NR 302 HESI HEALTH ASSESSMENT PRE TEST: Chamberlain University (Already graded A)
NR 302 HESI HEALTH ASSESSMENT PRE TEST: Chamberlain University
NR302 HESI HEALTH ASSESSMENT PRE TEST: Chamberlain University
1) The nurse hears bilateral louder, longer, and lower tones when percussing over the lungs of a 4-year old child. What should the nurse do next?
a) Palpate over the area for increased pain and tenderness.
b) Ask the child to take shallow breaths and percuss over the area again.
c) Refer the child immediately because of an increased amount of air in the lungs.
d) Consider this a normal finding for a child this age and proceed with the examination.
2) A patient has suddenly developed shortness of breath and appears to be in significant respiratory distress. After putting a call in to the physician and placing the patient on oxygen, which of these is the best action for the nurse to take when assessing the patient further?
a) Count the patient’s respirations.
b) Percuss the thorax bilaterally, noting any differences in percussion tones.
c) Call for a chest x-ray and wait for the results before beginning an assessment.
d) Inspect the thorax for any new masses and bleeding associated with respirations.
3) The nurse is teaching a class on basic assessment skills. Which of these statements is true regarding the stethoscope and its use?
a) The slope of the earpieces should point posteriorly (toward the occiput).
b) The stethoscope does not magnify sound but does block out extraneous room noise.
c) The fit and quality of the stethoscope are not as important as its ability to magnify sound.
d) The ideal tubing length should be 22 inches to dampen distortion of sound.
4) The nurse is preparing to use a stethoscope for auscultation. Which statement is true regarding the diaphragm of the stethoscope?
a) The diaphragm is used to listen for high-pitched sounds.
b) The diaphragm is used to listen for low-pitched sounds.
c) The diaphragm should be held lightly against the person’s skin to block out low
d) The diaphragm should be held lightly against the person’s skin to listen for extra heart sounds and murmurs.
5) Before auscultating the abdomen for the presence of bowel sounds on a patient, the nurse should:
a) Warm the end piece of the stethoscope by placing it in warm water
b) Leave the gown on so that the patient does not get chilled during the examination
c) Make sure that the bell side of the stethoscope is turned to the ―on‖ position
d) Check the temperature of the room and offer blankets to the patient if he or she feels cold
6) The nurse will use which technique of assessment to determine the presence of crepitus, swelling, and pulsations?
5. In an interview, the nurse may find it necessary to take notes to aid his or her memory later. Which statement is true regarding note-taking?
A) Note-taking may impede the nurse's observation of the patient's nonverbal behaviors.
B) Note-taking allows the patient to continue at his or her own pace as the nurse records what is said.
C) Note-taking allows the nurse to shift attention away from the patient, resulting in an increased comfort level.
D) Note-taking allows the nurse to break eye contact with the patient, which may increase his or her level of comfort.
6. During an interview, the nurse states, "You mentioned shortness of breath. Tell me more about that." Which verbal skill is used with this statement?
C) Direct question
D) Open-ended question
7. A nurse is taking complete health histories on all of the patients attending a wellness workshop. On the history form, one of the written questions asks, "You don't smoke, drink, or take drugs, do you?" This question is an example of:
A) talking too much.
B) Using confrontation.
C) Using biased or leading questions.
D) Using blunt language to deal with distasteful topics.
8. During an interview, a parent of a hospitalized child is sitting in an open position. As the interviewer begins to discuss his son's treatment, however, he suddenly crosses his arms against his chest and crosses his legs. This would suggest that the parent is:
A) just changing positions.
B) More comfortable in this position.
C) Tired and needs a break from the interview.
D) Uncomfortable talking about his son's treatment.
9. The nurse is interviewing a patient who has a hearing impairment. What techniques would be most beneficial in communicating with this patient?
A) Determine the communication method he prefers.
B) Avoid using facial and hand gestures because most hearing-impaired people find this degrading.
C) Request a sign language interpreter before meeting with him to help facilitate the communication.
D) Speak loudly and with exaggerated facial movement when talking with him because this helps with lip reading.
10. The nurse is performing a health interview on a patient who has a language barrier, and no interpreter is available. Which is the best example of an appropriate question for the nurse to ask in this situation?
A) "Do you take medicine?"
B) "Do you sterilize the bottles?"
C) "Do you have nausea and vomiting?"
D) "You have been taking your medicine, haven't you?"
11. A female patient does not speak English well, and the nurse needs to choose an interpreter. Which of the following would be the most appropriate choice?
A) A trained interpreter
B) A male family member
C) A female family member
D) A volunteer college student from the foreign language studies department
12. The nurse is conducting an interview. Which of these statements is true regarding open-ended questions? Select all that apply.
A) They elicit cold facts.
B) They allow for self-expression.
C) They build and enhance rapport.
D) They leave interactions neutral.
E) They call for short one- to two-word answers.
F) They are used when narrative information is needed.
13. The nurse is conducting an interview in an outpatient clinic and is using a computer to record data. Which is the best use of the computer in this situation? Select all that apply.
A) Collect the patient's data in a direct, face-to-face manner.
B) Enter all the data as the patient states it.
