbilicus and bottom edge of the ribcage
C) Near the bottom of the sternum
D) Under the edge of the ribcage


4. The nursing instructor is teaching students about normal changes of pregnancy. The instructor talks about diastasis recti. What is the instructor presenting?
A) Separation of the muscles of the abdominal wall
B) Raising of the uterus into the abdomen
C) Relaxation of the kidneys
D) Movement of the bladder to the rear of the pelvis behind the uterus


5. A patient of normal weight and new to the obstetric clinic asks the nurse how much weight to gain during pregnancy. What is the best response the nurse can give?
A) 5 lbs over the first 3 months; 5 lbs over the second three months; 10 lbs over the last three months
B) 7 lbs over the first 3 months; 7 lbs over the second three months; 7 lbs over the last three months
C) 10 lbs over the first 20 weeks; 1 lb per week after that
D) 5 lbs over the first 20 weeks; 2 lbs per week after that


6. A woman entering her third trimester of pregnancy asks the nurse how much weight she should gain during this trimester. What is the nurse’s best answer?
A)  0.5 lb/week    B)  1 lb/week    C)  1.5 lb/week    D)  2 lbs/week


7. A patient in her third trimester comes in for a routine prenatal visit. The nurse places her in a comfortable position and attaches the tocodynamometer and ultrasound monitor to the patient’s abdomen. What is the purpose of this test?
A) Assesses readiness for dilation C) Assesses fetal well-being
B) Assesses fetal position D) Assesses readiness for delivery


8. At each prenatal visit, a patient provides a urine sample to the health care provider. What is this urine sample tested for at each visit?
A) Protein and glucose C) Protein and albumin
B) Glucose and white blood cells D) White blood cells and albumin


9. The nurse is teaching a class about pregnancy to a group of expectant mothers. What would be the primary method of prevention that the nurse would focus on related to hemorrhoids and constipation?
A) Take a mild laxative daily C) Increase the intake of protein
B) Decrease the intake of fiber D) Increase exercise


10. A 15-year-old girl comes to the clinic and reports that she thinks she is pregnant. A pregnancy test is positive. While developing a care plan for this patient, the nurse should consider the patient’s age and associated risk factors, which include what? (Select all that apply.)
A) Preeclampsia
B) Undeveloped pelvis
C) Inadequate nutrition
D) Gestational diabetes
E) Pyelonephritis


11. A patient at 39 weeks’ gestation presents at the labor and delivery suite saying that she is in labor. She reports that her water has not broken yet. Physical assessment reveals that the patient is not in true labor. The nurse explains that what the patient is feeling are Braxton Hicks contractions. What assessment findings would tell the nurse that these contractions are, in fact, Braxton Hicks? (Select all that apply.)
A) 30 to 45 seconds in duration
B) Fewer than five in 1 hour
C) Not painful
D) Resolve with position change
E) Less than 30 seconds


12. A patient presents at the emergency department. During the assessment, the nurse notes the following: Patient is a 22-week primipara, age 25, pulse 82, BP 110/76, temp 38.3°C. The patient is diagnosed with pyelonephritis. What would be the treatment of choice?
A) Hospitalization and intravenous antibiotics
B) Oral antibiotics and bed rest at home
C) Hospitalization and intravenous hydration
D) Home care and oral hydration and antibiotics


13. What is the purpose of asking a pregnant woman about her religious preference?
A) To know whom to call if the patient asks for a cleric
B) To identify religious beliefs that may affect the mother or the fetus
C) To aid in research on how many births occur yearly in a religious denomination
D) To have a cleric of the right denomination in the hospital during the birth


14. A woman in her second trimester of pregnancy calls the obstetrician’s office and tells the nurse that she is having pains all around her umbilicus. What would be the nurse’s best response?
A) “You are having growing pains. There is nothing to worry about.”
B) “These pains are caused by the stretching of ligaments as your uterus grows. They are nothing to worry about.”
C) “These are called Braxton Hicks contractions. They are a kind of ‘practice’ for when the baby is born.”
D) “You are having preterm labor. Go to the emergency room right away.”


