Health Assessment Review questions ch. 1,2,3,11,4,5,6,13,14,15,16,17,22

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lansmith
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Health Assessment Review questions ch. 1,2,3,11,4,5,6,13,14,15,16,17,22
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2011-07-04 21:39:01
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Health Assessment
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Review questions
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  1. A patient is having side effects from a medication. The nurse calls the provider to request a change to the medication order. The nurse is functioning as an/a
    A. Educator
    B. Organizer
    C. Counselor
    D. Advocate
    D. Advocate
    (this multiple choice question has been scrambled)
  2. Nurses advocate for underserved populations to reduce health disparities. This promotes
    A. Autonomy
    B. Altruism
    C. social justice
    D. Human dignity
    C. Social justice
    (this multiple choice question has been scrambled)
  3. Nurses belong to the ANA as part of their
    A. Cultural education activities
    B. Wellness promotion for patients
    C. ongoing professional responsibility
    D. Role as manager of care
    C. Ongoing professional responsibility
    (this multiple choice question has been scrambled)
  4. The purpose of health assessment is to
    A. Obtain subjective and objective data
    B. Intervene to correct problems
    C. Outline care that is appropriate
    D. Determine if interventions are effective
    A. Obtain subjective and objective data
    (this multiple choice question has been scrambled)
  5. The nurse documents the following information in a patient's chart: "cough and deep breathe every hour while awake." This is an example of
    A. Comprehensive assessment
    B. Evidence-based nursing
    C. Priority setting
    D. Nursing interventions
    D. Nursing interventions
    (this multiple choice question has been scrambled)
  6. The nurse provides teaching about smoking cessation to a 20-year-old man. The nurse assesses that the patient is concerned because his father died from lung cancer. Which theory would the nurse most likely use when providing teaching to this patient?
    A. Diagnostic reasoning model
    B. Body systems model
    C. Health belief model
    D. Cultural competence model
    C. Health belief model
    (this multiple choice question has been scrambled)
  7. Which of the following processes is the most important when providing nursing care to an ill patient?
    A. Collecting objective data
    B. Writing outcomes
    C. Performing a focused assessment
    D. Using Critical thinking
    D. Using critical thinking
    (this multiple choice question has been scrambled)
  8. A patient is admitted to a hospital for surgery for colon cancer. What type of assessment is the nurse most likely to perform upon admission?
    A. Illness
    B. Comprehensive
    C. Emergency
    D. Focused
    B. Comprehensive
    (this multiple choice question has been scrambled)
  9. Which of the following are components of a comprehensive health assessment?
    A. Goals and outcomes
    B. Nursing diagnoses
    C. Examination of body systems
    D. Collaborative problems
    C. Examination of Body systems
    (this multiple choice question has been scrambled)
  10. The nurse conducts the health history based upon the patient's responses to the medical diagnosis. This type of framework is based on the
    A. Functional framework
    B. Coordinator framework
    C. Objective framework
    D. Collaborative framework
    A. Functional framework
    (this multiple choice question has been scrambled)
  11. Nonverbal communication skills include
    A. word choice and questions
    B. speed of the voice and dress
    C. facial expression and body position
    D. Voice volume and gestures
    C. facial expression and body position
    (this multiple choice question has been scrambled)
  12. The nurse talks with the patient and asks, "So tell me more about the chest pain that you had." This is an example of
    A. reflection
    B. restatement
    C. encouraging elaboration
    D. clarifying
    C. Encouraging elaboratoin
    (this multiple choice question has been scrambled)
  13. When the patient says, "I'm so angry that I have to have surgery," the nurse says, "you sound very frustrated." This is an example of
    A. Focusing
    B. silence
    C. Summarizing
    D. reflection
    D. refelction
    (this multiple choice question has been scrambled)
  14. The nurse is gathering the health history data before performing the physical assessment. This phase of the interview process is the
    A. closing phase
    B. working phase
    C. preinteraction phase
    D. Beginning phase
    D. Working phase
    (this multiple choice question has been scrambled)
  15. When working with a medical interpreter, the nurse knows that it is best to
    A. use close-ended questions
    B. speak slightly louder than normal
    C. avoid using medical terms
    D. Look directly at the patient
    D. Look directly at the patient
    (this multiple choice question has been scrambled)
  16. When interviewing adolescents, the nurse recognizes that
    A. the peer group has little influence
    B. medical authorities have the answers
    C. privacy may be especially important
    D. parents retain strict control
    C. Privacy may be especially important
    (this multiple choice question has been scrambled)
  17. The patient is crying after being given a diagnosis with a poor prognosis. The best response from the nurse is
    A. "I think that you should have surgery."
    B. "I'll stay with you." (and gets a tissue)
    C. "Don't cry. It will be OK."
    D. "My mother has the same thing."
    B. "I'll stay with you." (and gets a tissue)
    (this multiple choice question has been scrambled)
  18. An older adult says, "How come you're asking me so many questions?" The best response from the nurse is
    A. "Are you getting tired? I can come back later."
    B. "Why are you asking me that?"
    C. "We need a complete understanding of your problems."
    D. "It's all a part of the health history."
    A. "Are you getting tired? I can come back later."
    (this multiple choice question has been scrambled)
  19. When the nurse asks the patient during a health history about mental health problems, the patient responds by saying, "Don't you tell me I'm crazy!" The best response by the nurse is