C) Ask the patient to wait as the nurse enters data.
D) Type the data into the computer after the narrative is fully explored.
E) Allow the patient to see the monitor during typing.
14. During an assessment, the nurse notices that a patient is handling a small charm that is tied to a leather strip around his neck. Which action by the nurse is appropriate?
A) Ask the patient about the item and its significance.
B) Ask the patient to lock the item with other valuables in the hospital's safe.
C) Tell the patient that a family member should take valuables home.
D) No action is necessary.
15. In the majority culture of America, coughing, sweating, and diarrhea are symptoms of an illness. For some individuals of Mexican-American origin, however, these symptoms are a normal part of living. The nurse recognizes that this is true, probably because Mexican-Americans:
A) have less efficient immune systems and are often ill.
B) Consider these symptoms a part of normal living, not symptoms of ill health.
C) Come from Mexico and coughing is normal and healthy there.
D) Are usually in a lower socioeconomic group and are more likely to be sick.
16. Among many Asians there is a belief in the yin/yang theory, rooted in the ancient Chinese philosophy of Tao. The nurse recognizes which statement that most accurately reflects "health" in an Asian with this belief?
A) A person is able to work and produce.
B) A person is happy, stable, and feels good.
C) All aspects of the person are in perfect balance.
D) A person is able to care for others and function socially.
17. An individual who takes the magicoreligious perspective of illness and disease is likely to believe that his or her illness was caused by:
A) germs and viruses.
B) Supernatural forces.
C) Eating imbalanced foods.
D) An imbalance within his or her spiritual nature.
18. If an American Indian has come to the clinic to seek help with regulating her diabetes, the nurse can expect that she:
A) will comply with the treatment prescribed.
B) Has obviously given up her beliefs in naturalistic causes of disease.
C) May also be seeking the assistance of a shaman or medicine man.
D) Will need extra help in dealing with her illness and may be experiencing a crisis of faith.
19. An elderly Mexican-American woman with traditional beliefs has been admitted to an inpatient care unit. A culturally-sensitive nurse would:
A) contact the hospital administrator about the best course of action.
B) Automatically get a curandero for her because it is not culturally appropriate for her to request one.
C) Further assess the patient's cultural beliefs and offer the patient assistance in contacting a curandero or priest if she desires.
D) Ask the family what they would like to do because Mexican-Americans traditionally give control of decisions to their families.
20. The nurse is reviewing concepts of cultural aspects of pain. Which statement is true regarding pain?
A) All patients will behave the same way when in pain.
B) Just as patients vary in their perceptions of pain, so will they vary in their expressions of pain.
C) Cultural norms have very little to do with pain tolerance, because pain tolerance is always biologically determined.
D) A patient's expression of pain is largely dependent on the amount of tissue injury associated with the pain.
21. The nurse recognizes that working with children with a different cultural perspective may be especially difficult because:
A) children have spiritual needs that are influenced by their stages of development.
B) Children have spiritual needs that are direct reflections of what is occurring in their homes.
C) Religious beliefs rarely affect the parents' perceptions of the illness.
D) Parents are often the decision makers, and they have no knowledge of their children's spiritual needs.
22. When providing culturally competent care, nurses must incorporate cultural assessments into their health assessments. Which statement is most appropriate to use when initiating an assessment of cultural beliefs with an elderly American Indian patient?
A) "Are you of the Christian faith?"
B) "Do you want to see a medicine man?"
C) "How often do you seek help from medical providers?"
D) "What cultural or spiritual beliefs are important to you?"
23. When planning a cultural assessment, the nurse should include which component?
A) Family history
B) Chief complaint
C) Medical history
D) Health-related beliefs
24. When the nurse is evaluating the reliability of a patient's responses, which of these statements would be correct? The patient:
A. has a history of drug abuse and therefore is not reliable.
B. provided consistent information and therefore is reliable.
C. smiled throughout interview and therefore is assumed reliable.
D. would not answer questions concerning stress and therefore is not reliable.
25. In recording the childhood illnesses of a patient who denies having had any, which note by the nurse would be most accurate?
A. Patient denies usual childhood illnesses.
B. Patient states he was a "very healthy" child.
C. Patient states sister had measles, but he didn't.
D. Patient denies measles, mumps, rubella, chickenpox, pertussis, and strep throat.
26. A 5-year-old boy is being admitted to the hospital to have his tonsils removed. Which information should the nurse collect before this procedure?
A. The child's birth weight
B. The age at which he crawled
C. Whether he has had the measles
D. Reactions to previous hospitalizations
27. The nurse is preparing to do a functional assessment. Which statement best describes the purpose of a functional assessment?
A. It assesses how the individual is coping with life at home.
B. It determines how children are meeting developmental milestones.
C. It can identify any problems with memory the individual may be experiencing.
D. It helps to determine how a person is managing day-to-day activities.
28. The nurse is performing a functional assessment on an 82-year-old patient who recently had a stroke. Which of these questions would be most important to ask?
A. "Do you wear glasses?"
B. "Are you able to dress yourself?"
C. "Do you have any thyroid problems?"
D. "How many times a day do you have a bowel movement?
29. The nurse is conducting a developmental history on a 5-year-old child. Which questions are appropriate to ask the parents for this part of the assessment? Select all that apply.
