ATI Test For Nursing Fundamentals Part I Practice Test

1. The most important nursing intervention to correct skin dryness is:

Ask the physician to refer the patient to a dermatologist, and suggest that the patient wear home-laundered sleepwear.

Consult the dietitian about increasing the patient’s fat intake, and take necessary measures to prevent infection.

Avoid bathing the patient until the condition is remedied, and notify the physician.

The correct answer is to encourage the patient to increase their fluid intake, use non-irritating soap when bathing, and apply lotion to the affected areas. This intervention addresses the underlying cause of skin dryness, which is dehydration. Increasing fluid intake helps to hydrate the body from within, while using non-irritating soap and applying lotion helps to moisturize the skin externally. These measures can help to improve skin dryness and prevent further complications. Referring the patient to a dermatologist or avoiding bathing until the condition is remedied are not appropriate interventions for addressing skin dryness.

Explanation

The correct answer is to encourage the patient to increase their fluid intake, use non-irritating soap when bathing, and apply lotion to the affected areas. This intervention addresses the underlying cause of skin dryness, which is dehydration. Increasing fluid intake helps to hydrate the body from within, while using non-irritating soap and applying lotion helps to moisturize the skin externally. These measures can help to improve skin dryness and prevent further complications. Referring the patient to a dermatologist or avoiding bathing until the condition is remedied are not appropriate interventions for addressing skin dryness.

2. When talking to a child who is seated, the nurse should

Touch the child

Stand facing the child

Stand with a relaxed posture

Sit at eye level with the child

The nurse should be at the same eye level as the child to facilitate communication. Touching may intimidate the child and bock communication. Standing will prevent the nurse from being at eye level with the child.

Explanation

The nurse should be at the same eye level as the child to facilitate communication. Touching may intimidate the child and bock communication. Standing will prevent the nurse from being at eye level with the child.

3. Once a nurse has counseled a client about her situational role changes, and she has accepted them, what is the next step in her recovery?

Apprehension

Tension

Resentment

Adaptation

A client who has accepted role changes will demonstrate adaptation. Resentment, tension, and apprehension are not behaviors or emotions consistent with acceptance.

Explanation

A client who has accepted role changes will demonstrate adaptation. Resentment, tension, and apprehension are not behaviors or emotions consistent with acceptance.

4. A diabetic patient lost his wife 4 months ago. Tearful, he says, "How could you possibly understand what I am going through?" Which of the following would be an appropriate response?

"It takes time to get over the loss of a loved one."

"You are right; I cannot really understand. Perhaps you'd like to tell me more about what you're feeling."

"Why don't you try something to take your mind off your troubles, like watching a funny movie."

By stating that she is not in his situation, the nurse is using the therapeutic communication technique of validation, whereby she shows sensitivity to the meaning behind his behavior. She is also creating a supportive and nonjudgmental environment, and inviting him to express his frustrations. Telling the patient to try a distraction dismisses the client's feelings and gives common advice instead of expert advice. Saying she knows what clients feel is presumptive and inappropriate.

Explanation

By stating that she is not in his situation, the nurse is using the therapeutic communication technique of validation, whereby she shows sensitivity to the meaning behind his behavior. She is also creating a supportive and nonjudgmental environment, and inviting him to express his frustrations. Telling the patient to try a distraction dismisses the client's feelings and gives common advice instead of expert advice. Saying she knows what clients feel is presumptive and inappropriate.

5. A patient who had a mastectomy 6 months ago tells the nurse that she has not had much desire for sexual relations since her surgery. "My body is different now." Which of the following is an appropriate response from the nurse?

"Really, you look just fine to me. There's no need to feel undesirable

I'm interested in finding out more about how your body feels to you".

"Consider an afternoon at a spa. A facial will make you feel more attractive"

"it is still too soon to expect to feel normal. Give it a little more time

Showing interest in a client is a therapeutic communication technique of offering self; asking more about how the client feels is a therapeutic communication technique of encouraging a description of prescription. Telling the client she looks fine is using the nontherapeutic communication technique of giving an opinion. Assuming she feels undesirable is not therapeutic and it is called interpreting. Suggesting a facial is using a nontherapeutic technique of giving advice. Telling her it is too soon to feel normal and to give it more time is belittling the client's feelings and giving false reassurance.