    A. "having mental health problems is different from being crazy."
    B. "This sounds like a sensitive subject for you."
    C. "I didn't say that you were crazy."
    D. "Tell me more about what you mean by that."
    D. "Tell me more about what you mean by that."
    (this multiple choice question has been scrambled)
  20. The mother of an infant with severe asthma is extremely anxious. The nurse is treating the patient in the emergency room. When collecting the history, the best response of the nurse is
    A. "Is there anyone here that you can talk to?"
    B. "You must be extremely worried."
    C. "You seem worried, but I need to ask a few questions."
    D. "I'd be in worse shape than you are if it was my baby."
    C. "You seem worried, but I need to ask a few questions."
    (this multiple choice question has been scrambled)
  21. A patient says that she is having throbbing pain that she rates as 6 o a 10-point scale. This is referred to as
    A. Objective primary data
    B. Subjective secondary data
    C. Objective secondary data
    D. Subjective primary data
    D. Subjective primary data
    (this multiple choice question has been scrambled)
  22. The patient is having crushing chest pain that he rates as 8 on a 10-point scale. His blood pressure is 80/62. The nurse performs which type of assessment?
    A. Emergency
    B. Comprehensive
    C. Focused
    D. Acute
    A. Emergency
    (this multiple choice question has been scrambled)
  23. As part of the past health history, the nurse collects the following data:
    A. Child rolls onto stomach; reflexes intact
    B. Patient had breast cancer in 2007; treated with chemotherapy
    C. Mother had a history of thyroid disease at 50 years.
    D. Patient uses walker to ambulate at home
    B. Patient had breast cancer in 2007; treated with chemotherapy
    (this multiple choice question has been scrambled)
  24. When gathering the family history, the nurse draws a genogram, using
    A. Lines between parents to show marriage.
    B. The patient on the left to show birth order
    C. Circles for males and squares for females
    D. Health problems listed above the symbol
    A. Lines between parents to show marriage.
    (this multiple choice question has been scrambled)
  25. The history of present illness includes an assessment of
    A. feeding, bathing, toileting, dressing, grooming, mobility, home maintenance, shopping, and cooking
    B. nutrition/hydration, skin/hair/nails, head/neck, eyes/ears, heart, peripheral vascular, breasts, abdominal, musculoskeletal, neurological, genitalia, rectum, and endocrine/hematological
    C. location, intensity,duration, description, aggravating and alleviating factors, functional impairment, and pain goal
    D.health perception, nutrition, elimination, activity, sleep, cognition, self-perception, roles, sexuality, coping, and values
    C. location, intensity,duration, description, aggravating and alleviating factors, functional impairment, and pain goa
    (this multiple choice question has been scrambled)
  26. The nurse asks, "What are the most important things to you in life?" to assess the function pattern related to
    A. self-perception
    B. values
    C. role
    D. coping
    B. values
    (this multiple choice question has been scrambled)
  27. To assess self-perception, the nurse asks
    A. Are you having difficulty handling any family problems?
    B. How do you usually deal with stress? Is it effective?
    C. How would you describe yourself?
    D. What gives you hope when times are troubled?
    C. How would you describe yourself
    (this multiple choice question has been scrambled)
  28. When the nurse asks about feeding, bathing, toileting, dressing, grooming, mobility, home maintenance, shopping, and cooking, he or she is assessing
    A. ADLs
    B. functional health patterns
    C. review of systems
    D. whether the patient is a reliable historian
    A. ADLs
    (this multiple choice question has been scrambled)
  29. The nurse assessing the child focuses the health history on
    A. birth history, immunizations, growth and development
    B. religion, spirituality, culture, and values
    C.sensory deficits, illness history, lifestyle factors
    D. previous pregnancies, obstetrical history, psychosocial factors
    A. birth history, immunizations, growth and development
    (this multiple choice question has been scrambled)
  30. The nurse performs patient teaching after assessing that the nutritional history reveals a patient generally consumes a high-fat, high-calirie diet. This critical thinking
    A. uses subjective data to analyze findings and intervene
    B. documents and communicates data using appropriate medical terminologies
    C. uses assessment findings to identify medical and nursing diagnoses
    D. individualizes health assessment considering the age, gender, and culture of the patient
    A. uses subjective data to analyze findings and intervene
    (this multiple choice question has been scrambled)
  31. National standards for Culturally and Linguistically Appropriate Services in Health Care mandate that the standards
    A. should be used in hospitals
    B. may be used in public settings
    C. be upheld in every health care setting
    D. should be applied in private offices
    C. be upheld in every health care setting
    (this multiple choice question has been scrambled)
  32. CAM therapies used instead of conventional treatments to restore health are often termed
    A. advantaged
    B. complementary
    C. alternative
    D. conventional
    C. alternative
    (this multiple choice question has been scrambled)
  33. The social context influences the patterns of health and illness for individuals, communities, and societies. An example is
    A. Assessment of the religious practices of the patient
    B. Assessment of the patients health beliefs and practices
    C. Assessment of focus groups in multiple locations
    D. Assessment of culturally based postpartum practices
    C. Assessment of focus groups in multiple location
    (this multiple choice question has been scrambled)
  34. The purpose of comparing culture care needs of the specific individual to the general themes of people from similar cultural background is to
    A. Determine if the patient needs a spiritual consultation
    B. identify the dietary needs of a specific religious preference
    C. Provide a picture of the individual's culture-based health care needs
    D. Consider how closely the patient follows his or her religion
    C. Provide a picture of the individual's culture-based health care needs
    (this multiple choice question has been scrambled)