A. "How much junk food does your child eat?"
B. "How many teeth has he lost, and when did he lose them?"
C. "Is he able to tie his shoelaces?"
D. "Does he take a children's vitamin?"
E. "Can he tell time?"
F. "Does he have any food allergies?
30. During an examination, the nurse can assess mental status by which activity?
A) Examining the patient's electroencephalogram
B) Observing the patient as he or she performs an IQ test
C) Observing the patient and inferring health or dysfunction
D) Examining the patient's response to a specific set of questions
31. The nurse is assessing a 75-year-old man. As the nurse begins the mental status portion of the assessment, the nurse expects that this patient:
A) will have no decrease in any of his abilities, including response time.
B) Will have difficulty on tests of remote memory because this typically decreases with age.
C) May take a little longer to respond, but his general knowledge and abilities should not have declined.
D) Will have had a decrease in his response time because of language loss and a decrease in general knowledge.
32. The nurse is preparing to do a mental status examination. Which statement is true regarding the mental status examination?
A) A patient's family is the best resource for information about the patient's coping skills.
B) It is usually sufficient to gather mental status information during the health history interview.
C) It takes an enormous amount of extra time to integrate the mental status examination into the health history interview.
D) It is usually necessary to perform a complete mental status examination to get a good idea of the patient's level of functioning.
33. During a mental status examination, the nurse wants to assess a patient's affect. The nurse should ask the patient which question?
A) "How do you feel today?"
B) "Would you please repeat the following words?"
C) "Have these medications had any effect on your pain?"
D) "Has this pain affected your ability to get dressed by yourself?"
34. During a mental status assessment, which question by the nurse would best assess a person's judgment?
A) "Do you feel that you are being watched, followed, or controlled?"
B) "Tell me about what you plan to do once you are discharged from the hospital."
C) "What does the statement, 'People in glass houses shouldn't throw stones,' mean to you?"
D) "What would you do if you found a stamped, addressed envelope lying on the sidewalk?"
35. The nurse is performing a mental status examination. Which statement is true regarding the assessment of mental status?
A) Mental status assessment diagnoses specific psychiatric disorders.
B) Mental disorders occur in response to everyday life stressors.
C) Mental status functioning is inferred through assessment of an individual's behaviors.
D) Mental status can be assessed directly, just like other systems of the body (e.g., cardiac and breath sounds).
36. When performing a physical assessment, the technique the nurse will always use first is:
37. The nurse is assessing a patient's skin during an office visit. What is the best technique to use to best assess the patient's skin temperature? Use the:
A) fingertips because they're more sensitive to small changes in temperature.
B) Dorsal surface of the hand because the skin is thinner than on the palms.
C) Ulnar portion of the hand because there is increased blood supply that enhances temperature sensitivity.
D) Palmar surface of the hand because it is most sensitive to temperature variations because of increased nerve supply in this area.
38. The nurse is preparing to assess a patient's abdomen by palpation. How should the nurse proceed?
A) Avoid palpation of reported "tender" areas because this may cause the patient pain.
B) Quickly palpate a tender area to avoid any discomfort that the patient may experience.
C) Begin the assessment with deep palpation, encouraging the patient to relax and take deep breaths.
D) Start with light palpation to detect surface characteristics and to accustom the patient to being touched.
39. The nurse would use bimanual palpation technique in which situation?
A) Palpating the thorax of an infant
B) palpating the kidneys and uterus
C) Assessing pulsations and vibrations
D) assessing the presence of tenderness and pain
40. When percussing over the liver of a patient, the nurse notices a dull sound. The nurse should:
A) consider this a normal finding.
B) Palpate this area for an underlying mass.
C) Reposition the hands and attempt to percuss in this area again.
D) Consider this an abnormal finding and refer the patient for additional treatment.
41. The nurse is unable to palpate the right radial pulse on a patient. The best action would be to:
A) auscultate over the area with a fetoscope.
B) Use a goniometer to measure the pulsations.
C) Use a Doppler device to check for pulsations over the area.
D) Check for the presence of pulsations with a stethoscope.
42. When performing a physical examination, safety must be considered to protect the examiner and the patient against the spread of infection. Which of these statements describes the most appropriate action the nurse should take when performing a physical examination?
A) There is no need to wash one's hands after removing gloves, as long as the gloves are still intact.
B) Wash hands before and after every physical patient encounter.
C) Wash hands between the examinations of each body system to prevent the spread of bacteria from one part of the body to another.
D) Wear gloves throughout the entire examination to demonstrate to the patient concern regarding the spread of infectious diseases.
43. The nurse is examining an infant and prepares to elicit the Moro reflex at which time during the examination?
A) When the infant is sleeping
B) At the end of the examination
C) Before auscultation of the thorax
D) Halfway through the examination
44. A 6-month-old infant has been brought to the well-child clinic for a check-up. She is currently sleeping. What should the nurse do first when beginning the examination?
A) Auscultate the lungs and heart while the infant is still sleeping.
B) Examine the infant's hips because this procedure is uncomfortable.