Explanation

Showing interest in a client is a therapeutic communication technique of offering self; asking more about how the client feels is a therapeutic communication technique of encouraging a description of prescription. Telling the client she looks fine is using the nontherapeutic communication technique of giving an opinion. Assuming she feels undesirable is not therapeutic and it is called interpreting. Suggesting a facial is using a nontherapeutic technique of giving advice. Telling her it is too soon to feel normal and to give it more time is belittling the client's feelings and giving false reassurance.

6. Match the following readings on the right with the blood pressure classification on the left according to JNC 7

Normal

Prehypertension

Stage 1 hypertension

Stage 2 hypertension

Submit

7. A mother tells a nurse that her 2-year old has temper tantrums. The child says "no" every time the mother tries to help her get dressed. The nurse explains that, developmentally, the child is

Trying to increase her independence

Developing a sense of trust

Manifesting an anger management problem

Attempting to finish a project she started

Toddlers express independence by opposing those in authority as they attempt to do everything on their own. Developing trust is a task for infants. Finishing a project belongs to school-age children. The behavior that is left is normal for a 2 year old child and is not an expression of anger management problems.

Explanation

Toddlers express independence by opposing those in authority as they attempt to do everything on their own. Developing trust is a task for infants. Finishing a project belongs to school-age children. The behavior that is left is normal for a 2 year old child and is not an expression of anger management problems.

8. A patient is concerned about the confidentiality of the information she is disclosing during a health history interview. The nurse should provide a response by telling the client.

Exactly with whom the information will be shared

That it is required for her to give any information that is requested

A confidential piece of information about herself

Her family members will be informed of necessary information

The client has a right to confidentiality and the right to know with whom her information will be shared. The client has the right to refuse to reveal information if she chooses. The nurse telling the client confidential information about herself is not professional. Giving information to family members is a violation of confidentiality

Explanation

The client has a right to confidentiality and the right to know with whom her information will be shared. The client has the right to refuse to reveal information if she chooses. The nurse telling the client confidential information about herself is not professional. Giving information to family members is a violation of confidentiality

9. Assessment of an older adult reveals significant skin tenting over the forearm. Why?

Loss of adipose tissue and elasticity

Parchment-like skin

Significant flaking and dryness

Skin tags

Tenting is a result of loss of adipose tissue and elasticity of the skin. Thin, parchment-like skin,dryness, and skin tags do not cause tenting

Explanation

Tenting is a result of loss of adipose tissue and elasticity of the skin. Thin, parchment-like skin,dryness, and skin tags do not cause tenting

10. Which of the following developmental tasks is appropriate for a preschool child?

Using a knife to cut meat at mealtime

Dressing independently

Following several directions at once

Comprehending satire

Preschoolers should be able to dress themselves with occasional help in tying shoes or fastening complex buckles or closures. Using a knife to cut meat at mealtime, following several directions at once, and comprehending satire are developmental tasks of school-age children.

Explanation

Preschoolers should be able to dress themselves with occasional help in tying shoes or fastening complex buckles or closures. Using a knife to cut meat at mealtime, following several directions at once, and comprehending satire are developmental tasks of school-age children.

