NYU HAP FINAL EXAM
A nurse assessing patient reflexes strokes up and then across the
sole of the foot. If the toes fan upward this would be documented
as (wk 10)
A. Positive Cremaster reflex
B. Positive Babinski sign
C. Positive Romberg sign
D. Cogwheeling
B. Positive Babinski sign
The nurse is testing the function of cranial nerve VIII. Which of
these best describes the response the nurse should expect if the
nerve is intact? The patient: (wk 10)
A. follows an object with eyes without nystagmus or strabismus.
B. sticks tongue out midline without tremors or deviation.
C. moves the head and shoulders against resistance with equal
strength.
D. demonstrates ability to hear normal conversation.
E. can identify the smell of coffee
D. demonstrates ability to hear normal conversation.
When does the health assessment begin? (wk 11)
A. When the patient consents to have a health assessment
performed.
B. When the patient tells the nurse his name and age.
C. When the nurse asks the patient the first health-related
question.
D. When the nurse first meets the patient.
D. When the nurse first meets the patient.
,The nurse has assessed the patients on the unit. Which patient
should be attended to first? (wk 11)
A. Patient who had a stroke 5 years ago and presently has 5/5
strength in all extremities.
B. A patient with a heart rate of 84 beats per minute and oxygen
saturation of 99%
C. A patient with blood pressure of 180/110 mm Hg and urine
output of 20 mL/hr
D. A patient with a respiratory rate of 16 breaths per minute and
temperature of 98.6 F
C. A patient with blood pressure of 180/110 mm Hg and urine output
of 20 mL/hr
At the beginning of rounds when entering the room, what would
the nurse do first? (wk 11)
A. Check the intravenous(IV) infusion site for swelling or redness
B. Check infusion pump setting for accuracy
C. Make eye contact with the patient, and introduce themself as
the patient's nurse
D. Offer patient something to drink
C. Make eye contact with the patient, and introduce themself as the
patient's nurse
Which data does a nurse collect during the general inspection?
(SELECT ALL THAT APPLY) (wk 11)
A. Mood or affect
B. Gait
C. Hearing and speech abilities
D. Breath sounds
E. Muscle strength
F. Heart sounds
A. Mood or affect, B. Gait, C. Hearing and speech abilities
,During auscultation of breath sounds, the examiner should: (wk
11)
A. only listen to the posterior chest for adventitious sounds.
B. listen with the bell of the stethoscope.
C. instruct the patient to breathe in and out through the nose.
D. compare sounds on the left and right side.
D. compare sounds on the left and right side.
A patient's uvula rises midline when she says "ahh" and she has a
positive gag reflex. The nurse has just tested which cranial
nerves? (wk 11)
A. IX, X
B. IX, XII
C. X, XII
D. XI, XII
A. IX, X
Rationale: IX (Glossopharyngeal) and X (Vagus) we look at gag
reflex and voice sounds. Don't normally test gag reflex except in
comatose patients.
The nurse is giving report to the next shift and is using the
situation, background, assessment, recommendation (SBAR)
framework for communication. Which of these statements reflects
the Background portion of the report? (wk 11)
A. I'm concerned that his gastrointestinal bleeding is getting
worse.
B. My name is Mr Hope, and I'm giving report on Mrs X in room
1045.
C. He is 4 days postoperative, and his incision is open to air.
D. We need and order for oxygen.
C. He is 4 days postoperative, and his incision is open to air.
, The nurse is conducting a cultural assessment for a new patient.
This is important to ensure that: (wk 11)
A. the nurse can avoid making assumptions.
B. the patient has access to the appropriate chaplain.
C. the patient can get the proper dietary nutrients.
D. the nurse can communicate with the family.
A. the nurse can avoid making assumptions.
How does a nurse assess perfusion to the foot when a patient has a
cast from the left middle calf to the toes? (wk 11)
A. Palpate the popliteal pulse of the left leg.
B. Assess the capillary refill of the left toes.
C. Palpate the posterior tibial pulse of the left leg.
D. Assess movement and sensation of the left toes.
B. Assess the capillary refill of the left toes.
During the assessment, the nurse determines that the patient's
Glasgow Coma Scale score is 15. What is the meaning of this
number for this patient? (wk 11)
A. This patient is fully conscious.
B. This patient has movement but does not open the eyes or speak.
C. This patient is unable to respond to any stimuli.
D. This patient opens the eyes but does not speak or move.
A. This patient is fully conscious.
The patient reports pain in the right lower quadrant of the
abdomen. The nurse suspects a potential problem in which of
these organs? (wk 12)
A. Spleen
B. Sigmoid colon
C. Gallbladder
D. Appendix
A nurse assessing patient reflexes strokes up and then across the
sole of the foot. If the toes fan upward this would be documented
as (wk 10)
A. Positive Cremaster reflex
B. Positive Babinski sign
C. Positive Romberg sign
D. Cogwheeling
B. Positive Babinski sign
The nurse is testing the function of cranial nerve VIII. Which of
these best describes the response the nurse should expect if the
nerve is intact? The patient: (wk 10)
A. follows an object with eyes without nystagmus or strabismus.
B. sticks tongue out midline without tremors or deviation.
C. moves the head and shoulders against resistance with equal
strength.