  35. With transcultural assessment, the nurse must
    A. Determine which questions to ask
    B. ask all the questions for completeness
    C. wait until the relationship is established to ask questions
    D. include all the questions as part of an admitting assessment
    A. Determine which questions to ask
    (this multiple choice question has been scrambled)
  36. A shared, learned, and symbolic system of values, beliefs, and attitudes that shapes and influences the way people see and behave in the world is defined as
    A. culture
    B. spirituality
    C. society
    D. community
    A. culture
    (this multiple choice question has been scrambled)
  37. Even when daily prayers or other religious practices are not a part of a patient's life routine, they often take central position during life transitions, such as loss of a loved one, accident, or serious illness. A related nursing diagnosis might be
    A. impaired social interaction
    B. readiness for enhanced spiritual well-being
    C. social isolation
    D. spiritual distress
    D. spiritual distress
    (this multiple choice question has been scrambled)
  38. It is important to identify similarities and differences among the cultural beliefs of the patient, health care agency, and the nurse to
    A. avoid making assumptions
    B. get the proper diet
    C. communicate with family
    D. perform a spiritual consult
    A. avoid making assumptions
    (this multiple choice question has been scrambled)
  39. Seeking understanding of one's culturally base health care practices is essential to nursing because each culture has its own traditional values and beliefs about health and illness that
    A. use various health methods that might be harmful
    B. has things that need to be avoided
    C. may affect patients' adherence to treatments
    D. affect the body image and overweight habits
    C. may affect patients' adherence to treatments
    (this multiple choice question has been scrambled)
  40. What is the nurse's best response when a Muslim patient has a basin of water on his bedside stand that he does not want emptied?
    A. Support and accommodate his preference
    B. Empty it because it could spill and get the bed wet
    C. Talk with him about why he should not have it there
    D. Tell him that the water is a health hazard
    A. Support and accommodate his preference
    (this multiple choice question has been scrambled)
  41. Which of the following interventions is most important to prevent nosocomial infections?
    A. Proper glove use
    B. Appropriate draping
    C. Quiet environment
    D. Hand hygiene
    D. Hand hygiene
    (this multiple choice question has been scrambled)
  42. Standard precautions
    A. are used on every patient, because many infections are unknown
    B. include the use of gowns, gloves, and masks with all patients
    C. recognize that transmission-based precautions are common
    D. State that hand gel is used for infection with C. difficile
    A. are used on every patient, because many infections are unknown
    (this multiple choice question has been scrambled)
  43. Latex allergies
    A. cannot be cause by equipment such as a stethoscope
    B. can be reduced by moisturizing the hands after washing
    C.always result in anaphylactic reactions and shock
    D. are more common in nurses and frequently hospitalized patients.
    D. are more common in nurses and frequently hospitalized patients.
    (this multiple choice question has been scrambled)
  44. Which of the following is an appropriate use of gloves? Gloves are
    A. worn during anticipated contact with intact skin
    B. worn during anticipated contact with body secretions
    C. removed when going from clean to contaminated areas
    D. removed when assessing the back of an incontinent patient
    B. worn during anticipated contact with body secretions
    (this multiple choice question has been scrambled)
  45. Which of the following is an example of inspection?
    A. Skin pink
    B. Heart rate and rhythm regular
    C. Abdomen tympanic
    D. Lungs clear
    A. Skin pink
    (this multiple choice question has been scrambled)
  46. The patient is complaining of abdominal pain. What technique is used to form an overall impression?
    A. Light palpation
    B. Auscultation
    C. Deep palpation
    D. Direct percussion
    A. Light palpation
    (this multiple choice question has been scrambled)
  47. Tympany is a percussion sound commonly located in the
    A. lower leg
    B. upper arm
    C. abdomen
    D. thorax
    C. abdomen
    (this multiple choice question has been scrambled)
  48. The nurse auscultates which organs as part of the admitting assesment?
    A. Kidneys, bladder, ureters
    B. Abdomen, flank, and groin
    C. Neck, jaw, and clavicle
    D. Heart, lungs and abdomen
    D. Heart, lungs and abdomen
    (this multiple choice question has been scrambled)
  49. What technique facilitates accurate auscultation?
    A. the chestpiece of the stethoscope is sealed against the skin
    B.The tubing of the stethoscope is long and dark in color
    C. Earpieces of the stethoscope are positioned to point toward the back
    D. The diaphragm of the stethoscope is used for low-frequency sounds
    A. the chestpiece of the stethoscope is sealed against the skin
    (this multiple choice question has been scrambled)
  50. When assessing the child, the nurse makes the following adaption to the usual techniques:
    A. The child is seated away from the parent
    B. The room is full of toys for play
    C. The child is undressed, including the diaper
    D. A pediatric stethoscope provides better contact
    D. A pediatric stethoscope provides better contact
    (this multiple choice question has been scrambled)
  51. Which of the following are advantages of the electronic medical record? Select all that apply
    A. Nurses can enter data by checking boxes and adding free full text
    B. It allows primary providers to directly order into the computer
    C. It cannot be used as a legal document in case of a lawsuit
    D. It is economical and easy to learn and implement
    A. Nurses can enter data by checking boxes and adding free full text
    (this multiple choice question has been scrambled)
  52. Which of the following are high-risk assessments for liability? Select all that apply.
    A. Failure to document completely
    B. Inadequate admission assessment
    C. Charting in advance
    D. Bunch charting at the end of the shift
    • All of the above
    • failure to doc completely, inadequate admission assessment, charting in advance, bunch charting at the end of the shift.