11. What is the right sequence when performing an abdominal assessment?

Inspection, palpation, percussion, auscultation

Auscultation, inspection, palpation, and percussion

Percussion, inspection, auscultation and palpation

Inspection, auscultation, percussion and palpation

This sequence allows the client's bowel sounds to be heard without being disturbed or distorted by percussion or palpation assessments

Explanation

This sequence allows the client's bowel sounds to be heard without being disturbed or distorted by percussion or palpation assessments

12. Which of the following factors positively affect self-concept? Select all that apply

Diabetes mellitus

Parental approval

Success at school

Receiving a promotion at work

Excessive use of alcohol

Parental approval, success at school, and receiving a promotion at work will have a positive impact on the individual's self-concept, as these situations promote good feelings about self-concept. A chronic illness usually have a negative impact on self-concept, as the client is required to adapt to the changes. Excessive use of alcohol is a symptom of a poor self-concpt

Explanation

Parental approval, success at school, and receiving a promotion at work will have a positive impact on the individual's self-concept, as these situations promote good feelings about self-concept. A chronic illness usually have a negative impact on self-concept, as the client is required to adapt to the changes. Excessive use of alcohol is a symptom of a poor self-concpt

Submit

13. A nurse is checking the vital signs of a 92-year old patient. The patient's radial pulse has an irregular beat about every 5th or 6th beat. The rate is 92/min. The patient is asymptomatic. What should be the first intervention?

Report the findings to the physician immediately.

Obtain an electrocardiogram

Check an apical pulse for 60 seconds and note any pulse deficits

Place the patient on telemetry

This radial pulse does not require immediate medical treatment; therefore, the nurse should next measure the client's apical pulse to assess the client's status further. The nurse should then report the findings to the provider, who will then decide if the client requires telemetry and an electrocardiogram

Explanation

This radial pulse does not require immediate medical treatment; therefore, the nurse should next measure the client's apical pulse to assess the client's status further. The nurse should then report the findings to the provider, who will then decide if the client requires telemetry and an electrocardiogram

14. When assessing a skin temperature, which side of the hand should be used?

Fingertips

Dorsal surface

Palmar surface

Base of the hand

The dorsal surface of the hand is the most sensitive to temperature changes.

Explanation

The dorsal surface of the hand is the most sensitive to temperature changes.

15. A nurse is teaching a class on accident prevention to a group of parents with their toddlers. Which of the following should be included in the teaching? Select all that apply:

Keep toxic agents in locked cabinets

Keep toilet seats up

Turn pot handles toward the back of the stove

Place safety gates across stairway

Raise the setting on the hot water heater

Place fences around swimming pools

Keeping toxic agents out of reach, turning pot handles to the back of the stove, and placing safety gates across stairways and fences around pools are ways to prevent accidents. Toilet seat should be kept down to prevent drowning and the temperature on the hot water heater should be lowered to prevent burns.

Explanation

Keeping toxic agents out of reach, turning pot handles to the back of the stove, and placing safety gates across stairways and fences around pools are ways to prevent accidents. Toilet seat should be kept down to prevent drowning and the temperature on the hot water heater should be lowered to prevent burns.

Submit

16. A nurse is providing postoperative teaching for a client who is scheduled for a mastectomy the next day. Which of the following client statements indicates that the client is ready to learn?

"I don't want my spouse to see my incision."

"Will you be able to give me pain medicine after surgery?"

"Can you tell me about how long the surgery will take?"

"My room mate listens to everything I say."

Asking a concrete question about the surgery indicates that the client is ready to discuss the surgery. The client's new diagnosis of cancer may cause anxiety, fear, or depression, all of which can interfere with the learning process. The client's concern about her spouse seeing the incision may indicate anxiety or depression. The client's request for pain medicine may indicate fear and anxiety. The lack of privacy due to the presence of a roommate may be a barrier to learning.

Explanation

Asking a concrete question about the surgery indicates that the client is ready to discuss the surgery. The client's new diagnosis of cancer may cause anxiety, fear, or depression, all of which can interfere with the learning process. The client's concern about her spouse seeing the incision may indicate anxiety or depression. The client's request for pain medicine may indicate fear and anxiety. The lack of privacy due to the presence of a roommate may be a barrier to learning.

17. Which of the following therapeutic techniques is used to provide a comfortable environment for performing a health assessment? Select all that apply:

Provide privacy

Examine sensitive areas first

Reduce environmental noises

Explain various techniques before performing them

Use medical terminology for accuracy

Providing privacy, reducing environmental noise and explaining techniques to be used will establish trust and rapport. Sensitive areas should be examined after the client has developed some trust and feels more comfortable Medical terminology may confuse the client and lead to misunderstanding of the intended message.

