Question 1

The nurse is preparing to examine a patient who has chronic lung disease.She realizes that the patient most likely will need to be in which position for the examination?

Accepted Answer

A) Sitting upright 
B) Supine 
C) Side-lying 
D) Prone 
A) Sitting upright 
B) Supine 
C) Side-lying 
D) Prone A

Question 2

The patient has been immobile at home after having had leg trauma in an automobile accident and is now being admitted with calf pain and localized swelling of the calf muscle.One test that is contraindicated in assessment of this patient is testing for _____________.

Accepted Answer

Homans' sign
Homans' sign is no longer considered a reliable indicator for the presence or absence of DVT and should not be considered a reliable test.Trauma to the vein or muscle,reduced mobility,and increased blood clotting are reliable risk factors.If the calf is swollen,tender,or red,notify the patient's health care provider for further assessment and evaluation.If there is a strong suspicion of DVT,testing for Homans' sign is contraindicated.If a clot is present,it may become dislodged from its original site during this test.This could result in a pulmonary embolism.

Question 3

What should the nurse do when preparing to complete an assessment for a 16-year-old patient?

Accepted Answer

A) Focus on illness behaviors. 
B) Plan for a diminished energy level. 
C) Treat the patient as an individual. 
D) Have the parents present throughout. 
A) Focus on illness behaviors. 
B) Plan for a diminished energy level. 
C) Treat the patient as an individual. 
D) Have the parents present throughout. C

Question 4

Petechiae are noted on the patient as a result of the nurse finding:

Accepted Answer

A) bluish-black patches. 
B) tenting. 
C) pinpoint-sized red dots. 
D) large areas of raised,irritated skin. 
A) bluish-black patches. 
B) tenting. 
C) pinpoint-sized red dots. 
D) large areas of raised,irritated skin.

Question 5

The nurse is assessing the patient by grasping a fold of skin on his forearm.She notices that the skin remains suspended for a longer than normal period.What could this indicate?

Accepted Answer

A) Stage 1 pressure ulcer 
B) Increased blood flow to the area 
C) Localized vasodilation 
D) Dehydration 
A) Stage 1 pressure ulcer 
B) Increased blood flow to the area 
C) Localized vasodilation 
D) Dehydration

Question 6

While performing a cardiovascular assessment on a patient with suspected left-sided congestive heart failure,the nurse is unable to palpate the PMI with the patient lying supine.What might her next step be?

Accepted Answer

A) Have the patient turn onto his left side. 
B) Have the patient lean forward. 
C) Have the patient move to a sitting position. 
D) Palpate the PMI to the right of the midclavicular line. 
A) Have the patient turn onto his left side. 
B) Have the patient lean forward. 
C) Have the patient move to a sitting position. 
D) Palpate the PMI to the right of the midclavicular line.

Question 7

Which skin condition would cause a nurse to suspect chickenpox?

Accepted Answer

A) Wheals 
B) Nodules 
C) Pustules 
D) Vesicles 
A) Wheals 
B) Nodules 
C) Pustules 
D) Vesicles

Question 8

What technique should the nurse implement for assessment of the carotid artery?

Accepted Answer

A) Massaging the arteries briskly 
B) Using the diaphragm of the stethoscope 
C) Palpating each carotid artery separately 
D) Placing the patient in a supine position 
A) Massaging the arteries briskly 
B) Using the diaphragm of the stethoscope 
C) Palpating each carotid artery separately 
D) Placing the patient in a supine position

Question 9

Which patient position maximizes the nurse's ability to assess the patient's body for symmetry?

Accepted Answer

A) Sitting 
B) Supine 
C) Prone 
D) Dorsal recumbent 
A) Sitting 
B) Supine 
C) Prone 
D) Dorsal recumbent

Question 10

Which of the following may a nursing assistive personnel (NAP)be responsible for determining?

Accepted Answer

A) Vital signs 
B) Cranial nerve function 
C) Neck vein distention 
D) Auscultation of bowel sounds 
A) Vital signs 
B) Cranial nerve function 
C) Neck vein distention 
D) Auscultation of bowel sounds

Question 11

The purpose of the physical assessment is to: (Select all that apply. )

Accepted Answer

A) compare the patient's status with previous findings. 
B) help the nurse gather additional data. 
C) help select the best nursing measures. 
D) teach patients about better health promotion. 
A) compare the patient's status with previous findings. 
B) help the nurse gather additional data. 
C) help select the best nursing measures. 
D) teach patients about better health promotion.

Question 12

Measurement of the patient's ability to differentiate between sharp and dull sensations over the forehead tests which cranial nerve?

Accepted Answer

A) Abducens 
B) Facial 
C) Trigeminal 
D) Oculomotor 
A) Abducens 
B) Facial 
C) Trigeminal 
D) Oculomotor

Question 13

The general survey begins with a review of the patient's primary health problems and an evaluation of the patient's vital signs,height and weight,general behavior,and appearance.It also provides information about the patient's illness,hygiene,skin condition,body image,and emotional state.Which of the following cannot be delegated to nursing assistive personnel?

Accepted Answer

A) Reporting subjective signs and symptoms 
B) Measuring the patient's height and weight 
C) Monitoring I&O 
D) Obtaining initial vital signs 
A) Reporting subjective signs and symptoms 
B) Measuring the patient's height and weight 
C) Monitoring I&O 
D) Obtaining initial vital signs

Question 14

The patient is diagnosed with Bell's palsy.The nurse assesses the patient and notices drooping of the patient's right eye and the right side of his mouth.When the functions of the following nerves are compared,the most likely cause of these symptoms would be a dysfunction of the:

Accepted Answer

A) facial nerve (CN VII). 
B) trigeminal nerve (CN V). 
C) oculomotor nerve (CN III). 
D) glossopharyngeal nerve (CN IX). 
A) facial nerve (CN VII). 
B) trigeminal nerve (CN V). 
C) oculomotor nerve (CN III). 
D) glossopharyngeal nerve (CN IX).

