practice questions

Flashcard maker : James Storer
A nurse teaches a group of young women about how to properly perform a self breast examination. How should the nurse explain the best time to perform the exam?

a) Right after the menstrual flow stops
b) On the third day after the menstrual cycle begins
c) On the 14th day of the menstrual cycle
d) Immediately before the menstrual cycle starts

a) Right after the menstrual flow stops
A nurse teaches a client about breast self-examination. What should the nurse tell the client about examining the underarm? The arm should be:

a) rested on the hips
b) kept at 90 degrees
c) raised straight up
d) slightly raised

d) slightly raised
inspection of the breast is done with patient in a supine position?

True or false?

false
A nurse is teaching a client about self breast examination. What would the nurse emphasize? (Mark all that apply.)

a) Pain
b) Timing
c) Pallor
d) Inspection
e) Palpation

palpation
inspection
timing
Which type of discharge should a nurse consider normal with palpation of the nipples during a breast examination of a non-lactating female client?

a) Clear
b) Milky
c) Blood-tinged
d) Unilateral

a) Clear
Nurse G. is conducting a teaching session on breast self-examination to a group of women at a health fair sponsored by the local community centre. Which of the following instructions is most accurate?

a) \”Remember that doing BSE regularly is not a replacement for regularly-scheduled mammograms or clinical examinations.\”
b) \”It’s best not to do BSE in the shower because you need a mirror and a place to lie down in order to do it correctly.\”
c) \”If you detect a lump that is larger than a grape, you should follow up with your doctor.\”
d) \”The best time to do BSE is at the midpoint of your menstrual cycle.\”

a) \”Remember that doing BSE regularly is not a replacement for regularly-scheduled mammograms or clinical examinations.\”
A 50-year-old female presents to the health care clinic as a new client for a complete physical examination. Which data in her health history should a nurse recognize as a risk factor for the development of breast cancer?

a) Early menopause
b) Late menarche
c) Nulliparity
d) Low dose use of birth control pills

c) Nulliparity
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) 4 to 7
c) 8 to 11
d) 12 to 15

b) 4 to 7
Which factors should the nurse include in a discussion with a young female to assist the client to reduce her risk for breast cancer? Select all that apply.

a) Increase the intake of fat in the diet
b) Breast-feed if possible
c) Regular intake of alcohol, two to three drinks daily
d) Engage in regular, strenuous physical activity
e) Pregnancy is beneficial before 30 years of age

b) Breast-feed if possible
d) Engage in regular, strenuous physical activity
e) Pregnancy is beneficial before 30 years of age
Gynecomastia is a normal occurrence in adolescent males. What are abnormal causes of gynecomastia? Select all that apply.

a) Diseases
b) Malignancies
c) Infections
d) Side effect of some medications
e) Anabolic steroids

a) Diseases
d) Side effect of some medications
e) Anabolic steroids
Which is true of women who have had a unilateral mastectomy?

a) They should be examined carefully along the surgical scar for masses.
b) They no longer require breast examination.
c) Women with breast reconstruction over their mastectomy site no longer require examination.
d) Lymphedema of the ipsilateral arm usually suggests recurrence of breast cancer.

a) They should be examined carefully along the surgical scar for masses.
A 44-year-old woman comes to the clinic complaining of severe dry skin in the area over her right nipple. She denies any trauma to the area. She noticed the skin change during a self-breast examination 2 months ago. She also admits that she had felt a lump under the nipple but kept putting off making an appointment. She does admit to 6 months of fatigue but no weight loss, weight gain, fever, or night sweats. Her past medical history is significant for hypothyroidism. She does not have a history of eczema or allergies. She denies any tobacco, alcohol, or drug use. Examination shows a middle-aged woman appearing her stated age. Inspection of her right breast reveals a scaly eczema-like crust around her nipple. Underneath a nontender 2-cm mass is palpable. The axilla contains only soft moveable nodes. The left breast examination and axilla are unremarkable. What visible skin change of the breast does she have?

a) Nipple retraction
b) Paget’s disease
c) Peau d’orange sign

b) Paget’s disease
The nurse is collating data obtained from a 56-year-old woman. Given the following data, the patient would be classified at what level of risk for breast cancer: first full-term pregnancy at age 33, menarche at 11 years old, high bone density, and sister with breast cancer?

a) minimal risk
b) greater than 4.0
c) 2.1-4.0
d) 1.1-2.0

c) 2.1-4.0
During the physical examination of a client a nurse notes that a client has tenderness of the breasts. Which question should the nurse ask the client with regard to this finding?

a) \”Have you ever noticed a lump in your breast?\”
b) \”How much do you drink or smoke?\”
c) \”Are you taking oral contraceptive pills?\”
d) \”Does anyone in your family have breast cancer?\”

c) \”Are you taking oral contraceptive pills?\”
A client is concerned about a dark skin lesion on her anterolateral abdomen. The lesion has not changed, nor is there any discharge or bleeding. On examination there is a medium brown circular lesion on the anterolateral wall of the abdomen. It is soft, has regular borders, is evenly pigmented, and is about 7 mm in diameter. What is this lesion?