Explanation

Providing privacy, reducing environmental noise and explaining techniques to be used will establish trust and rapport. Sensitive areas should be examined after the client has developed some trust and feels more comfortable Medical terminology may confuse the client and lead to misunderstanding of the intended message.

Submit

18. Which of the following should a nurse teach regarding the discipline of toddlers?

Establish consistent boundaries

Place the child in a room with the door closed

Have the child learn by trial and error

Use favorite snacks as reward

Toddlers need to have consistent boundaries for discipline to be effective. Placing the child in a room with the door closed may cause anxiety and fear to develop. Trial and error lacks consistent boundaries and may allow the toddler to experience unhealthy consequences. Using favorite foods as rewards may promote unhealthy eating habits.

Explanation

Toddlers need to have consistent boundaries for discipline to be effective. Placing the child in a room with the door closed may cause anxiety and fear to develop. Trial and error lacks consistent boundaries and may allow the toddler to experience unhealthy consequences. Using favorite foods as rewards may promote unhealthy eating habits.

19. Which of the following approaches should be used when working with a family using an open structure for coping with crisis?

Prescribing tasks unilaterally

Convening a family meeting

Delegating care to one member

Speaking to the primary client privately

An open structure is loose, and convening a family meeting would give all family members input and an opportunity to express their feelings. Prescribing tasks and delegating care are too rigid for acceptance by a family with an open structure. Speaking to the primary client privately excludes the family.

Explanation

An open structure is loose, and convening a family meeting would give all family members input and an opportunity to express their feelings. Prescribing tasks and delegating care are too rigid for acceptance by a family with an open structure. Speaking to the primary client privately excludes the family.

20. Which of the following is a situational role change?

A young adult getting married for the first time

A toddler learning to control elimination

An adolescent experiencing puberty

A middle adult experiencing menopause

Marriage adds the role of spouse. Puberty, menopause and elimination control are expected physiological growth and development phases and are not considered situational role changes.

Explanation

Marriage adds the role of spouse. Puberty, menopause and elimination control are expected physiological growth and development phases and are not considered situational role changes.

21. A 19-year old female client has come to the college health clinic for a Pap test. It is her first visit. Which of the following interventions should the nurse perform first to determine the client's need for health promotion and disease prevention?

Measure the client's vital signs

Encourage the client to be screened for HIV

Determine the client's risk factors

Instruct the client to use condoms for birth control

Under the nursing process, the first action the nurse should take is to assess the client. Assessment of risk factors must occur first before health promotion or disease prevention interventions are developed. The nurse should conduct an interview with the client before performing any physical exam. This allows the nurse time to establish rapport with the client prior to any invasive procedures. Stressing the need for HIV screening and instructing the client in the use of birth control may be necessary if the assessment reveals any related risk factors.

Explanation

Under the nursing process, the first action the nurse should take is to assess the client. Assessment of risk factors must occur first before health promotion or disease prevention interventions are developed. The nurse should conduct an interview with the client before performing any physical exam. This allows the nurse time to establish rapport with the client prior to any invasive procedures. Stressing the need for HIV screening and instructing the client in the use of birth control may be necessary if the assessment reveals any related risk factors.

22. A nurse recognizes that a helping relationship is established with a patient if the communication.

Occurs spontaneously throughout the nurse-client relationship

Has no time limits

Is equally reciprocal between the nurse and the patient.

Encourages the patient to express his thoughts and feelings

Therapeutic communication facilitates a helping relationship that maximizes the client's ability to openly express his thoughts and feelings. The communication is not reciprocal but client-focused. Therapeutic communication is limited to the boundaries of the therapeutic relationship. Therapeutic communication is planned by a health care professional.

Explanation

Therapeutic communication facilitates a helping relationship that maximizes the client's ability to openly express his thoughts and feelings. The communication is not reciprocal but client-focused. Therapeutic communication is limited to the boundaries of the therapeutic relationship. Therapeutic communication is planned by a health care professional.