C) Begin with the assessment of the eye and continue with the remainder of the examination in a head-to-toe approach.
D) Wake the infant before beginning any portion of the examination to obtain the most accurate assessment of body systems.
45. The nurse is assessing an 80-year-old male patient. Which assessment findings would be considered normal?
A) An increase in body weight from younger years
B) Additional deposits of fat on the thighs and lower legs
C) The presence of kyphosis and flexion in the knees and hips
D) A change in overall body proportion, a longer trunk, and shorter extremities.
46. When assessing the force, or strength, of a pulse, the nurse recalls that it:
A) is usually recorded on a 0- to 2-point scale.
B) Demonstrates elasticity of the vessel wall.
C) Is a reflection of the heart's stroke volume?
D) Reflects the blood volume in the arteries during diastole.
47. When assessing the quality of a patient's pain, the nurse should ask which question?
A) "When did the pain start?"
B) "Is the pain a stabbing pain?"
C) "Is it a sharp pain or dull pain?"
D) "What does your pain feel like?"
48. The nurse is providing care for a 68-year-old woman who is complaining of constipation. What concern exists regarding her nutritional status?
A) The absorption of nutrients may be impaired.
B) The constipation may represent a food allergy.
C) She may need emergency surgery for the problem.
D) The gastrointestinal problem will increase her caloric demand.
49. During a nutritional assessment, why is it important for the nurse to ask a patient what medications he or she is taking?
A) Certain drugs can affect the metabolism of nutrients.
B) The nurse needs to assess the patient for allergic reactions.
C) Medications need to be documented on the record for the physician's review.
D) Medications can affect one's memory and ability to identify food eaten in the last 24 hours.
50. The nurse is reviewing the nutritional assessment of an 82-year-old patient. Which of these factors is most likely to affect the nutritional status of an elderly person?
A) Increase in taste and smell
B) living alone on a fixed income
C) Change in cardiovascular status
D) Increase in gastrointestinal motility and absorption
51. When the mid-upper arm circumference and triceps skinfold of an 82-year-old man are evaluated, which is important for the nurse to remember?
A) These measurements are no longer necessary for the elderly.
B) Derived weight measures may be difficult to interpret because of wide ranges of normal.
C) These measurements may not be accurate because of changes in skin and fat distribution.
D) Measurements may be difficult to obtain if the patient is unable to flex his elbow to at least 90 degrees.
52. The nurse needs to perform anthropometric measures of an 80-year-old man who is confined to a wheelchair. Which of the following is true in this situation?
A) Changes in fat distribution will affect the waist-to-hip ratio.
B) Height measurements may not be accurate because of changes in bone.
C) Declining muscle mass will affect the triceps skinfold measure.
D) Mid-arm circumference is difficult to obtain because of loss of skin elasticity.
53. The nurse is performing a nutritional assessment on an 80-year-old patient. The nurse knows that physiological changes that directly affect the nutritional status of the elderly include:
A) slowed gastrointestinal motility.
B) Hyper stimulation of the salivary glands.
C) An increased sensitivity to spicy and aromatic foods.
D) Decreased gastrointestinal absorption causing esophageal reflux.
54. The nurse keeps in mind that a thorough skin assessment is very important because the skin holds information about a person's:
A) support systems.
B) Circulatory status.
C) Socioeconomic status.
D) Psychological wellness.
55. A patient tells the nurse that he has noticed that one of his moles has started to burn and bleed. When assessing his skin, the nurse would pay special attention to the danger signs for pigmented lesions and would be concerned with which additional finding?
A) Color variation
B) Border regularity
C) Symmetry of lesions
D) Diameter less than 6 mm
56. An elderly woman is brought to the emergency department after being found lying on the kitchen floor 2 days, and she is extremely dehydrated. What would the nurse expect to see upon examination?
A) Smooth mucous membranes and lips
B) Dry mucous membranes and cracked lips
C) Pale mucous membranes
D) White patches on the mucous membranes
57. A 65-year-old man with emphysema and bronchitis has come to the clinic for a follow-up appointment. On assessment, the nurse might expect to see which assessment finding?
C) Pedal erythema
D) Clubbing of the nails
58. The nurse has discovered decreased skin turgor in a patient and knows that this is an expected finding in which of these conditions?
A) Severe obesity
B) Childhood growth spurts
C) Severe dehydration
D) Connective tissue disorders such as scleroderma
59. A 40-year-old woman reports a change in mole size, accompanied by color changes, itching, burning, and bleeding over the past month. She has a dark complexion and has no family history of skin cancer, but she has had many blistering sunburns in the past. The nurse would:
A) tell the patient to watch the lesion and report back in 2 months.
B) Refer the patient because of the suspicion of melanoma on the basis of her symptoms.
C) Ask additional questions regarding environmental irritants that may have caused this condition.
D) Suspect that this is a compound nevus, which is very common in young to middle-aged adults.
60. The nurse is assessing for clubbing of the fingernails and would expect to find:
A) a nail base that is firm and slightly tender.
B) Curved nails with a convex profile and ridges across the nail.
C) A nail base that feels spongy with an angle of the nail base of 150 degrees.