a) Dermatofibroma
b) Supernumerary nipple
c) Melanoma
d) Dysplastic nevus

b) Supernumerary nipple
The nurse is performing a breast exam. Which area would be most important for the nurse to assess?

a) Upper outer quadrant
b) Lower inner quadrant
c) Upper inner quadrant
d) Lower outer quadrant

a) Upper outer quadrant
What are the causes of lymphadenopathy? Select all that apply.

a) Infection
b) Lactation
c) Malignancy
d) Blocked nodes postmastectomy
e) Hormonal fluctuation

a) Infection
c) Malignancy
d) Blocked nodes postmastectomy
A 42-year-old female client says she does not perform breast self-examination because she believes that mammograms are more thorough. Which response by the nurse would be most appropriate?

a) \”Mammograms don’t’ always detect the lumps that you might feel.\”
b) \”You should do the exam. It’s the best way to detect breast cancer early.\”
c) \”Once you hit 50 years, you really won’t have a choice about doing them.\”
d) \”Be sure to have your breasts checked by a doctor and have a mammogram every year.\”

d) \”Be sure to have your breasts checked by a doctor and have a mammogram every year.\”
A 14-year-old junior high school student is brought in by his mother and father because he seems to be developing breasts. The mother is upset because she read on the Internet that smoking marijuana leads to breast enlargement in males. The young man adamantly denies using any tobacco, alcohol, or drugs. He has recently noticed changes in his penis, testicles, and pubic hair pattern. Otherwise, his past medical history is unremarkable. His parents are both in good health. He has two older brothers who never had this problem. Examination shows a mildly overweight teenager with enlarged breast tissue that is slightly tender on both sides. Otherwise his examination is normal. He is agreeable to taking a drug test. What is the most likely cause of his gynecomastia?

a) Breast cancer
b) Imbalance of hormones of puberty
c) Drug use

b) Imbalance of hormones of puberty
The nurse practitioner in an oncology clinic is examining a client who had a mastectomy 5 weeks ago. What is one area of the breast that the nurse would be especially careful to examine because it is known for recurrent malignancies?

a) Within 1 cm of areola
b) Nipple area
c) Tail of Spencer
d) Scar site

d) Scar site
A client is experiencing parietal abdominal pain. The nurse would expect the client to describe the pain as which type of sensation?

a) Dull
b) Burning
c) Steady
d) Cramping

c) Steady
A client reports the onset of discomfort and pain in the right upper quadrant of the abdomen after eating. The nurse should assess this finding using which test?

a) Obturator
b) Rovsing’s
c) Murphy’s
d) Psoas

c) Murphy’s
Mr. Patel, 64 years old, was told by another care provider that his liver was enlarged. Although he is a lifelong smoker with a history of emphysema, the client has never used drugs or alcohol, nor does he have any knowledge of liver disease. Indeed, on examination, a liver edge is palpable 4 cm below the costal arch. Which of the following would the examiner do next?

a) Determine liver span by percussion.
b) Check an ultrasound of the liver.
c) Adopt a \”watchful waiting\” approach.
d) Obtain a hepatitis panel.

a) Determine liver span by percussion.
The nurse is preparing to assess the abdomen of a client who is complaining of abdominal pain. Which statement by the nurse would be most appropriate?

a) \”Before I get ready to examine the painful area, I will let you know in plenty of time.\”
b) \”You don’t need to worry about anything. I will make sure to be very gentle during the exam.\”
c) \”I’m going to examine the area where you’re having pain first to get a better picture of what’s going on.\”
d) \”Since you’re having pain in a certain area, I won’t have to do a very thorough exam there.\”

a) \”Before I get ready to examine the painful area, I will let you know in plenty of time.\”
Which action by the nurse will facilitate relaxation of the abdominal muscles during examination of the abdomen?

a) Raise the client’s arms or fold them behind the head
b) Provide privacy to the client and instruct him to relax
c) Avoid the use of pillow under the head during examination
d) Flex the client’s legs by placing a pillow under the knees

d) Flex the client’s legs by placing a pillow under the knees
The nurse understands this abdominal organ is responsible for storing red blood cells and platelets.

a) Liver
b) Gallbladder
c) Spleen
d) Pancreas

c) spleen
When assessing risk of colon cancer, which of the following health-history components should the nurse prioritize?

a) Family history; dietary habits
b) Social patterns; past medical history
c) Dietary habits; social patterns
d) Surgical history; family history

a) Family history; dietary habits
Mr. Kruger, 84 years old, presents with a smooth lower abdominal mass in the midline, which is minimally tender. There is dullness to percussion up to 6 cm above the symphysis pubis. What does this most likely represent?