23. Assessment of the musculoskeletal system should start with

Measuring limb length

Testing range of motion

Inspecting for symmetry and posture

Assessing of muscle strength

Assessment of the musculoskeletal system should start with inspection of the skeleton. Measuring limb length, testing range of motion and muscle strength are performed after inspection.

Explanation

Assessment of the musculoskeletal system should start with inspection of the skeleton. Measuring limb length, testing range of motion and muscle strength are performed after inspection.

24. A nurse witnesses assistive personnel (AP) under her supervision reprimanding a client for not using the urinal properly. The AP threatens to put a diaper on the client if he does not use the urinal more carefully next time. Which of the following torts is the AP committing?

Assault

Battery

False imprisonment

Invasion of privacy

By threatening the client, the AP is committing assault. Her threats could make the client become fearful and apprehensive. Since the AP has only verbally threatened the client, battery has not occurred. False imprisonment and invasion of privacy have not been committed.

Explanation

By threatening the client, the AP is committing assault. Her threats could make the client become fearful and apprehensive. Since the AP has only verbally threatened the client, battery has not occurred. False imprisonment and invasion of privacy have not been committed.

25. What is the most appropriate way to auscultate breathe sounds?

Listen to the top of the anterior chest and then the top of the posterior chest

Compare side to side proceeding from top to bottom

Listen only to the posterior chest

Complete one side of the chest before proceeding to the other side

Comparing side to side breath sounds is the correct technique to use. This allows the nurse to make comparisons between right and left lungs in a systematic way. The nurse should listen to the anterior and posterior aspects of the chest in a consistent manner.

Explanation

Comparing side to side breath sounds is the correct technique to use. This allows the nurse to make comparisons between right and left lungs in a systematic way. The nurse should listen to the anterior and posterior aspects of the chest in a consistent manner.

26. Which of the following should be included in a transfer report?

The client is alert and oriented

The client does not like Spinach

The client has an allergy to shellfish

The client needs morphine every 4 hours

The client has two cats at home

The client's level of consciousness, allergies, and need for pain medication are relevant to evaluating the client's health status and maintaining safety and comfort. Personal preferences such as the client not liking spinach and keeping cats as pets, may sometimes be helpful but neither is clinically significant for a transfer report.

Explanation

The client's level of consciousness, allergies, and need for pain medication are relevant to evaluating the client's health status and maintaining safety and comfort. Personal preferences such as the client not liking spinach and keeping cats as pets, may sometimes be helpful but neither is clinically significant for a transfer report.

Submit

27. Which of the following is an effective technique to use when interviewing a client?

Start interview with nonthreatening topics

Use only non-directive questions

Have the client fill out a printed history form

Ask questions word for word from the history form

A nonthreatening topic will establish rapport and trust between client and nurse. Nondirective questions may make the client feel comfortable, but may allow the client to avoid discussing important details. Having the client fill out a history form and asking questions word for word may discourage the establishment of a therapeutic relationship with client.

Explanation

A nonthreatening topic will establish rapport and trust between client and nurse. Nondirective questions may make the client feel comfortable, but may allow the client to avoid discussing important details. Having the client fill out a history form and asking questions word for word may discourage the establishment of a therapeutic relationship with client.

28. A nurse is checking the vital signs of a newly admitted patient who has a femur fracture. The patient's blood pressure is 140/94 mm Hg. The client denies any history of hypertension. What should the nurse do next?