D) An angle of the nail base of 180 degrees or greater with a nail base that feels spongy.
61. A patient has been admitted for severe psoriasis. The nurse can expect to see what finding in the patient's fingernails?
A) Splinter hemorrhages
D) Beau lines
62. The nurse suspects that a patient has hyperthyroidism and laboratory data indicate that the patient's thyroxine and tri-iodothyronine hormone levels are elevated. Which of these findings would the nurse most likely find on examination?
C) Rapid dyspnea
D) Atrophied nodular thyroid
63. During an examination, the nurse knows that Paget's disease would be indicated by which of these assessment findings?
A) Positive Macewen sign
B) Premature closure of the sagittal suture
C) Headache, vertigo, tinnitus, and deafness
D) Elongated head with heavy eyebrow ridge
64. A woman comes to the clinic and states, "I've been sick for so long! My eyes have gotten so puffy, and my eyebrows and hair have become coarse and dry." The nurse will assess for other signs and symptoms of:
B) Parkinson's syndrome.
65. The physician reports that a patient with a neck tumor has a tracheal shift. The nurse is aware that this means that the patient's trachea is:
A) pulled to the affected side.
B) pushed to the unaffected side.
C) pulled downward.
D) pulled downward in a rhythmic pattern.
66. During an assessment of an infant, the nurse notes that the fontanels are depressed and sunken. The nurse suspects which condition?
C) Mental retardation
D) Increased intracranial pressure
67. The nurse is performing an assessment on a 7-year-old child who has symptoms of chronic watery eyes, sneezing, and clear nasal drainage. The nurse notices the presence of a transverse line across the bridge of the nose, dark blue shadows below the eyes, and a double crease on the lower eyelids. These findings are characteristic of:
B) a sinus infection.
C) nasal congestion.
D) an upper respiratory infection.
68. A mother asks when her newborn infant's eyesight will be developed. The nurse should reply:
A) "Vision is not totally developed until 2 years of age."
B) "Infants develop the ability to focus on an object at around 8 months."
C) "By about 3 months, infants develop more coordinated eye movements and can fixate on an object."
D) "Most infants have uncoordinated eye movements for the first year of life."
69. The nurse is performing an eye assessment on an 80-year-old patient. Which of these findings is considered abnormal?
A) A decrease in tear production
B) Unequal pupillary constriction in response to light
C) The presence of arcus senilis seen around the cornea
D) Loss of the outer hair on the eyebrows due to a decrease in hair follicles
70. The nurse notices the presence of periorbital edema when performing an eye assessment on a 70-year-old patient. The nurse should:
A) check for the presence of exophthalmos.
B) Suspect that the patient has hyperthyroidism.
C) Ask the patient if he or she has a history of heart failure.
D) Assess for blepharitis because this is often associated with periorbital edema.
71. A patient comes to the emergency department after a boxing match, and his left eye is swollen almost shut. He has bruises on his face and neck. He says he is worried because he "can't see well" from his left eye. The physician suspects retinal damage. The nurse recognizes that signs of retinal detachment include:
A) loss of central vision.
B) Shadow or diminished vision in one quadrant or one half of the visual field.
C) Loss of peripheral vision.
D) Sudden loss of pupillary constriction and accommodation.
72. A 68-year-old woman is in the eye clinic for a checkup. She tells the nurse that she has been having trouble with reading the paper, sewing, and even seeing the faces of her grandchildren. On examination, the nurse notes that she has some loss of central vision but her peripheral vision is normal. These findings suggest that:
A) she may have macular degeneration.
B) Her vision is normal for someone her age.
C) She has the beginning stages of cataract formation.
D) She has increased intraocular pressure or glaucoma.
73. An ophthalmic examination reveals papilledema. The nurse is aware that this finding indicates:
A) retinal detachment.
B) Diabetic retinopathy.
C) acute-angle glaucoma.
D) Increased intracranial pressure.
74. During an examination, a patient states that she was diagnosed with open-angle glaucoma 2 years ago. The nurse assesses for characteristics of open-angle glaucoma. Which of these are characteristics of open-angle glaucoma? Select all that apply.
A) The patient may experience sensitivity to light, nausea, and halos around lights.
B) The patient experiences tunnel vision in late stages.
C) Immediate treatment is needed.
D) Vision loss begins with peripheral vision.
E) It causes sudden attacks of increased pressure that cause blurred vision.
F) There are virtually no symptoms.
75. The nurse is taking the history of a patient who may have a perforated eardrum. What would be an important question in this situation?
A) "Do you ever notice ringing or crackling in your ears?"
B) "When was the last time you had your hearing checked?"
C) "Have you ever been told you have any type of hearing loss?"
D) "Was there any relationship between the ear pain and the discharge you mentioned?"
76. The nurse is performing an ear examination of an 80-year-old patient. Which of these would be considered a normal finding?
A) A high-tone frequency loss
B) Increased elasticity of the pinna
C) A thin, translucent membrane
D) A shiny, pink tympanic membrane
77. During an examination, the patient states he is hearing a buzzing sound and says that it is "driving me crazy!" The nurse recognizes that this symptom indicates:
78. The nurse is testing the hearing of a 78-year-old man and keeps in mind the changes in hearing that occur with aging include which of the following? Select all that apply.