a) Tumour in the abdominal wall
b) Enlarged bladder
c) Hernia
d) Sigmoid mass

b) Enlarged bladder
Which of the following acute abdominal symptoms could be life threatening?

a) Striae
b) Abdominal pain
c) Kidney stones
d) Indigestion

b) Abdominal pain
The nurse demonstrates the correct technique for assessing the psoas sign by which action?

a) Flexing the client’s right hip, applying downward pressure on the right thigh
b) Flexing the client’s right hip and knee, rotating the hip internally and externally
c) Tapping fingerpads over the client’s abdominal wall, feeling for a floating mass
d) Applying deep palpation pressure to the client’s right lower quadrant, then suddenly releasing

a) Flexing the client’s right hip, applying downward pressure on the right thigh
A group of students is reviewing information about the locations of various organs within the abdomen. The students demonstrate understanding of the material when they identify which organ as being found in the left upper quadrant?

a) Gallbladder
b) Liver
c) Spleen
d) Head of pancreas

c) Spleen
A 23-year-old man has recently graduated from university and is preparing to embark on a backpacking trip around Southeast Asia. In preparation for his trip, the client has visited a clinic to obtain vaccinations. The client will be able to obtain vaccines protecting against which of the following?

a) Hepatitis B and C
b) Hepatitis C
c) Hepatitis A
d) Hepatitis A and B

d) Hepatitis A and B
A patient has COPD. On examination, the nurse would expect

a) the liver to be enlarged
b) the liver span to be decreased
c) difficulty in percussing liver dullness
d) liver dullness to be displaced downward

d) liver dullness to be displaced downward
When inspecting the abdomen, which of the following client positions facilitates correct examination technique?

a) Semi-Fowler’s with pillows under head and knees
b) Trendelenberg with hands over head
c) Supine with arms at sides or folded across chest
d) Sitting with hands on hips

a) Semi-Fowler’s with pillows under head and knees
A nurse determines that the liver span of an older adult male client measures 6 cm. The nurse would interpret this as indicating which of the following?

a) The liver has atrophied.
b) The liver is larger than normal.
c) The liver is smaller than normal.
d) It is a normal-sized liver.

d) It is a normal-sized liver.
A nurse observes striae on the abdomen of a middle-aged female client during the examination of the abdomen. What is an appropriate question to ask this client in regards to this finding?

a) \”How many times have you been pregnant?\”
b) \”Do you have high blood pressure?\”
c) \”Are you experiencing any abdominal pain?’
d) \”Have you noticed any color change to the skin?’

a) \”How many times have you been pregnant?\”
An emergency department nurse is caring for a teenage client who has severe pain in the umbilical area. Documentation shows that the client exhibits \”Rovsing’s sign.\” What might this client’s medical diagnosis be?

a) Gastroenteritis
b) Enlarged spleen
c) Liver disease
d) Appendicitis

d) Appendicitis
A nurse observes tenderness over the costovertebral angle on the right side. The nurse recognizes this as an abnormal finding for which organ?

a) Liver
b) Kidney
c) Gallbladder
d) Spleen

b) Kidney
The nurse notes that an older adult client is wearing layers of clothing on a warm, fall day. Which of the following would be the priority assessment at this time?

a) Reviewing the client’s culture for possible influence
b) Asking whether the client often feels cold
c) Observing the client’s overall hygiene
d) Assessing the client’s developmental level

b) Asking whether the client often feels cold
A 29-year-old woman comes to the office. During history taking, the nurse notices that the client is speaking very quickly and jumping from topic to topic so rapidly that it is difficult to follow her. The nurse can find some connections between ideas, but it is difficult. Which word best describes this thought process?

a) Incoherence
b) Circumstantiality
c) Flight of ideas
d) Derailment

c) Flight of ideas
When the mental health nurse ask the client \”Do you recall what month and year this is?\” The nurse is assessing which part of the mental status examination?

a) Orientation
b) Abstract reasoning
c) Judgment
d) Insight

a) Orientation
A nursing instructor is teaching a group of students about assessing a client’s orientation. The instructor determines that the teaching was successful when the students state that the ability to identify which of the following usually is lost first?

a) Place
b) Self
c) Family members
d) Time

d) Time
A nurse begins the mental status exam of an older adult. Before assessing the client’s thought processes and perceptions, the nurse should first obtain the results of what other assessments?

a) Vital signs and nutritional status
b) Vision and hearing
c) Speech and facial expressions
d) Ability to follow commands and move extremities

b) Vision and hearing
You are conducting an interview with a psychiatric-mental health client who is becoming increasingly agitated. She accuses you or recording the interview so that you can send it to the FBI. What type of delusion is this client experiencing?

a) Erotomanic
b) Paranoid
c) Somatic
d) Grandiose

b) Paranoid
When observing a patient diagnosed with mania, the nurse observes his mood to be elated. Another term for this type of mood includes which of the following?