  53. Which of the following is the purpose of auditing charting?
    A. To enhance nurses' learning and understanding of complex clinical situations
    B. To identify staff members who document completely and counsel those who do not
    C. To determine if staff members are providing and documenting standards of care
    D. To locate data in the chart the evening before a morning clinical
    C. To determine if staff members are providing and documenting standards of care
    (this multiple choice question has been scrambled)
  54. Which of the following are acceptable under the Hippa Privacy Rule?
    A. Communicate report with the next nurse during change of shift
    B. Communicate with the primary provider about a patient's change in assessment
    C. Consult in the hall with the instructor about the patient's abnormal feelings
    D. Describe patient assessment findings to a colleague in the cafeteria
    A. Communicate report with the next nurse during change of shift
    (this multiple choice question has been scrambled)
  55. Which of the following is the proper technique for correcting written documentation?
    A. Completely black out the error with a black marker
    B. Draw a single line through the error and initial
    C. Write over the error in dark ink
    D. Use whiteout and write over the error
    B. Draw a single line through the error and initial
    (this multiple choice question has been scrambled)
  56. What do the different formats of progress notes have in common?
    A. All use the nursing process in some form to show nursing thinking
    B. All have a section for evaluation of care so that nurses may revise interventions
    C. All include head-to-toe assessment data for completeness
    D. All identify the patient outcomes or goals to evaluate
    A. All use the nursing process in some form to show nursing thinkin
    (this multiple choice question has been scrambled)
  57. What are some strategies for effective handoffs during change-of-shift report?
    A. Vary the format to individualize to the patient
    B. Put report in writing so that the next shift provider can get right to work
    C. Allow an opportunity to ask and answer questions
    D. Tape record the report for efficiency
    C. Allow an opportunity to ask and answer questions
    (this multiple choice question has been scrambled)
  58. In the SBAR reporting format, which of the following would be an example of data found in the assessment?
    A. Ms. Choi needs to have a social work consult
    B. Mrs. Kelly's diagnosis is Stage II breast cancer
    C. Mr. Imami's lungs sounds are decreased
    D. Mr. Jones was admitted at 10:30 this morning
    C. Mr. Imami's lungs sounds are decreased
    (this multiple choice question has been scrambled)
  59. Nursing assessment of trends in an unconscious patient's neurological status over time is best recorded on
    A. a POC
    B. a progress note
    C. an admission assessment
    D. a focused assessment flow sheet
    D. a focused assessment flow sheet
    (this multiple choice question has been scrambled)
  60. Your patient with a humerus fracture is stating pain of 15 on a 10-point scale. His hand is pale, cool, and swollen. His pain medication is ineffective, and he is at risk for compartment syndrome. What action will the nurse take first?
    A. Reassess the pain in 30 minutes and contact the provider if unresolved
    B. Document the abnormal findings and give an extra dose of pain medication now.
    C. Give additional pain medication and reassess the pain in 30 minutes
    D. Contact the primary provider and document the findings now
    D. Contact the primary provider and document the findings now
    (this multiple choice question has been scrambled)
  61. Mr. Holmes has come to the clinic for a well-patient visit. When assessing his vital signs, the nurse palpates an irregular heart rate. The nurse must then auscultate for a full minute at the apical pulse site. Locate the apical pulse on the diagram below.
    The apical pulse is close to the left nipple
  62. What are the four characteristics of a pulse?
    Rate, rhythm, force(amplitude ), elasticity
  63. An unconscious 20-year-old woman arrives at the hospital after drinking large quantities of alcohol. Her vital signs are T 98.2 0F, po; P 58; R 9; BP 100/64. What conclusion would a nurse make about this patient's respiratory status?
    A. The patient is experiencing bradypnea
    B. The patient is experiencing apnea
    C. The patient is experiencing bradycardia
    D. The patient's respiratory status is within normal limits
    A. The patient is experiencing bradypnea
    (this multiple choice question has been scrambled)
  64. The patient's radial pulse is weak and thready. The nurse would document the finding as
    A. 3+/4+
    B. 1+/4+
    C. 2+/4+
    D. Radial pulse absent
    B. 1+/4+
    (this multiple choice question has been scrambled)
  65. The nurse is preparing to assess the vital signs of a 62-year-old woman following hip surgery. When the nurse arrives, the patient is sitting in her chair having just finished breakfast. What is the appropriate nursing action?