D. demonstrates ability to hear normal conversation.
E. can identify the smell of coffee
D. demonstrates ability to hear normal conversation.
When does the health assessment begin? (wk 11)
A. When the patient consents to have a health assessment
performed.
B. When the patient tells the nurse his name and age.
C. When the nurse asks the patient the first health-related
question.
D. When the nurse first meets the patient.
D. When the nurse first meets the patient.
,The nurse has assessed the patients on the unit. Which patient
should be attended to first? (wk 11)
A. Patient who had a stroke 5 years ago and presently has 5/5
strength in all extremities.
B. A patient with a heart rate of 84 beats per minute and oxygen
saturation of 99%
C. A patient with blood pressure of 180/110 mm Hg and urine
output of 20 mL/hr
D. A patient with a respiratory rate of 16 breaths per minute and
temperature of 98.6 F
C. A patient with blood pressure of 180/110 mm Hg and urine output
of 20 mL/hr
At the beginning of rounds when entering the room, what would
the nurse do first? (wk 11)
A. Check the intravenous(IV) infusion site for swelling or redness
B. Check infusion pump setting for accuracy
C. Make eye contact with the patient, and introduce themself as
the patient's nurse
D. Offer patient something to drink
C. Make eye contact with the patient, and introduce themself as the
patient's nurse
Which data does a nurse collect during the general inspection?
(SELECT ALL THAT APPLY) (wk 11)
A. Mood or affect
B. Gait
C. Hearing and speech abilities
D. Breath sounds
E. Muscle strength
F. Heart sounds
A. Mood or affect, B. Gait, C. Hearing and speech abilities
,During auscultation of breath sounds, the examiner should: (wk
11)
A. only listen to the posterior chest for adventitious sounds.
B. listen with the bell of the stethoscope.
C. instruct the patient to breathe in and out through the nose.
D. compare sounds on the left and right side.
D. compare sounds on the left and right side.
A patient's uvula rises midline when she says "ahh" and she has a
positive gag reflex. The nurse has just tested which cranial
nerves? (wk 11)
A. IX, X
B. IX, XII
C. X, XII
D. XI, XII
A. IX, X
Rationale: IX (Glossopharyngeal) and X (Vagus) we look at gag
reflex and voice sounds. Don't normally test gag reflex except in
comatose patients.
The nurse is giving report to the next shift and is using the
situation, background, assessment, recommendation (SBAR)
framework for communication. Which of these statements reflects
the Background portion of the report? (wk 11)
A. I'm concerned that his gastrointestinal bleeding is getting
worse.
B. My name is Mr Hope, and I'm giving report on Mrs X in room
1045.
C. He is 4 days postoperative, and his incision is open to air.
D. We need and order for oxygen.
C. He is 4 days postoperative, and his incision is open to air.
, The nurse is conducting a cultural assessment for a new patient.
This is important to ensure that: (wk 11)
A. the nurse can avoid making assumptions.
B. the patient has access to the appropriate chaplain.
C. the patient can get the proper dietary nutrients.
D. the nurse can communicate with the family.
A. the nurse can avoid making assumptions.
How does a nurse assess perfusion to the foot when a patient has a
cast from the left middle calf to the toes? (wk 11)
A. Palpate the popliteal pulse of the left leg.
B. Assess the capillary refill of the left toes.
C. Palpate the posterior tibial pulse of the left leg.
D. Assess movement and sensation of the left toes.
B. Assess the capillary refill of the left toes.
During the assessment, the nurse determines that the patient's
Glasgow Coma Scale score is 15. What is the meaning of this
number for this patient? (wk 11)
A. This patient is fully conscious.
B. This patient has movement but does not open the eyes or speak.
C. This patient is unable to respond to any stimuli.
D. This patient opens the eyes but does not speak or move.
A. This patient is fully conscious.
The patient reports pain in the right lower quadrant of the
abdomen. The nurse suspects a potential problem in which of
these organs? (wk 12)
A. Spleen
B. Sigmoid colon
C. Gallbladder
D. Appendix