a) Dysphoric
b) Euthymic
c) Euphoric
d) Labile

c) Euphoric
As part of a mental status assessment, the nurse asks a client to draw the face of a clock. The nurse is assessing which of the following?

a) Concentration and orientation
b) Visual perceptual and constructional ability
c) Expressions and feelings
d) Perceptions and thought processes

b) Visual perceptual and constructional ability
The nurse is completing a mental health assessment. When the nurse asks the patient to interpret a proverb, the nurse is assessing which of the following?

a) Memory
b) Abstract reasoning
c) Concentration
d) Insight

b) Abstract reasoning
A new nurse asks the charge nurse what the Mini-Mental Status Examination tests. What is the appropriate response by the charge nurse?

a) \”A quick tool that is useful to examine the orientation, memory, speech, and cognitive functions\”
b) \”This scale allows for tracking of the client’s response to stimulation and early detection of changes\”
c) \”This examination tests the mood, feelings, thought processes, and perceptions of the client\”
d) \”Testing of remote and recent memory makes this test useful to track the progression of dementia in a client\”

a) \”A quick tool that is useful to examine the orientation, memory, speech, and cognitive functions\”
During the initial assessment of a client with a mental health disorder, what would be the priority information for the nurse to obtain? (Select all that apply.)

a) Current mental health disorders
b) Preexisting mental health disorder
c) Religious preference
d) Current financial status
e) Family history of mental illness

a) Current mental health disorders
b) Preexisting mental health disorder
The nurse is conducting a health history with an older adult who recently lost a spouse. Which nursing assessment data cue supports a diagnosis of depression?

a) Social isolation
b) Confusion
c) Thoughts of self-harm
d) Difficulty sleeping
e) Lack of motivation

a) Social isolation
d) Difficulty sleeping
e) Lack of motivation
A 72-year-old man comes to the clinic with his daughter for a follow-up visit after a recent hospitalization. He had been admitted to the local hospital for speech problems and weakness in his right arm and leg. On admission his MRI showed a small stroke. The client was in rehabilitation for 1 month following his initial presentation. He is now walking with a walker and has good use of his arm. His daughter complains, however, that everyone is still having trouble communicating with him. The nurse asks the client how he thinks he is doing. Although it is hard to make out his words, the nurse believes the client’s answer is \”well . . . fine . . . doing . . . okay.\” His prior medical history involved high blood pressure and coronary artery disease. He is a widower and retired handyman. He has three children who are healthy. He denies tobacco, alcohol, or drug use. He has no other current symptoms. On examination he is in no acute distress but does seem embarrassed when it takes him so long to answer. Blood pressure is 150/90; other vital signs are normal. Other than his weak right arm and leg, physical examination findings are unremarkable. What disorder of speech does he have?

a) Stutter
b) Broca’s aphasia
c) Dysarthria
d) Wernicke’s aphasia

b) Broca’s aphasia
A nurse asks a client the following question: \”What do you do if you have pain?\” The nurse is assessing which of the following?

a) Memory
b) Orientation
c) Abstract reasoning
d) Judgment

d) Judgment
A group of students is reviewing material about mental and psychosocial status in preparation for an examination. The students demonstrate understanding of the topic when they identify which of the following as a major system affecting a client’s status?

a) Cardiovascular
b) Renal
c) Respiratory
d) Neurological

d) Neurological
The nurse is admitting a patient to the mental health unit with a diagnosis of attempted suicide. Which is the best question for the nurse to ask first?

a) Do you have any thoughts of wanting to harm or kill yourself?
b) Do you hear voices that tell you what to do?
c) On a sense of 0 to 10, with 10 being most intense, how suicidal do you feel now?
d) Do you have a sense of hope for the future?

a) Do you have any thoughts of wanting to harm or kill yourself?
When assessing the client’s ability to make sound judgments, what question should the nurse ask?

a) \”How many dimes are in one dollar?\”
b) \”Can you keep track of your finances on an ongoing basis?\”
c) \”Do you eat breakfast?\”
d) \”How do you plan to pay rent if you lose your job?\”

d) \”How do you plan to pay rent if you lose your job?\”
The nurse is admitting a client with substance abuse. What screening tool would be best to use if this client is in denial about his substance abuse?

a) Mini-Cog exam
b) Mini-mental status examination
c) CAGE questionnaire
d) SAD PERSONAS

c) CAGE questionnaire
The nurse asks the client to draw the face of a clock with numbers and hands and to make it read 3 o’clock. What is tested by the completion of this task?

a) Constructional ability
b) Time orientation
c) Visual spatial ability
d) New learning ability

a) Constructional ability
On assessment of a client, the nurse finds that the client has difficulty in producing and understanding language. How should the nurse document this finding in the client’s record?