15. The nurse is assessing a 27-year-old woman pregnant for the first time during her initial visit to the obstetric clinic. The patient is currently at 8 weeks’ gestation. During the assessment, the patient reports that she is experiencing sharp stabbing pains in her lower abdomen, especially when she changes position. How would the nurse document this finding?
A) The patient is having growing pains
B) The patient is having a miscarriage
C) The patient is having preterm labor
D) The patient is having Braxton Hicks contractions


16. Which of the following patients would most likely be found to have undergone female circumcision during a genital examination?
A)  East Asian    B)  African    C)  Pacific Islander    D)  Eastern European


17. Mothers of advanced maternal age are at increased risk for what? (Select all that apply.)
A) Genetic anomalies in the fetus
B) Increased preexisting health problems
C) Gestational diabetes
D) Cephalopelvic disproportion
E) Miscarriage


18. What is the most appropriate nursing intervention when writing a care plan for a pregnant woman and using the nursing diagnosis “Readiness for enhanced family coping due to new role?”
A) Help the patient move toward an enriching lifestyle
B) Educate the patient about nutrition and overeating, exercise, and stress management techniques
C) Provide breast-feeding support
D) Assess the structure, resources, and coping abilities of the family


1. The nurse is assessing a 14-year-old boy who has reached puberty. What glands would the nurse know have become active?
A)  Eccrine    B)  Apocrine    C)  Pineal    D)  Parathyroid


2. A 17-year-old male athlete comes to the clinic for a sports screening examination. He tells the nurse that he “parties” every weekend. What is the most appropriate topic for patient teaching with this patient?
A) Safe sex practices C) Physiologic changes in adolescence
B) Nutrition for athletes D) Drinking and driving


3. A 16-year-old girl shows symptoms of human papillomavirus during a health surveillance visit. What is the first action the nurse should take to educate the child about her condition?
A) Reassure the girl that findings will remain confidential
B) Recruit the help of the child’s parents
C) Explain how girls are more susceptible to sexually transmitted infections (STIs)
D) Describe all the risks of unprotected sex


4. An 8-year-old boy comes to the emergency department with abdominal pain. The nurse notes that when the child walks to the treatment room, he is walking on his toes. What might the nurse suspect is wrong with this child?
A) Incarcerated hernia C) Testicular torsion
B) Appendicitis D) Wilms’ tumor


5. A 13-year-old girl is visiting the pediatric clinic for leg pain. Her mother states that she has been limping for “2 to 3 weeks.” What does the nurse know needs to be ruled out? (Select all that apply.)
A) Dislocation
B) Compound fracture
C) Simple fracture
D) Graves’ disease
E) Bone tumor


6. The nurse is assessing siblings, 8 and 12 years old, for school physical examinations. They are recent immigrants to the United States; this is their first visit to the clinic. When doing the initial assessment, the nurse would assess their nutrition by asking what questions? (Select all that apply.)
A) Do you eat pork?
B) Do your grandparents live with you?
C) Is family food prepared at home?
D) With whom do you eat?
E) What food do you eat for the last meal of the day?


7. According to Bright Futures, within what context should the nurse address the child’s health needs?
A) School and extended family C) Family and community
B) Community and health care facilities D) Family and school


8. When working with children, what diagnostic tests are indicated specifically for well-child examinations?
A)  Lead levels    B)  Tuberculosis test    C)  Urinalysis    D)  None


9. A 12-year-old girl has been admitted to the pediatric unit with bilateral lower lobe pneumonia. When writing a plan of care for this child, what would be the most appropriate intervention?
A) Provide information for age-appropriate community activities
B) Identify normal findings in the child
C) Assess parenting
D) Provide information that contributes to an improved state of health


10. The nurse is doing an initial assessment on an 8-year-old admitted to the pediatric unit in sickle cell crisis. When inspecting the eyes, the nurse finds that they are normal. How would the nurse chart these findings?
A) Eyes are PERRL(A) with corneal light reflexes equal bilaterally
B) Eyes are PERRL(A). EOMs are at 180o degrees. Corneal light reflexes are equal
C) Eyes are WNL
D) Eyes are PERRL(A) with EOMs at 180° bilaterally


11. The school nurse is assessing vision and hearing for several kindergarteners. At what age does visual acuity approximate that of the adult?
A)  5 to 6    B)  4 to 5    C)  6 to 7    D)  3 to 4


12. An instructor asks a student nurse, “What is the most common infectious disease of childhood?” What would be the student nurse’s best answer?
A)  Dental caries    B)  Otitis media    C)  Thrush    D)  Otitis externa


13. A mother brings her 4-year-old son to the clinic and explains to the nurse that her son turns blue sometimes when he is playing. The nurse assesses the child’s pulses and notes a significant difference in the pulses in the upper and lower extremities. The nurse would suspect that the child has what?
A) Tetralogy of Fallot C) Femoral artery aneurysm
B) Coarctation of the aorta D) Transposition of the great vessels


14. A 5-year-old girl arrives at the emergency department with severe acute abdominal pain and tenderness. The nurse would expect this child to be evaluated for what? (Select all that apply.)
A) Stomach virus
B) Gastroenteritis
C) Ulcerative colitis
D) Appendicitis
E) Incarcerated umbilical hernia


15. A woman brings her 7-year-old son to the clinic. The mother states that she was giving her son a bath and noted irritation around his rectum. The nurse would expect this patient to be evaluated for what? (Select all that apply.)
A) Sexual abuse
B) Constipation
C) Hemorrhoids
D) Worms
E) Yeast infection


1. A student nurse asks the instructor why it is necessary to do a comprehensive health assessment on a new patient. What would be the instructor’s best response?
A) “A new patient needs a more complete assessment.”
B) “It is a better assessment than any other assessment.”
C) “The comprehensive health assessment integrates all body systems and helps give the nurse an overall impression of the patient and his or her condition.”
D) “You need to know what is going on with the patient at that point in time.”