Ask the patient if she is having pain

Report the elevated BP to the physician

Return within 30 minutes to check the blood pressure

Check orthostatic blood pressure

The patient has a broken femur and her blood pressure is elevated due to pain. The nurse should ask if she is having pain and continue a full pain assessment. If the patient's BP is still elevated after pain intervention. the nurse should report this finding to the physician. This client needs further assessment at this time, so returning in 30 minutes is not appropriate. There is no indication for orthostatic pressure, and it might be difficult to have the client sit or stand with a fractured femur

Explanation

The patient has a broken femur and her blood pressure is elevated due to pain. The nurse should ask if she is having pain and continue a full pain assessment. If the patient's BP is still elevated after pain intervention. the nurse should report this finding to the physician. This client needs further assessment at this time, so returning in 30 minutes is not appropriate. There is no indication for orthostatic pressure, and it might be difficult to have the client sit or stand with a fractured femur

29. A home health nurse performs a 3-day postpartum visit for a first-time mother. The household includes her husband, her mother, and her father. What type of family form is represented here?

Nuclear

Extended

Blended

Alternative

In an extended family, in an addition to the nuclear members, grandparents and other family members may live in the same household. A blended family includes step children in addition to the nuclear members. An alternative family can have single adults, cohabiting partners, or same-gender partners.

Explanation

In an extended family, in an addition to the nuclear members, grandparents and other family members may live in the same household. A blended family includes step children in addition to the nuclear members. An alternative family can have single adults, cohabiting partners, or same-gender partners.

30. Asking the client to tip her head to one side and slightly forward, palpating either side of the trachea at the lower half of the neck, and then asking the client to swallow is the correct technique for examining what?

Lymph nodes

ROM of the neck

Symmetry of the skull

Thyroid gland

This is the correct technique in assessing the thyroid gland.

Explanation

This is the correct technique in assessing the thyroid gland.

31. Match the activities on the left to the appropriate level of health care prevention on the right.

Driver's education. Newborn immunization

Blood pressure screening at a senior center. Community cholesterol screening

Monitored exercise therapy at a cardiac rehabilitation center. Teaching self-catherization to a client with a spinal cord injury

Submit

32. A 17-year old male patient was hospitalized because of a fractured femur. Which of the following are age-appropriate interventions?

Suggest that his parents room in with him

Provide a television and DVDs for him to watch

Restrict visitors

Encourage him to get enough rest

Allow him to perform his own morning care

DVDs are appropriate diversional activities for an adolescent. It is important for him to get adequate rest, and allowing him to perform his own morning care will provide a sense of independence. Rooming in is most appropriate for an infant, toddler, preschooler, and school-age child. There is no reason to restrict visitors and allowing his friends to visit can prevent feelings of isolation.

Explanation

DVDs are appropriate diversional activities for an adolescent. It is important for him to get adequate rest, and allowing him to perform his own morning care will provide a sense of independence. Rooming in is most appropriate for an infant, toddler, preschooler, and school-age child. There is no reason to restrict visitors and allowing his friends to visit can prevent feelings of isolation.

Submit

33. During palpation of the breast, the client is instructed to extend an arm over her head, and a small pillow or folded towel is placed under her shoulder. What for?

Spread tissue more evenly over the chest wall for easier palpation

Keep client from guarding during the exam

Expose the tail of Spence for eaisier inspection

Determine whether or not a breast mass is consistently irregular when palpating a nodule.

This position spreads the tissue more evenly over the chest wall for easier palpation. It does not keep the client from guarding, exposing the tail of Spence, or determining the irregularity of breast mass.

Explanation

This position spreads the tissue more evenly over the chest wall for easier palpation. It does not keep the client from guarding, exposing the tail of Spence, or determining the irregularity of breast mass.

34. A nurse employed by a large hospital is serving on a committee updating its disaster plan. In case of a mass casualty event, which of the following clients will receive the highest priority?

A client who received crush injuries to the chest and abdomen and is expected to die

A client who has a 4-in laceration to the head

A client who has partial thickness and full thickness burns to his face, neck and chest.

A client who has a fractured fibula and tibia.

The client who has the greatest chance of survival with prompt intervention should be given priority in a mass casualty event. If not treated immediately, a client who has burns to his face, neck, and chest is at risk for airway obstruction, but is still expected to live. Therefore, this client is the highest priority (Emergent category - Class I). A client with major fractures would be the second priority (Urgent category - class II). A client with a minor injury that is not life threatening, such as a laceration to the head, would have the third priority (Nonurgent category - Class III). The lowest priority would be given to a client who is not expected to live. Comfort measures would be provided for this client (Expectant category - Class IV).