a) Apraxia
b) Aphasia
c) Dysphonia
d) Dysarthria

b) Aphasia
A 60-year-old retired seamstress comes to the office reporting decreased sensation in her hands and feet. She states that she began to have the problems in her feet 1 year ago but now it has started in her hands also. She also complains of some weakness in her grip. She has had no recent illnesses or injuries. Her past medical history consists of having type 2 diabetes for 20 years. She now takes insulin and oral medications for her diabetes. She has been married for 40 years. She has two healthy children. Her mother has Alzheimer’s disease and coronary artery disease. Her father died of a stroke and also had diabetes. She denies any tobacco, alcohol, or drug use. On examination she has decreased deep tendon reflexes in the patellar and Achilles tendons. She has decreased sensation of fine touch, pressure, and vibration on both feet. She has decreased two-point discrimination on her hands. Her grip strength and her plantar and dorsiflexion strength are decreased. Where is the disorder of the peripheral nervous system in this client?

a) Neuromuscular junction
b) Anterior horn cell
c) Peripheral polyneuropathy
d) Spinal root and nerve

c) Peripheral polyneuropathy
When testing the biceps reflex, what type of response should the nurse expect if normal?

a) Forearm flexes and supinates
b) Forearm adducts and wrist rotates
c) Elbow extends and muscle contracts
d) Elbow flexes and muscle contracts

d) Elbow flexes and muscle contracts
When assessing cranial nerves IX and X, which of the following would the nurse consider as a normal finding?

a) Asymmetrical soft palate
b) Stationary soft palate on phonation
c) Uvula and soft palate rising bilaterally
d) Deviation of uvula when client says \”ah\”

c) Uvula and soft palate rising bilaterally
Which of the following would lead the nurse to suspect meningeal irritation?

a) Reports of decreased pain with flexion of the hips and knees
b) Pain and flexion of the hips and knees with neck flexion
c) Hips and knees remain relaxed and motionless when neck is flexed
d) Discomfort behind the knee with full extension of the leg

b) Pain and flexion of the hips and knees with neck flexion
A patient is in the emergency room with what could be a lumbar injury. Which deep tendon reflex would be most appropriate to test?

a) patellar
b) ankle
c) triceps
d) supinator

a) patellar
The nurse is preparing to assess balance in an older adult client. Which test would the nurse plan on possibly omitting from the exam?

a) Gait
b) Romberg
c) Hop on one foot
d) Tandem walking

c) Hop on one foot
When testing sensory function of the trigeminal nerve (CN V), which of the following sensations would the nurse assess?

a) Pain and light touch
b) Dull touch and vibration
c) Proprioception and extinction
d) Vibration and stereognosis

a) Pain and light touch
Which of the following would the nurse most likely expect to find when assessing a client diagnosed with a frontal lobe contusion following a motor vehicle accident?

a) Loss of tactile sensation
b) Inability to hear high-pitched sounds
c) Difficulty speaking
d) Blurred vision

c) Difficulty speaking
Which of the following is usually the first sign of neurological deterioration?

a) Dilating pupil
b) Altered mentation and decreasing level of consciousness
c) Posturing
d) No response to painful stimulation

b) Altered mentation and decreasing level of consciousness
The nurse is tapping the spine for the level of vertebral pain. The nurse is testing the dermatomes.

a) True
b) False

a) true
A nurse is preparing to assess a client’s cerebellar function. Which of the following would the nurse expect to test?

a) Mental status exam
b) Sensation
c) Balance
d) Remote memory

c) Balance
Which area of the brain integrates the understanding of spoken and written words?

a) Broca’s area
b) Wernicke’s area
c) Basal ganglia
d) Cerebrum

b) Wernicke’s area
What task should a nurse ask a client to perform to assess the function of cranial nerve XI?

a) shrug shoulders against resistance
b) swallow water
c) walk in heel-to-toe fashion
d) move tongue side to side

a) shrug shoulders against resistance
When preparing to test a client for meningeal irritation, which of the following would be most important for the nurse to do first?

a) Check for a Babinski reflex
b) Position the client prone
c) Ensure no injury to the cervical spine
d) Check for evidence of fever and chills

c) Ensure no injury to the cervical spine
The brain is a network of interconnecting neurons that control and integrate the body’s activities. What components make up these neurons? Select all that apply.

a) Dendrite
b) Axon
c) Cortex
d) Gyrus
e) Cell body

a) Dendrite
b) Axon
e) Cell body
Which action by a nurse demonstrates the correct technique to use the reflex hammer?

a) Tap the tendon gently to avoid pain and tingling
b) Instruct the client to tense the muscles before striking
c) Strike the tendon then palpate for a response
d) Use rapid wrist movement and strike the tendon

d) Use rapid wrist movement and strike the tendon
Which of the following assessments is most likely to provide insight into the function of the client’s CN VIII?