    A. Ask the patient to lie down in bed to assess vital signs
    B. Take a rectal temperature
    C. Take vital sings as planned
    D. Wait 20 to 30 minutes and then take vital signs
    D. Wait 20 to 30 minutes and then take vital sign
    (this multiple choice question has been scrambled)
  66. The postoperative vital signs of a 47-year-old man with a ruptured appendix are BP 112/68, pulse 56, R 8, T 37.6 C temporally. The patient is pale and confused, with minimal urine output. The nurse should
    A. administer pain medication
    B. recheck the vitals signs in 30 minutes
    C. notify the clinician
    D. continue with care as planned
    C. notify the clinician
    (this multiple choice question has been scrambled)
  67. The pulse pressure for a patient with a BP of 144/86 is
    A. 144
    B. 230
    C. 58
    D. 86
    C. 58
    (this multiple choice question has been scrambled)
  68. The nurse is caring for an elderly confused patient. In assessing temperature, the nurse will obtain the reading using
    A. A rectal thermometer
    B. an oral thermometer
    C. A tympanic thermometer
    D. A mercury thermometer
    C. A tympanic thermometer
    (this multiple choice question has been scrambled)
  69. PThe nurse notes an irregular radial pulse in a patient. Further assessment includes assessing
    A. femoral pulse
    B. brachial pulse
    C. carotid pulse
    D. apical pulse
    D. apical pulse
    (this multiple choice question has been scrambled)
  70. Which action will result in an accurate BP reading? Select all that apply.
    A. Applying the center of the bladder of the cuff directly over the brachial artery
    B. Raising the arm to the level of the heart
    C. Using the bell to assess the BP
    D. Pumping the cuff 60 mm Hg above the estimated BP
    • A. Applying the center of the bladder of the cuff directly over the brachial artery
    • B. Raising the arm to the level of the heart
    • C. Using the bell to assess the BP
  71. The nurse is admitting a 75-year-old man with a 50-year history of smoking one pack of cigarettes per day. Among the patient's concerns is his chronic shortness of breath. One nail finding that demonstrates chronic hypoxia is
    A. pitting
    B. clubbing
    C. Brittleness and cracking of the nails
    D. Thickening and discoloration of the nailbed
    B. clubbing
    (this multiple choice question has been scrambled)
  72. All of the following skin lesions are papular except
    A. acne
    B. herpes zoster
    C. moles
    D. warts
    B. herpes zoster
    (this multiple choice question has been scrambled)
  73. The ABCDs of melanoma identification include all of the following except
    A. C (color): pigmentation is not uniform; there may be shades of tan, brown, and black as well as red, white and blue
    B. D (diameter): greater than 6 mm
    C. B (birthmark): recently changed in appearance
    D. A (asymmetry): one half does not match the other half
    C. B (birthmark): recently changed in appearance
    (this multiple choice question has been scrambled)
  74. A nurse observes a skin lesion with a well-defined borders on the upper left thigh. It is 1.5 cm in diameter, flat, hypopigmented, and nonpalpable. What is the correct terminology for this lesion?
    A. Macule
    B. Papule
    C. Patch
    D. Plaque
    C. Patch
    (this multiple choice question has been scrambled)
  75. When assessing hydration in an infant, the nurse would
    A. pinch a fold of skin just below the midpoint of one of the clavicles and allow the skin to recoil to normal
    B. Pinch a fold of skin on the abdomen and observe for recoil to normal
    C. pinch a fold of skin on the head and allow for skin to recoil in children
    D. pinch a fold of skin on the medial aspect of the forearm and observe for recoil to normal
    B. Pinch a fold of skin on the abdomen and observe for recoil to normal
    (this multiple choice question has been scrambled)
  76. A fari-skinned, blonde, 18-year-old woman is at the clinic for a skin examination. She reports that she always turns red within 10 minutes of going outside. She is planning a trip to Mexico and wants to avoid getting sunburned. What would the nurse teach the patient?
    A. Excessive exposure to UVA and UVB rays increases risk of sunburn and skin cancer.
    B. Apply a sunscreen or sunblock at least 15 to 30 minutes prior to sun exposure
    C. Avoid sun exposure between 10am and 4pm to reduce UVA and UVB exposure
    D. All of the above.
    • D. All of the above.
    • Excessive exposure to UVA and UVB rays increases risk of sunburn and skin cancer
    • Apply a sunscreen or sunblock at least 15 to 30 minutes prior to sun exposure
    • Avoid sun exposure between 10am and 4pm to reduce UVA and UVB exposure
  77. An 8-year-old patient presents to the clinic with erythematous vesicles on the face and chest. Some vesicles have broken open, revealing a moist, shallow ulcerated surface; some have scabbed over. The nurse suspects which of the following infectious illnesses?
    A. Varicella
    B. Measles
    C. Roseola
    D. Herpes simplex
    A. Varicella
    (this multiple choice question has been scrambled)
  78. A 24-year-old patient reports an itchy red rash under her breasts. Examination reveals large, reddened moist patches under both breasts in the skin folds. Several smaller, raised, red lesions surround the edges of the large patch. What is the correct terminology for the distribution patter of these smaller lesions?
    A. Discrete
    B. Zosteriform
    C. Confluent
    D. Satellite
    D. Satellite
    (this multiple choice question has been scrambled)
  79. A 22-year-old patient presents to the clinic with a large firm mass on her left earlobe. She had her ears pierced approximately 3 weeks ago. The mass began as a small bump and progressively enlarged to its current size of approximately 1 inch in diameter. It is not tender, redened, or seeping any drainage. What is the term used to describe this secondary skin lesion?
    A. Lichenification
    B. Crust
    C.Keloid
    D. Scale
    C.Keloid
    (this multiple choice question has been scrambled)
  80. An 83-year-old woman is undergoing a routine physical examination. Which of the following assessment findings would the nurse consider an expected age-related variation?
    A. Hypopigmented, flat macules and patches over sun-exposed areas
    B. Thinning of the skin
    C. Multiple purplish bruises on the arms and legs
    D. Increased skin turgor
    B. Thinning of the skin
    (this multiple choice question has been scrambled)
  81. A patient has several red, inflamed, superficial, palpable lesions containing a thickened yellowish substance. How would the nurse document this lesion?