2. When conducting a focused health assessment, the nurse asks questions specifically targeting what?
A) The patient’s culture
B) The patient’s gender
C) The patient’s sexual orientation
D) Issues and symptoms specific to the patient


3. Students are learning about subjective data collection. What data are collected subjectively? (Mark all that apply.)
A) Risk factors
B) Common symptoms
C) Family history
D) Auscultated sounds
E) Visualized signs


4. When collecting subjective data, the nurse gives the patient time and encouragement to do what?
A) Tell stories about his or her family C) List common findings
B) Express complaints D) Tell his or her story


5. A nursing instructor is explaining to students about primary prevention services that nurses offer as part of their professional responsibilities. What would the instructor list as these services?
A)  Palpation    B)  Auscultation    C)  Screening    D)  Rehabilitation


6. The nurse is assessing risk factors on a new clinic patient. These risk factors are assessed according to what?
A) The individual’s age C) The individual’s gender
B) The individual’s risks D) The individual’s lifestyle


7. The nurse is conducting a head-to-toe assessment on a patient. For what would the nurse inspect the skin? (Mark all that apply.)
A) Peeling
B) Rashes
C) Goose bumps
D) Lesions
E) Color


8. While assessing a patient’s eyes, the nurse notes a depressed corneal response. In what type of patient would this finding be considered normal?
A) None
B) Wearer of contact lenses
C) With a history of macular degeneration
D) Blind


9. The nurse is assessing a 77-year-old patient who complains about being “very tired” all the time. What is the best way to assess this patient?
A) In a warm, well-lighted room C) Like all other patients
B) Divided over several time periods D) Slowly in a draft-free room


10. When considering the culture of a patient, the nurse would be aware that in some cultures
A) A health care provider of the same gender is preferred
B) Only a male health care provider is acceptable
C) A chaperone always has to be with the patient
D) A translator is always necessary


11. When auscultating the chest near the collar bone of a 10-year-old child, the nurse would be most likely to hear what benign heart sound?
A)  Bruit    B)  Friction rub    C)  Venous hum    D)  Rhonchi


12. The nurse is palpating the abdomen of a patient newly admitted to the unit. What would be an abnormal finding?
A)  Softness    B)  Guarding    C)  Nonpalpable organs    D)  Nontender areas


13. When doing a shift assessment on a new patient, the nurse notes that the popliteal pulses are within normal limits (WNL). How would the nurse chart this?
A) Popliteal pulses 1-2+ C) Pulses 3-4+
B) Pulses 2-3+ D) Popliteal pulses 4+


14. The nurse is caring for a patient who fell from a two-story building and was brought to the emergency department by ambulance. Initial findings include asymmetry of the thorax and paradoxical respirations. The nurse would document these findings as what?
A)  Flail chest    B)  Barrel chest    C)  Scoliosis    D)  Kyphosis


15. A nurse is caring for a patient with inflammatory bowel changes and has identified a nursing diagnosis of “Diarrhea related to inflammatory changes in the bowel.” What would be an appropriate intervention for this diagnosis?
A) Use a heat or cold pack for pain relief.
B) Ensure adequate hydration and electrolyte replacements.
C) Provide periods of rest by clustering care.
D) Gather resources for home care and daily activities.


16. A new patient presents at the clinic and reports difficulty hearing. During the interview, the patient asks the nurse to repeat questions several times. Examination of the ears reveals large amounts of cerumen filling the canals bilaterally. What would be an appropriate outcome for this patient?
A) Hearing will be restored to WNL
B) The patient will learn to safely clean ears with cotton swabs
C) Ears will be cleaned at the clinic with hearing improved
D) The patient will clean ears at home


17. To increase the number of people with a specific source of ongoing care, what would a nurse teach the patient?
A) Review healthy diet, regular exercise, weight reduction, and recommended screenings
B) Remind patients with diabetes to get foot checks annually
C) Discuss safe-sex practices and encourage patients who are at risk to get testing
D) Teach the patient to have regular visits for screening and health promotion


18. What type of assessment would a hospital nurse perform on a patient being admitted?
A)  Screening    B)  Focused    C)  Acute    D)  Comprehensive