a) Ask the client to raise his or her eyebrows, frown, and close both eyes tightly.
b) Ask the client to shrug both shoulders upward against the examiner’s hands.
c) Test the client’s hearing for lateralization and bone and air conduction.
d) Test the client’s ability to identify a familiar smell with his or her eyes closed.

c) Test the client’s hearing for lateralization and bone and air conduction.
What is the level of the spinal cord associated with the knee (patellar) deep tendon reflex?

a) S1
b) L2 to L4
c) T11 and T12
d) T9 and T10

b) L2 to L4
Which part of the brain controls the vital functions of temperature, heart rate, blood pressure, sleep, the anterior and posterior pituitary, the autonomic nervous system, and emotions and maintains overall autonomic control?

a) Brain stem
b) Cerebral cortex
c) Medulla
d) Hypothalamus

d) Hypothalamus
During the health-history interview, which of the following components of cognitive function can the nurse quickly assess?

a) Calculation and language
b) Memory and attention
c) Abstract thinking and perceptions
d) Judgment and behaviour

b) Memory and attention
When assessing the mental status of a 67-year-old woman, the nurse detects some difficulty with free-flow of thought and following directions. Which of the following would the nurse do first?

a) Use a Geriatric Depression Scale.
b) Refer the client to social services for home assistance.
c) Refer for further medical evaluation.
d) Assess the client’s vision and hearing.

d) Assess the client’s vision and hearing.
The nurse has been asked to assess a 54-year-old client’s memory. Which of the following techniques would allow the nurse to evaluate recent memory?

a) Provide the client with three words and ask the client to recall the words several minutes later.
b) Ask the client to recall event from childhood.
c) Ask the client to recall events that have occurred over the past few weeks.
d) Provide the client with three words and ask the client to recall the words several months later.

c) Ask the client to recall events that have occurred over the past few weeks.
Assessment of a client reveals that he is unresponsive to all stimuli and his eyes remain closed. The nurse documents the client’s level of consciousness as which of the following?

a) Obtunded
b) Coma
c) Stupor
d) Lethargy

b) Coma
A nurse wants to assess a client’s orientation. The nurse recognizes that which orientation is usually lost first when the client is confused?

a) Location
b) Time
c) Place
d) Person

b) Time
A client states, \”I’m worthless and I don’t deserve to live.\” This theme in the client’s expressed thought may signal unhealthy responses to which disorder?

a) Depression
b) Delirium tremens
c) ADHD
d) Mania

a) Depression
A nurse performs an admission assessment and notices that the client’s speech is slow and the client has difficulty answering some of the questions. How can the nurse differentiate the cause of the client’s slow speech?

a) Have the client read a few sentences out loud
b) Give the client the history form to read
c) Assess the client’s hearing in both ears
d) Ask the client about his education level

a) Have the client read a few sentences out loud
A 75-year-old homemaker brings her 76-year-old husband to the clinic. She states that 4 months ago he had a stroke; ever since she has been frustrated with his problems with communication. They were at a restaurant after church one Sunday when he suddenly became quiet. When she realized something was wrong, he was taken to the hospital by ambulance. He spent 2 weeks in the hospital with right-sided weakness and difficulty speaking. After hospitalization he was in a rehab center where he regained the ability to walk and most of the use of his right hand. He also began to speak more, but she says that much of the time \”he doesn’t make any sense.\” She gives an example that when she reminded him the car needed to be serviced he told her \”I will change the Kool-Aid out of the sink myself with the ludrip.\” She says that these sayings are becoming frustrating. She wants the nurse to tell her what is wrong and what can be done about it. What type of aphasia does the client have?

a) Dysarthria
b) Receptive aphasia
c) Broca’s aphasia
d) Wernicke’s aphasia

d) Wernicke’s aphasia
Which question asked by the nurse assesses judgment of the patient?

a) \”How did you and your siblings get along as children?\”
b) \”What will you do if you feel the need to use cocaine again?\”
c) \”Where are you right now?\”
d) \”What did you have for breakfast?\”

b) \”What will you do if you feel the need to use cocaine again?\”
The nurse begins the physical examination of a client by assessing the client’s mental status. The nurse does this primarily based on which rationale?

a) The exam can provide clues about the validity of the client’s responses now and throughout.
b) The exam provides data about mental health problems that the client may be afraid to report.
c) The client’s fears about having a serious illness may be alleviated by the results of the exam.
d) The client will be less anxious early, providing the nurse with more accurate and reliable data.

a) The exam can provide clues about the validity of the client’s responses now and throughout.
A nurse reviews the documentation of the nurse on the previous shift and finds that the client was obtunded. The nurse anticipates the client will respond to stimulation in what manner?

a) Does not respond even to painful stimuli
b) Opens eyes, answers the question, and falls back to sleep
c) Awakens only to a vigorous shake or painful stimuli
d) Opens eyes to a loud voice and answers with confusion

d) Opens eyes to a loud voice and answers with confusion
Which question is appropriate for a nurse to ask a client to assess the client’s recent memory?