    A. Pustule
    B. Cyst
    C. Vesicle
    D. Papule
    A. Pustule
    (this multiple choice question has been scrambled)
  82. While examining the patient's neck, the nurse finds the trachea midline but has difficulty palpating the thyroid. What action would the nurse take next?
    A. Report to the physician a suspicion of a slow growing goiter
    B. Tell the patient that this finding is abnormal
    C. Document this finding as normal
    D. Look for signs of hypothyroidism
    C. Document this finding as normal
    (this multiple choice question has been scrambled)
  83. The lymph nodes that lie superficial to the mastoid bone are the
    A. Posterior auricular nodes
    B. Preauricular nodes
    C. Superficial cervical nodes
    D. Supraclavicular nodes
    A. Posterior auricular node
    (this multiple choice question has been scrambled)
  84. Which of the following descriptions is most consistent with a patient who has hypothyroidism?
    A. Slightly obese female with periorbital edema and a flat facial expression, who complains of constipation, deceased appetite and fatigue
    B. Thin, anxious-appearing female with exophthalmos and a rapid pulse, and who complains of diarrhea
    C. Slightly obese, perspiring female, who complains of feeling cold all the time and having diarrhea
    D. Thin, perspiring male with a deep hoarse voice, facial edema, a thick tongue, and reports of diarrhea
    A. Slightly obese female with periorbital edema and a flat facial expression, who complains of constipation, deceased appetite and fatigue
    (this multiple choice question has been scrambled)
  85. Physical examination of a patient reveals an enlarged tonsilar node. Acutely infected nodes would be
    A. Irregular and hard
    B. Firm but movable and tender
    C. Fixed and soft
    D. Hard and nontender
    B. Firm but movable and tender
    (this multiple choice question has been scrambled)
  86. While assessing the skin of a 24-year-old patient, the nurse notes decreased skin turgor. The nurse should further assess for signs and symptoms of
    A. malnutrition
    B. hyperthyroidism
    C. hypothyroidism
    D. dehydration
    D. dehydration
    (this multiple choice question has been scrambled)
  87. The nurse can best evaluate the strength of the sternocleidomastoid muscle by having the patient
    A. extend his or her arms against resistance
    B. turn his or her head against resistance
    C. clench his or her teeth during muscle palpation
    D. bring his or her head to the chest
    B. turn his or her head against resistance
    (this multiple choice question has been scrambled)
  88. Which of the following best describes the instructions the nurse should give a patient when assessing the thyroid from the posterior approach?
    A. pelase look straight ahead and tilt your head slightly down and to one side.
    B. Please turn your head as far to the right as you can
    C. Please tilt your head back as far as possible
    D. Please bring your chin down toward your neck
    A. pelase look straight ahead and tilt your head slightly down and to one side.
    (this multiple choice question has been scrambled)
  89. While assessing a patient, the nurse finds a palpable lymph node in the left supraclavicular region. Which of the following should be the next action?
    A. Recognize that this is a common area for lymph nodes to be enlarged with minor infections
    B. Recognize that a palpable node in this region is a dangerous indication of metastatic cancer that requires further evaluation
    C. Recognize that a palpable lymph node in this region is always indicative of malignancy
    D. Recognize that it is common to palpate lymph nodes in this region and they are usually not pathologic
    B. Recognize that a palpable node in this region is a dangerous indication of metastatic cancer that requires further evaluation
    (this multiple choice question has been scrambled)
  90. While reviewing laboratory values for thyroid function on an adult patient, the nurse sees that the TSH is elevated, and the T3 and T4 are decreased. The nurse recognizes that these findings are indicative of
    A. hypothyroidism
    B. thyroid cancer
    C. normal thyroid function
    D. hyperthyroidism
    A. hypothyroidism
    (this multiple choice question has been scrambled)
  91. A patient presents with a complaint of drooping of his eyes, cheeks, and mouth on one side. This finding is most likely associated with pathology of which cranial nerve?
    A. Cranial nerve IX
    B. Cranial nerve VI
    C. Cranial nerve VII
    D. Cranial nerve III
    C. Cranial nerve VII
    (this multiple choice question has been scrambled)
  92. Which of the following patients would require the most emergent nursing care?
    A. A 20-year-old man with sudden visual loss after playing football
    B. A 77-year-old man with loss of vision in his peripheral fields.
    C. A 52-year-old woman with clouding of vision
    D. An 8-year-old girl with pink conjunctiva and drainage
    A. A 20-year-old man with sudden visual loss after playing football
    (this multiple choice question has been scrambled)
  93. Which of the following teaching points would the nurse emphasize related to eye health?
    A. Exercise five times a week for at least 20 minutes
    B. Eat a diet high in animal protein and dairy
    C. Get at least 7 hours of sleep each night
    D. Always wear eye protection for occupational exposures
    D. Always wear eye protection for occupational exposures
    (this multiple choice question has been scrambled)
  94. Which of the following symptoms would the nurse expect the patient to report as translucent specks that drift across the visual field?
    A. Ptosis
    B.Halo
    C. Floater
    D. Blind spot
    C. Floater
    (this multiple choice question has been scrambled)
  95. When working with an older adult, what would the nurse emphasize as increased risks for the patient?
    A. Exophthalmos and presbyopia
    B. Blepharitis and chalazion
    C. Myopia and strabismus
    D. Glaucoma and cataracts
    D. Glaucoma and cataracts
    (this multiple choice question has been scrambled)
  96. A school nurse is performing annual vision screening for seventh grade students. Which of the following charts would the nurse most likely be using?