A) Hearing loss related to aging begins in the mid- 40s.
B) The progression is slow.
C) The aging person has low-frequency tone loss.
D) The aging person may find it harder to hear consonants than vowels.
E) Sounds may be garbled and difficult to localize.
F) Hearing loss reflects nerve degeneration of the middle ear.
79. When assessing a patient's lungs, the nurse recalls that the left lung:
A) consists of two lobes.
B) Is divided by the horizontal fissure.
C) Consists primarily of an upper lobe on the posterior chest.
D) is shorter than the right lung because of the underlying stomach
80. During an assessment, the nurse knows that expected assessment findings in the normal adult lung include the presence of:
A) adventitious sounds and limited chest expansion.
B) Increased tactile fremitus and dull percussion tones.
C) Muffled voice sounds and symmetrical tactile fremitus.
D) Absent voice sounds and hyperresonant percussion tones.
81. A 65-year-old patient with a history of heart failure comes to the clinic with complaints of "being awakened from sleep with shortness of breath." Which action by the nurse is most appropriate?
A) Obtain a detailed history of the patient's allergies and history of asthma.
B) Tell the patient to sleep on his or her right side to facilitate ease of respirations.
C) Assess for other signs and symptoms of paroxysmal nocturnal dyspnea.
D) Assure the patient that this is normal and will probably resolve within the next week.
82. When assessing tactile fremitus, the nurse recalls that it is normal to feel tactile fremitus most intensely over which location?
A) Between the scapulae
B) Third intercostal space, MCL
C) Fifth intercostal space, MAL
D) over the lower lobes, posterior side
83. The nurse is reviewing the technique of palpating for tactile fremitus with a new graduate. Which statement by the graduate nurse reflects a correct understanding of tactile fremitus? "Tactile fremitus:
A) is caused by moisture in the alveoli."
B) Indicates that there is air in the subcutaneous tissues."
C) Is caused by sounds generated from the larynx."
D) Reflects the blood flow through the pulmonary arteries."
84. When auscultating the lungs of an adult patient, the nurse notes that over the posterior lower lobes low-pitched, soft breath sounds are heard, with inspiration being longer than expiration. The nurse interprets that these are:
A) sounds normally auscultated over the trachea.
B) Bronchial breath sounds and are normal in that location.
C) Vesicular breath sounds and are normal in that location.
D) bronchovesicular breath sounds and are normal in that location.
85. The nurse is percussing over the lungs of a patient with pneumonia. The nurse knows that percussion over an area of atelectasis in the lungs would reveal:
86. The nurse knows that auscultation of fine crackles would most likely be noticed in:
A) a healthy 5-year-old child.
B) A pregnant woman.
C) The immediate newborn period.
D) Association with a pneumothorax
87. During auscultation of the lungs of an adult patient, the nurse notices the presence of bronchophony. The nurse should assess for signs of which condition?
A) Airway obstruction
C) Pulmonary consolidation
88. The nurse is listening to the breath sounds of a patient with severe asthma. Air passing through narrowed bronchioles would produce which of these adventitious sounds?
B) Bronchial sounds
D) Whispered pectoriloquy
89. An adult patient with a history of allergies comes to the clinic complaining of wheezing and difficulty in breathing when working in his yard. The assessment findings include tachypnea, use of accessory neck muscles, prolonged expiration, intercostal retractions, decreased breath sounds, and expiratory wheezes. The nurse interprets that these assessment findings are consistent with:
C) Lobar pneumonia.
D) Heart failure.
90. During auscultation of breath sounds, the nurse should use the stethoscope correctly, in which of the following ways?
A) Listen to at least one full respiration in each location.
B) Listen as the patient inhales and then go to the next site during exhalation.
C) Have the patient breathe in and out rapidly while the nurse listens to the breath sounds.
D) If the patient is modest, listen to sounds over his or her clothing or hospital gown.
91. During palpation of the anterior chest wall, the nurse notices a coarse, crackling sensation over the skin surface. On the basis of these findings, the nurse suspects:
A) tactile fremitus.
C) Friction rubs.
D) Adventitious sounds.
92. The nurse is auscultating the lungs of a patient who had been sleeping and notices short, popping, crackling sounds that stop after a few breaths. The nurse recognizes that these breath sounds are:
A) atelectatic crackles, and that they are not pathologic.
B) Fine crackles, and that they may be a sign of pneumonia.
C) Vesicular breath sounds.
D) Fine wheezes.
93. The nurse is assessing voice sounds during a respiratory assessment. Which of these findings indicates a normal assessment? Select all that apply.
A) Voice sounds are faint, muffled, and almost inaudible when the patient whispers "one, two, three" in a very soft voice.
B) As the patient says "ninety-nine" repeatedly, the examiner hears the words "ninety-nine" clearly.
C) When the patient speaks in a normal voice, the examiner can hear a sound but cannot distinguish exactly what is being said.
D) As the patient says a long "ee-ee-ee" sound, the examiner also hears a long "ee-ee-ee" sound.