a) \”When is your birthday?\”
b) \”What did you eat for breakfast today?\”
c) \”How are an orange and an apple different?\”
d) \”Why are you at the health care clinic today?\”

b) \”What did you eat for breakfast today?\”
When preparing to obtain information about a client’s mental and psychosocial status, which of the following would the nurse need to do first?

a) Question the patient about his or her usual lifestyle and behaviors.
b) Perform a neurological examination to determine any deficits.
c) Check the client’s level of consciousness for changes.
d) Explain the purpose of the exam and types of questions.

d) Explain the purpose of the exam and types of questions.
A group of students is reviewing material about assessing mental status. The students demonstrated understanding of the material when they identify which of the following as a cognitive ability to be assessed?

a) Speech
b) Posture
c) Thought processes
d) Orientation

d) Orientation
The nurse is seeing a patient at the local community mental health clinic. The patient states, \”I want to kill myself. I have nothing to live for; no one would miss me.\” What is the priority question the nurse should ask the patient?

a) \”What has caused you to have such feelings?\”
b) \”When do you plan to kill yourself?\”
c) \”What about your family – don’t you care about them?\”
d) \”Do you have a specific plan for killing yourself?\”

d) \”Do you have a specific plan for killing yourself?\”
The nurse observes a client’s entire body posture to be stiff, with his shoulders elevated upward toward the ears. The nurse would most likely interpret this to indicate that the client is:

a) Relaxed
b) Anxious
c) Feeling powerless
d) Restless

b) Anxious
A nurse has been asked to complete a mental status examination of a psychiatric-mental health client. Which of the following is included in this assessment?

a) A review of systems
b) Evaluation of medication compliance
c) Questions regarding past behaviors
d) Evaluation of insight and judgment

d) Evaluation of insight and judgment
The nurse is preparing to assess a client’s remote memory. Which question would be most appropriate for the nurse to use?

a) \”When did you get your first job?\”
b) \”What did you do last evening?\”
c) \”How are an apple and orange the same?\”
d) \”Can you tell me what you have eaten in the last 24 hours?\”

a) \”When did you get your first job?\”
A 40-year-old mother of two presents for consultation. She is interested in knowing what her relative risks are for developing breast cancer. She is concerned because her sister had unilateral breast cancer 6 years ago at age 38. The client reports on her history that she began having periods at age 11 and has been fairly regular ever since, except during her two pregnancies. Her first child arrived when she was 26 and her second at age 28. Otherwise she has had no health problems. Her father has high blood pressure. Her mother had unilateral breast cancer in her 70s. The client denies tobacco, alcohol, or drug use. She is a family law attorney and is married with two children. Her examination is essentially unremarkable. Which risk factor of her personal and family history puts her at the most in danger of getting breast cancer?

a) First live birth between the ages of 25 and 29
b) First-degree relative with postmenopausal breast cancer
c) Age at menarche of less than 12
d) First-degree relative with premenopausal breast cancer

d) First-degree relative with premenopausal breast cancer
A nonpregnant female presents to the health care facility and reports the new onset of breast discharge. The nurse assesses the discharge to be milky in appearance without breast tenderness or masses. What additional data should the nurse obtain from this client?

a) Environmental exposure to chemicals
b) Alcohol intake in excess of three drinks a day
c) Prescribed medications such as antipsychotic agents
d) Recent surgeries or trauma

c) Prescribed medications such as antipsychotic agents
A 19-year-old woman comes to the office and reports that she has had a clear discharge from her right breasts for 2 months. She states that she noticed it when she and her boyfriend were \”messing around\” and he squeezed her nipple. She continues to have this discharge anytime she squeezes that nipple. She denies any trauma to her breasts. Her past medical history is unremarkable. She denies any pregnancies. Both of her parents are healthy. She denies tobacco or illegal drugs and drinks three to four beers a week. On examination her breasts are symmetrical with no skin changes. The nurse can express clear discharge from the client’s right nipple. There are no discrete masses and the axillae are normal. The remainder of her heart, lung, abdominal, and pelvic examinations are unremarkable. A urine pregnancy test is negative. What cause of nipple discharge is most likely in her circumstance?

a) Benign breast abnormality
b) Nonpuerperal galactorrhea
c) Breast cancer

a) Benign breast abnormality
A nurse is conducting a class on mammogram screenings for a church group of women in their late 20s. According to the American Cancer Society guidelines, the nurse should stress breast self-examinations monthly and clinical breast examinations for their age group

a) every 5 years
b) every 4 years
c) every 2 years
d) every 3 years

d) every 3 years
When taking a health history for a female client, which factor would the nurse identify as placing the client at increased risk for breast cancer?

a) Bottle-feeding her children
b) Consumption of high-fat diet
c) First child after age 30
d) Low level of physical activity

c) First child after age 30
An adult 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
b) Fibroadenoma
c) Blocked lymph drainage
d) Fibrocystic disease

c) Blocked lymph drainage
When palpating the client’s axillae, which of the following would be most appropriate?