    A. Confrontation cards
    B. Allen's chart
    C. Ishihara cards
    D. Snellen's chart
    D. Snellen's chart
    (this multiple choice question has been scrambled)
  97. Which of the following scores for distance vision indicates the patient with the poorest vision?
    A. 20/100
    B. 18/20
    C. 200/20
    D. 24/100
    A. 20/100
    (this multiple choice question has been scrambled)
  98. The nurse recognizes that the 60-year-old patient may have difficulty reading fine print because of the loss in the ability of the eye to
    A. asthenopia
    B. aniscoria
    C. amblyopia
    D. accommodate
    D. accommodate
    (this multiple choice question has been scrambled)
  99. Peripheral vision is elevated by the nurse using
    A. corneal light test
    B. confrontation test
    C. cardinal fields of gaze
    D. cover test
    B. confrontation test
    (this multiple choice question has been scrambled)
  100. The cranial nerves involved with eye movement include
    A. II,V,VII
    B. IV,V, and VIII
    C. III, IV, and VI
    D. V, VI, and VII
    C. III, IV, and VI
    (this multiple choice question has been scrambled)
  101. The nurse assesses the response of the eye to light and documents normal findings as
    A. PERLAA
    B. PERLLA
    C. PERRLA
    D. PEERLA
    C. PERRLA
    (this multiple choice question has been scrambled)
  102. The function of the ear is for
    A. balance and equilibrium
    B. Hearing and equilibrium
    C. equilibrium and perforations
    D. perforations and balance
    B. Hearing and equilibrium
    (this multiple choice question has been scrambled)
  103. The inner ear
    A. conducts sound waves to the external ear
    B. provides the body with proprioception
    C. translates sound to the nerves and brainstem
    D. contains the malleus, incus, and stapes
    B. provides the body with proprioception
    (this multiple choice question has been scrambled)
  104. Cues of hearing loss include which of the following?
    Choose all that are correct
    A. Using a loud or monotonous voice
    B. Asking to repeat questions
    C. Concentrating on lip movement
    D. Leaning forward to hear
    • A. Using a loud or monotonous voice
    • B. Asking to repeat questions
    • C. Concentrating on lip movement
    • D. Leaning forward to hear
  105. Risk factors for hearing loss include which of the following? Choose all that are correct.
    A. Frequent ear infections
    B. Being current on immunizations
    C. Exposure to smoke
    D. Decreased age
    • A. Frequent ear infection
    • C. Exposure to smoke
  106. Tinnitus is described as
    A. ringing in the ear
    B. dizziness
    C. inability to hear well
    D. ear pain
    A. ringing in the ear
    (this multiple choice question has been scrambled)
  107. Which of the following patients is most likely to have hearing loss?
    A. Hispanic woman older than 50 years
    B. African girl younger than 10 years
    C. Asian man younger than 30 years
    D. Caucasian man older than 70 years
    D. Caucasian man older than 70 years
    (this multiple choice question has been scrambled)
  108. Which of the following differentiates the RN assessment from the APRN assessment?
    A. Inspection and palpation
    B. History and risk factors
    C. Symptom and analysis
    D. Otoscopic assessment
    D. Otoscopic assessment
    (this multiple choice question has been scrambled)
  109. A nursing diagnosis appropriate for a patient with ear problems includes
    A. kinesthetic disturbed perception
    B. disturbed sensory perception
    C. olfactory sensory perception
    D. sensory perception, gustatory
    B. disturbed sensory perception
    (this multiple choice question has been scrambled)
  110. An outcome that is appropriate for a patient with hearing impairment is
    A. Minimize background noise and close door
    B. Provide a communication board or picture to assist teaching
    C. Patient explains plan to accommodate hearing impariment
    D. Stand in front of patient and explain procedure
    C. Patient explains plan to accommodate hearing impariment
    (this multiple choice question has been scrambled)
  111. Which of the following are appropriate interventions for the patient who is at risk for ear infection? Select all that apply
    A. Be current on immunizations
    B. Avoid second hand smoke
    C. Clean only external ear
    D. Have audiogram yearly
    • A. Be current on immunizations
    • B. Avoid second hand smoke
    • C. Clean only external ear
  112. Which of the following is part of the upper gastrointestinal tract?
    A. Nasal septum
    B. Throat
    C. Sinuses
    D. Adenoids
    B. Throat
    (this multiple choice question has been scrambled)
  113. The nurse is assessing the nares to evaluate the site of epistaxis. The most common site of bleeding is which of the following?