Explanation

The client who has the greatest chance of survival with prompt intervention should be given priority in a mass casualty event. If not treated immediately, a client who has burns to his face, neck, and chest is at risk for airway obstruction, but is still expected to live. Therefore, this client is the highest priority (Emergent category - Class I). A client with major fractures would be the second priority (Urgent category - class II). A client with a minor injury that is not life threatening, such as a laceration to the head, would have the third priority (Nonurgent category - Class III). The lowest priority would be given to a client who is not expected to live. Comfort measures would be provided for this client (Expectant category - Class IV).

35. A patient told you that the results of her Snellen eye test were that the acuity for both of her eyes was 20/30. What does this mean

Patient sees at 20 ft what the normal sighted person sees at 30 ft.

Patient sees at 30 ft what the normal sighted person sees at 20 ft.

Patient sees at 10 ft what the normal sighted person sees at 50 ft.

Patient sees at 50 ft what the normal sighted person sees at 20 ft

The first number indicates the number of feet from the Snellen eye chart that the client is standing, and the second number is the distance at which a normal-sighted person can read the line of the Snellen eye chart.

Explanation

The first number indicates the number of feet from the Snellen eye chart that the client is standing, and the second number is the distance at which a normal-sighted person can read the line of the Snellen eye chart.

36. Match the appropriate technique for each of the following assessments

A vibrating tuning fork is placed on the mastoid process and then placed near the ear when the sound is no longer heard.

A vibrating tuning fork is placed midline on top of the head and the client is asked where the sound is heard best

The back of the throat is stimulated with tongue depressor

The client occludes one ear while the nurse whispersin the other ear from 30 cm away.

Submit

37. Which of the following are normal aging changes in the musculoskeletal system? Select all that apply;

Wider stance resulting in posture changes

Loss of height

Increased range of motion

Increased muscle bulk

Thinning intervertebral discs

Normal aging changes of the musculoskeletal system includes posture changes, loss of height, and thinning intervertebral discs. Range of motion and muscle size also decrease

Explanation

Normal aging changes of the musculoskeletal system includes posture changes, loss of height, and thinning intervertebral discs. Range of motion and muscle size also decrease

Submit

38. Dorsiflexion of the feet is assessed by instructing the client to

Point the toes toward the head

Point the toes toward the floor

Turn the soles of the feet outward

Turn the soles of the feet inward

Pointing the toes toward the head is dorsiflexion. Point the toes toward the floor results in plantar flexion.Turn the soles of the feet outward results in eversion, and turning the soles of the feet inward results in inversion.

Explanation

Pointing the toes toward the head is dorsiflexion. Point the toes toward the floor results in plantar flexion.Turn the soles of the feet outward results in eversion, and turning the soles of the feet inward results in inversion.

39. Match the following cranial nerves with the appropriate assessment technique

Olfactory CN I

Optic CN II

Oculomotor - CN III; Trochlear CN IV; Abducens CN VI

Facial CN VII

Spinal accessory CN XI

Hypoglossal CN XII

Submit

40. Which of the following developmental tasks should adolescents be expected to accomplish?

Identity vs role confusion

Autonomy vs shame

Initiative vs guilt

Industry vs inferiority

The developmental task of achieving identity vs role confusion should be accomplished by an adolescent. The developmental task of autonomy vs. shame should be accomplished during the toddler years. The developmental task of initiative vs guilt should be accomplished during the preschool years. The developmental task of industry vs inferiority should be accomplished during the school-age years.

Explanation

The developmental task of achieving identity vs role confusion should be accomplished by an adolescent. The developmental task of autonomy vs. shame should be accomplished during the toddler years. The developmental task of initiative vs guilt should be accomplished during the preschool years. The developmental task of industry vs inferiority should be accomplished during the school-age years.