a) Have the client hold the arm of the side being examined slightly away from the body.
b) Hold the client’s elbow of the side being examined with one hand.
c) Have the client lean forward from the waist with arms outstretched.
d) Tell the client to raise her arm on the side being examined up over her head.

b) Hold the client’s elbow of the side being examined with one hand.
When assessing the breast and lymphatics of the axillae, where would the nurse locate the central axillary nodes?

a) Inside the upper arm
b) Inside the lateral axillary fold
c) Along the lateral edge of the scapulae
d) High in the axillae at the top of the ribs

d) High in the axillae at the top of the ribs
The nurse is applying the blood pressure cuff on a client’s arm. Which action would be most appropriate?

a) The cuff is wrapped loosely around the arm.
b) The bladder inside the cuff encircles 50% of the arm circumference.
c) The cuff starts to be wrapped at the end of the bladder.
d) The cuff is placed about 1 inch above the antecubital area.

d) The cuff is placed about 1 inch above the antecubital area.
A nurse measures a client’s blood pressure at 174/102 mm Hg. The nurse recognizes this as what classification of blood pressure measurement according to the JNC VII guidelines?

a) Normal
b) Stage 3 Hypertension
c) Stage 2 Hypertension
d) Stage 1 Hypertension

c) Stage 2 Hypertension
The nurse obtains a client’s blood pressure when standing and compares it to the measurement obtained while the client was sitting. The client’s blood pressure when sitting was 122/72 mmHg. Which finding would suggest to the nurse that the client is experiencing orthostatic hypotension?

a) 108/58 mmHg
b) 114/68 mmHg
c) 98/52 mmHg
d) 110/62 mmHg

c) 98/52 mmHg
The nurse is providing care for an 83-year-old woman with a history of hypotension who has been admitted to hospital following a fall. The nurse recognizes the need to assess for orthostatic hypotension. How should the nurse perform this assessment?

a) Measure the client’s blood pressure and heart rate while she is standing then after 10 minutes of lying supine.
b) Measure the client’s heart rate and blood pressure while supine then within 3 minutes of standing.
c) Alternate the scheduled blood pressure measurements between the standing and lying positions.
d) Estimate systolic blood pressure by palpation while the client is lying, then measure blood pressure when the client is standing.

b) Measure the client’s heart rate and blood pressure while supine then within 3 minutes of standing.
A nurse is assessing the blood pressure of a client using the Korotkoff’s sounds technique. The nurse notes that the phase I sound disappears for 2 seconds. What should the nurse document on the progress record?

a) There is an auscultatory gap
b) There is a nonauscultatory gap
c) There is a widening in the diameter of the artery
d) There is an adult diastolic

a) There is an auscultatory gap
The nurse is seeing an older client who has not had medical care for many years. Vital signs are T 37.2, HR 78, BP 118/92, RR 14. The client denies pain. The nurse notices that the client has some hypertensive changes in her retinas; a urine test reveals mild proteinuria. The nurse expected the client’s BP to be higher. The client is not taking any medications. What do you think is causing this BP reading?

a) The client’s emotional state
b) A cuff size error
c) Resolution of the process that caused her retinopathy and kidney problems
d) An auscultatory gap

d) An auscultatory gap
Which of the following would be most important for the nurse to do when assessing a client’s blood pressure?

a) Palpate the pulsations of the radial artery.
b) Deflate the cuff about 5 mmHg per second.
c) Inflate the cuff 30 mmHg above where the radial pulse disappears.
d) Hold the client’s arm slightly flexed with palm down.

c) Inflate the cuff 30 mmHg above where the radial pulse disappears.
A nurse is assessing the blood pressure on an obese woman. What error might occur if the cuff used is too narrow?

a) Pressure on the cuff would be painful.
b) Reading is erroneously high.
c) Reading is erroneously low.
d) It will be difficult to pump up the bladder.

b) Reading is erroneously high.
During a busy shift, Nurse R. admitted a postsurgical patient who is obese. Nurse R. used the standard size of blood pressure cuff available on the unit, despite the fact that the patient’s upper arms have a high circumference. What are the potential consequences of Nurse R.’s action?
Nurse R. may obtain a blood pressure reading that is higher than actual blood pressure.
The current blood pressure measurement on a 24-hour uncomplicated postoperative patient while standing at the bedside is 105/65. The last two readings were 130/75 and 125/70 while resting in bed. The nurse should be alert for signs of….
orothostatic hypotension
The nurse is taking routine vital signs toward the end of shift. A client’s BP reads 204/148. The client’s baseline BP has been in the 130’s systolic. What should the nurse do first?

a) Notify the physician immediately
b) Document the findings
c) Give PRN blood pressure medications
d) Retake the blood pressure

d) Retake the blood pressure

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