    A. Kesselbach plexus
    B. Nasal septum
    C. Woodruff plexus
    D. Osteomeatal complex
    A. Kesselbach plexu
    (this multiple choice question has been scrambled)
  114. The nurse knows that the floor of the mouth is highly vascular so it is a good location for which of the following?
    A. Aspiration even if the gag reflex is present
    B. Considering an infection with streptococcus
    C. Identification of malignancy in the pharyngeal
    D. Absorption of sublingual medications
    D. Absorption of sublingual medications
    (this multiple choice question has been scrambled)
  115. Acute airway obstruction is a situation that should be
    A. quickly assessed and treated
    B. Evaluated within 8 hours
    C. further assessed thoroughly
    D. reassessed during the next visit
    A. quickly assessed and treated
    (this multiple choice question has been scrambled)
  116. Risk factors for nose, sinus, mouth, and throat problems include,
    A. high blood cholesterol, topical decongestant use, and smoking
    B. smoking, allergies, and high blood cholesterol
    C. allergies, high blood cholesterol, and topical decongestant use
    D. topical decongestant use, smoking, and allergies
    D. topical decongestant use, smoking, and allergie
    (this multiple choice question has been scrambled)
  117. The nurse has assesssed the nose and documents normal findings as
    A. nose symmetrical and midline
    B. nose assymmetrical and proportional to facial features
    C. nose symmetrical with yellow drainage
    D. nose asymmetrical with clear drainage
    A. nose symmetrical and midline
    (this multiple choice question has been scrambled)
  118. The nurse is assessing a patient who has been taking antibiotics for 10 days. Oral assessment is important because of the increased risk for which of the following?
    A. pharyngitis
    B. C. albicans
    C. Anosmia
    D. Fordyce granules
    B. C. albicans
    (this multiple choice question has been scrambled)
  119. An adolescent and male presents with complaints of nose bleeds. The nurse would further assess for
    A. angiogibroma
    B. nasal trauma
    C. cystic fibrosis
    D. hemangioma
    B. nasal trauma
    (this multiple choice question has been scrambled)
  120. The nurse assess the child with purulent unilateral nasa discharge. The nurse knows that the most likely causative factor is
    A. choanal atresia
    B. foreign body in nose
    C. cystic fibrosis
    D. allergic rhinitis
    B. foreign body in nose
    (this multiple choice question has been scrambled)
  121. During routine physical examination of a 20-year-old woman, the nurse notes a septal perforation. This finding may be significant for which of the following causes?
    A. Nasal trauma
    B. Illicit drug use
    C. Bifid uvula
    D. Nose picking
    B. Illicit drug use
    (this multiple choice question has been scrambled)
  122. When performing an abdominal assessment, what is the correct sequence?
    A. Inspection, auscultation, percussion, palpation
    B. Auscultation, inspection, palpation, percussion
    C. Palpation, percussion, inspection, auscultation
    D. Inspection, palpation, percussion, auscultation
    A. Inspection, auscultation, percussion, palpation
    (this multiple choice question has been scrambled)
  123. A patient reports a long history of changes in bowel pattern. Which is the BEST questions to determine normal bowel habit?
    A. Have any of your parents or siblings had cancer of the colon?
    B. How often you do have a bowel movement?
    C. Is there a family history of IBD
    D. What was your bowel pattern before you noticed the change?
    D. What was your bowel pattern before you noticed the change?
    (this multiple choice question has been scrambled)
  124. When palpating the abdomen, the nurse notices a mass in the LUQ lateral to the MCL. Which organ is involved?
    A. Spleen
    B. Left kedney
    C. Sigmoid colon
    D. Liver
    A. Spleen
    (this multiple choice question has been scrambled)
  125. What percussion sounds is heart over most of the abdomen
    A. Tympany
    B. Resonance
    C. Dullness
    D. Hyperresonance
    A. Tympany
    (this multiple choice question has been scrambled)
  126. A patient with a history of kidney stones presents with complains of pain, hematuria, and nausea with vomiting. What assessment technique will illicit kidney pain?
    A. Blumberg's sign
    B. Fist percussion for CVA tenderness
    C. Psoas sign
    D. Rosving's sign
    B. Fist percussion for CVA tenderness
    (this multiple choice question has been scrambled)
  127. When auscultating the abdomen, the nurse hears a bruit to the right of the midline slightly below the umbilicus. The nurse documents this finding as a bruit of which of the following?
    A. Abdominal aorta
    B. Right femoral artery
    C. Right iliac artery
    D. Right renal artery
    C. Right iliac artery
    (this multiple choice question has been scrambled)
  128. A patient with a history of cirrhosis tells the nurse that his or her abdomen seems to be getting larger and that he or she has gained 20 lb in the last 6 months. How will the nurse determine whether the abdominal enlargement is from accumulation of fluid or fat from the weight gain?
    A. Listen for a fluid wave
    B. Inspect the abdomen with the patient in different positions
    C. Palpate lightly and note the movement on the surface
    D. Percuss the abdomen with the patient in different positions
    D. Percuss the abdomen with the patient in different positions
    (this multiple choice question has been scrambled)
  129. A patient with a protuberant abdomen complains of pain in the RUQ. Which sign would the nurse expect to be positive?
    A. Psoas sign
    B. Rosving's sign
    C. Murphy's sign
    D. Obturator sign
    C. Murphy's sig
    (this multiple choice question has been scrambled)
  130. Which assessment technique would best confirm splenic enlargement?
    A. Deep palpation over the RUQ with the patient lying on the right side
    B. Deep palpation under the left costal margin
    C. Fist percussion of the spleen with the patient in a sitting position
    D. Percussion to estimate the size of the spleen and gentle palpation
    D. Percussion to estimate the size of the spleen and gentle palpation
    (this multiple choice question has been scrambled)
  131. The documenting a finding in the region over the stomach and above the umbilicus, the nurse would identify the region as
    A. RUQ
    B. epigastric
    C. LUQ
    D. hypogastric
    B. epigastric
    (this multiple choice question has been scrambled)

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