Question 15

____________ is a yellow-orange skin color seen with increased deposit of bilirubin in tissues.

Accepted Answer

Jaundice
Jaundice,a yellow-ora

Question 16

A late sign of decreased oxygen levels may cause a change in skin color known as _________.

Accepted Answer

cyanosis
Bluish (cyanosis)colo

Question 17

While performing a physical examination,the nurse incorporates health promotion by teaching the patient about how to reduce the risk of lung cancer.The nurse explains that besides cigarette smoking,exposure to other substances may lead to this disease.Some of these substances are: (Select all that apply. )

Accepted Answer

A) arsenic. 
B) asbestos. 
C) radiation. 
D) air pollution. 
A) arsenic. 
B) asbestos. 
C) radiation. 
D) air pollution.

Question 18

Which of the following is an expected outcome for a patient after cardiac assessment?

Accepted Answer

A) Apical pulse rate equals 58 beats per minute 
B) Carotid bruits present 
C) PMI palpable at left fifth intercostal space at midclavicular line 
D) Jugular veins distended with patient in sitting position 
A) Apical pulse rate equals 58 beats per minute 
B) Carotid bruits present 
C) PMI palpable at left fifth intercostal space at midclavicular line 
D) Jugular veins distended with patient in sitting position

Question 19

The patient is noted to have difficulty swallowing.The nurse realizes that the most probable cause of this difficulty is damage to cranial nerve ______.

Accepted Answer

IX
Damage to CN IX causes impaired swall

Question 20

The patient is admitted with fever and acute lower abdominal pain.He has taken Tylenol but says he still feels feverish.Before taking the patient's temperature,the nurse may:

Accepted Answer

A) touch the patient's skin with the dorsum of her hand. 
B) touch the patient's skin with the pads of her fingers. 
C) palpate the skin using the bimanual method. 
D) tap the patient's skin using the fingertips. 
A) touch the patient's skin with the dorsum of her hand. 
B) touch the patient's skin with the pads of her fingers. 
C) palpate the skin using the bimanual method. 
D) tap the patient's skin using the fingertips.

Exam 6: Health Assessment

The nurse is preparing to examine a patient who has chronic lung disease.She realizes that the patient most likely will need to be in which position for the examination?

The patient has been immobile at home after having had leg trauma in an automobile accident and is now being admitted with calf pain and localized swelling of the calf muscle.One test that is contraindicated in assessment of this patient is testing for _____________.

What should the nurse do when preparing to complete an assessment for a 16-year-old patient?

Petechiae are noted on the patient as a result of the nurse finding:

The nurse is assessing the patient by grasping a fold of skin on his forearm.She notices that the skin remains suspended for a longer than normal period.What could this indicate?

While performing a cardiovascular assessment on a patient with suspected left-sided congestive heart failure,the nurse is unable to palpate the PMI with the patient lying supine.What might her next step be?

Which skin condition would cause a nurse to suspect chickenpox?

What technique should the nurse implement for assessment of the carotid artery?

Which patient position maximizes the nurse's ability to assess the patient's body for symmetry?

Which of the following may a nursing assistive personnel (NAP)be responsible for determining?

The purpose of the physical assessment is to: (Select all that apply. )

Measurement of the patient's ability to differentiate between sharp and dull sensations over the forehead tests which cranial nerve?

The patient is diagnosed with Bell's palsy.The nurse assesses the patient and notices drooping of the patient's right eye and the right side of his mouth.When the functions of the following nerves are compared,the most likely cause of these symptoms would be a dysfunction of the:

____________ is a yellow-orange skin color seen with increased deposit of bilirubin in tissues.

A late sign of decreased oxygen levels may cause a change in skin color known as _________.

Which of the following is an expected outcome for a patient after cardiac assessment?

The patient is noted to have difficulty swallowing.The nurse realizes that the most probable cause of this difficulty is damage to cranial nerve ______.

The patient is admitted with fever and acute lower abdominal pain.He has taken Tylenol but says he still feels feverish.Before taking the patient's temperature,the nurse may:

Using Evidence in Practice

Admitting, Transfer, and Discharge

Communication and Collaboration

Documentation and Informatics

Vital Signs

Specimen Collection

Diagnostic Procedures

Medical Asepsis

Sterile Technique

Safe Patient Handling, Transfer, and Positioning

Exercise Mobility

Support Surfaces and Special Beds

Patient Safety

Disaster Preparedness

Pain Management

Palliative Care

Personal Hygiene and Bed Making

Care of the Eye and Ear

Safe Medication Preparation

Administration of Nonparenteral Medications

Administration of Parenteral Medications

Oxygen Therapy

Performing Chest Physiotherapy

Airway Management

Cardiac Care

Closed Chest Drainage Systems

Emergency Measure for Life Support

Intravenous and Vascular Access Therapy

Blood Therapy

Oral Nutrition

Enteral Nutrition

Parenteral Nutrition

Urinary Elimination

Bowel Elimination and Gastric Intubation

Ostomy Care

Preoperative and Postoperative Care

Intraoperative Care

Pressure Injury Prevention and Care

Wound Care and Irrigations

Dressings, Bandages, and Binders

Therapeutic Use of Heat and Cold

Home Care Safety

Home Care Teaching

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