E) As the patient says a long "ee-ee-ee" sound, the examiner hears a long "aaaaaa" sound.
94. During an assessment of a 68-year-old man with a recent onset of right-sided weakness, the nurse hears a blowing, swishing sound with the bell of the stethoscope over the left carotid artery. This finding would indicate:
A) a valvular disorder.
B) Blood flow turbulence.
C) Fluid volume overload.
D) Ventricular hypertrophy.
95. During an assessment of a healthy adult, where would the nurse expect to palpate the apical impulse?
A) Third left intercostal space at the midclavicular line
B) Fourth left intercostal space at the sternal border
C) Fourth left intercostal space at the anterior axillary line
D) Fifth left intercostal space at the midclavicular line
96. The nurse is preparing to auscultate for heart sounds. Which technique is correct?
A) Listen to the sounds at the aortic, tricuspid, pulmonic, and mitral areas.
B) Listen by inching the stethoscope in a rough Z pattern, from the base of the heart across and down, then over to the apex.
C) Listen to the sounds only at the site where the apical pulse is felt to be the strongest.
D) Listen for all possible sounds at a time at each specified area.
97. The nurse is assessing a patient's apical impulse. Which of these statements is true regarding the apical impulse?
A) It is palpable in all adults.
B) It occurs with the onset of diastole.
C) Its location may be indicative of heart size.
D) It should normally be palpable in the anterior axillary line.
98. During an assessment of an older adult, the nurse should expect to notice which finding as a normal physiologic change associated with the aging process?
A) Hormonal changes causing vasodilation and a resulting drop in blood pressure
B) Progressive atrophy of the intramuscular calf veins, causing venous insufficiency
C) Peripheral blood vessels growing more rigid with age, producing a rise in systolic blood pressure
D) Narrowing of the inferior vena cava, causing low blood flow and increases in venous pressure resulting in varicosities.
99. During an assessment, the nurse uses the "profile sign" to detect:
A) pitting edema.
B) Early clubbing.
C) Symmetry of the fingers.
D) Insufficient capillary refill.
100. When performing a peripheral vascular assessment on a patient, the nurse is unable to palpate the ulnar pulses. The patient's skin is warm and capillary refill time is normal. The nurse should next:
A) check for the presence of claudication.
B) Refer the individual for further evaluation.
C) Consider this a normal finding and proceed with the peripheral vascular evaluation.
D) Ask the patient if he or she has experienced any unusual cramping or tingling in the arm.
101. The nurse is attempting to assess the femoral pulse in an obese patient. Which of these actions would be most appropriate?
A) Have the patient assume a prone position.
B) Ask the patient to bend his or her knees to the side in a froglike position.
C) Press firmly against the bone with the patient in a semi-Fowler position.
D) Listen with a stethoscope for pulsations because it is very difficult to palpate the pulse in an obese person.
102. When using a Doppler ultrasonic stethoscope, the nurse recognizes arterial flow when which sound is heard?
A) Low humming sound
B) Regular "lub, dub" pattern
C) Swishing, whooshing sound
D) Steady, even, flowing sound
103. The nurse is reviewing an assessment of a patient's peripheral pulses and notices that the documentation states that the radial pulses are "2 ." The nurse recognizes that this reading indicates what type of pulse?
104. The nurse is percussing the seventh right intercostal space at the midclavicular line over the liver. Which sound should the nurse expect to hear?
105. Which structure is located in the left lower quadrant of the abdomen?
D) Sigmoid colon
106. The nurse suspects that a patient has a distended bladder. How should the nurse assess for this condition?
A) Percuss and palpate in the lumbar region.
B) Inspect and palpate in the epigastric region.
C) Auscultate and percuss in the inguinal region.
D) Percuss and palpate the midline area above the suprapubic bone.
107. While examining a patient, the nurse observes abdominal pulsations between the xiphoid and umbilicus. The nurse would suspect that these are:
A) pulsations of the renal arteries.
B) Pulsations of the inferior vena cava.
C) Normal abdominal aortic pulsations.
D) Increased peristalsis from a bowel obstruction.
108. A patient has hypoactive bowel sounds. The nurse knows that a potential cause of hypoactive bowel sounds is:
109. The physician comments that a patient has abdominal borborygmi. The nurse knows that this term refers to:
A) a loud continuous hum.
B) A peritoneal friction rub.
C) Hypoactive bowel sounds.
D) Hyperactive bowel sounds
109. During an abdominal assessment, the nurse would consider which of these findings as normal?
A) The presence of a bruit in the femoral area
B) A tympanic percussion note in the umbilical region
C) A palpable spleen between the ninth and eleventh ribs in the left midaxillary line
D) A dull percussion note in the left upper quadrant at the midclavicular line.
110. During an abdominal assessment, the nurse is unable to hear bowel sounds in a patient's abdomen. Before reporting this finding as "silent bowel sounds" the nurse should listen for at least:
A) 1 minute.
B) 5 minutes.
C) 10 minutes.
D) 2 minutes in each quadrant.
111. A patient is suspected of having inflammation of the gallbladder, or cholecystitis. The nurse should conduct which of these techniques to assess for this condition?
A) Obturator test
B) Test for Murphy's sign
C) Assess for rebound tenderness
D) Iliopsoas muscle test
112. During an assessment the nurse notices that a patient's umbilicus is enlarged and everted. It is midline, and there is no change in skin color. The nurse recognizes that the patient may have which condition?
A) Intra-abdominal bleeding
C) Umbilical hernia
D) An abdominal tumor
113. The nurse suspects that a patient has appendicitis. Which of these procedures are appropriate for use when assessing for appendicitis or a perforated appendix? Select all that apply.
A) Test for Murphy's sign.
B) Test for Blumberg's sign.
C) Test for shifting dullness.
D) Perform iliopsoas muscle test.
E) Test for fluid wave.
114. When assessing muscle strength, the nurse observes that a patient has complete range of motion against gravity with full resistance. What Grade should the nurse record using a 0 to 5 point scale?
115. The nurse is assessing the joints of a woman who has stated, "I have a long family history of arthritis, and my joints hurt." The nurse suspects that she has osteoarthritis. Which of these are symptoms of osteoarthritis? Select all that apply.
A) Symmetric joint involvement
B) Asymmetric joint involvement
C) Pain with motion of affected joints
D) Affected joints are swollen with hard, bony protuberances
E) Affected joints may have heat, redness, and swelling
116. During an assessment of an 80-year-old patient, the nurse notices the following: inability to identify vibrations at the ankle and to identify position of big toe, slower and more deliberate gait, and slightly impaired tactile sensation. All other neurologic findings are normal. The nurse should interpret that these findings indicate:
A) cranial nerve dysfunction.
B) Lesion in the cerebral cortex.
C) Normal changes due to aging.
D) Demyelization of nerves due to a lesion.
117. In obtaining a history on a 74-year-old patient the nurse notes that he drinks alcohol daily and that he has noticed a tremor in his hands that affects his ability to hold things. With this information, what should the nurse's response be?
A) "Does your family know you are drinking every day?"
B) "Does the tremor change when you drink the alcohol?"
C) "We'll do some tests to see what is causing the tremor."
D) "You really shouldn't drink so much alcohol; it may be causing your tremor."
118. During the neurologic assessment of a "healthy" 35-year-old patient, the nurse asks him to relax his muscles completely. The nurse then moves each extremity through full range of motion. Which of these results would the nurse expect to find?
A) Firm, rigid resistance to movement
B) Mild, even resistance to movement
C) Hypotonic muscles as a result of total relaxation
D) Slight pain with some directions of movement
119. When the nurse asks a 68-year-old patient to stand with feet together and arms at his side with his eyes closed, he starts to sway and moves his feet farther apart. The nurse would document this finding as a(n):
B) Lack of coordination.
C) NegativeHomans' sign.
D) Positive Romberg sign
120. During the history of a 78-year-old man, his wife states that he occasionally has problems with short-term memory loss and confusion: "He can't even remember how to button his shirt." In doing the assessment of his sensory system, which action by the nurse is most appropriate?
A) The nurse would not do this part of the examination because results would not be valid.
B) The nurse would perform the tests, knowing that mental status does not affect sensory ability.
C) The nurse would proceed with the explanations of each test, making sure the wife understands.
D) Before testing, the nurse would assess the patient's mental status and ability to follow directions at this time.
121. In assessing a 70-year-old patient who has had a recent cerebrovascular accident, the nurse notices right-sided weakness. What might the nurse expect to find when testing his reflexes on the right side?
A) Lack of reflexes
B) Normal reflexes
C) Diminished reflexes
D) Hyperactive reflexes
122. During the assessment of an 80-year-old patient, the nurse notices that his hands show tremors when he reaches for something and his head is always nodding. There is no associated rigidity with movement. Which of these statements is most accurate?
A) These are normal findings resulting from aging.
B) These could be related to hyperthyroidism.
C) These are the result of Parkinson disease.
D) This patient should be evaluated for a cerebellar lesion.
123. While the nurse is taking the history of a 68-year-old patient who sustained a head injury 3 days earlier, he tells the nurse that he is on a cruise ship and is 30 years old. The nurse knows that this finding is indicative of:
A) a great sense of humor.
B) Uncooperative behavior.
C) Inability to understand questions.
D) Decreased level of consciousness.
124. The nurse is caring for a patient who has just had neurosurgery. To assess for increased intracranial pressure, what would the nurse include in the assessment?
A) Cranial nerves, motor function, and sensory function
B) Deep tendon reflexes, vital signs, and coordinated movements
C) Level of consciousness, motor function, pupillary response, and vital signs
D) Mental status, deep tendon reflexes, sensory function, and pupillary response
125. During an assessment of a 22-year-old woman who has a head injury from a car accident 4 hours ago, the nurse notices the following change: pupils were equal, but now the right pupil is fully dilated and nonreactive, left pupil is 4 mm and reacts to light. What does finding this suggest?
A) Injury to the right eye
B) Increased intracranial pressure
C) Test was not performed accurately
D) Normal response after a head injury
126. The nurse knows that determining whether a person is oriented to his or her surroundings will test the functioning of which of these structures?
C) Cranial nerves
D) Medulla oblongata