41. Which of the following decreases respiratory rate? Select all that apply:

Morphine

Caffeine

Jogging in the park

General anesthesia during surgery

Smoking

Morphine is a potent analgesic and sedative that can decrease respiratory rate by depressing the central nervous system. General anesthesia during surgery also decreases respiratory rate as it involves the use of medications that suppress the respiratory drive. Caffeine, jogging in the park, and smoking, on the other hand, do not decrease respiratory rate. Caffeine is a stimulant that can actually increase respiratory rate, while jogging in the park and smoking may have variable effects on respiratory rate but are generally not known to decrease it.

Explanation

Morphine is a potent analgesic and sedative that can decrease respiratory rate by depressing the central nervous system. General anesthesia during surgery also decreases respiratory rate as it involves the use of medications that suppress the respiratory drive. Caffeine, jogging in the park, and smoking, on the other hand, do not decrease respiratory rate. Caffeine is a stimulant that can actually increase respiratory rate, while jogging in the park and smoking may have variable effects on respiratory rate but are generally not known to decrease it.

Submit

42. To evaluate STEREOGNOSIS, the nurse should ask the client to close his eyes and identify

A number drawn in the palm of his hand

A word whispered 30 cm from the ear

A familiar object placed in his hand

The vibration of a tuning fork placed on his foot

Identifying a familiar object placed in the hand assesses for sterognosis. Graphesthesia is identifying a number drawn in the palm of the hand. Hearing whispered words tests CN VIII. Identifying a tuning fork tests the vibratory sense.

Explanation

Identifying a familiar object placed in the hand assesses for sterognosis. Graphesthesia is identifying a number drawn in the palm of the hand. Hearing whispered words tests CN VIII. Identifying a tuning fork tests the vibratory sense.

43. Unilateral hypertrophy of the arm muscles is most likely seen in an individual who regularly

Lifts weights

Plays soccer

Moves furniture

Plays tennis

A tennis player will use one arm primarily and unilateral hypertrophy will most likely result. Lifting weights, moving furniture and playing soccer will most likely result in bilateral muscle hypertrophy

Explanation

A tennis player will use one arm primarily and unilateral hypertrophy will most likely result. Lifting weights, moving furniture and playing soccer will most likely result in bilateral muscle hypertrophy

44. When the triceps tendon is hit with a reflex hammer, the expected response is for the elbow to

Flex

Extend

Internally rotate

Pronate

Striking the triceps tendon with a hammer results in extension of the elbow. The elbow does not flex, internally rotate, or pronate.

Explanation

Striking the triceps tendon with a hammer results in extension of the elbow. The elbow does not flex, internally rotate, or pronate.

45. In which of the following scenarios would a simultaneous use of apical and radial sites be used to assess the pulse rate?

A 2-month old infant during a routing check-up

A 16-year old patient who has been stable for 3 hours following an appendectomy

A 76-year old client showing a tachycardia and an irregular rhythm on the cardiac monitor

A 56-year old patient with an order to receive a stat dose of Digoxin

A 20-yeard patient in the ER with a hand laceration

A simultaneous use of apical and radial sites would be used to assess the pulse rate in a 76-year old client showing a tachycardia and an irregular rhythm on the cardiac monitor. This is because in this scenario, the client's heart rate and rhythm are abnormal, and it is important to accurately assess the pulse rate from both the apical (heard with a stethoscope) and radial (felt at the wrist) sites to determine the severity and nature of the irregularities. By comparing the pulse rates from both sites, healthcare professionals can gather more comprehensive information about the client's cardiovascular status and make appropriate interventions.

Explanation

A simultaneous use of apical and radial sites would be used to assess the pulse rate in a 76-year old client showing a tachycardia and an irregular rhythm on the cardiac monitor. This is because in this scenario, the client's heart rate and rhythm are abnormal, and it is important to accurately assess the pulse rate from both the apical (heard with a stethoscope) and radial (felt at the wrist) sites to determine the severity and nature of the irregularities. By comparing the pulse rates from both sites, healthcare professionals can gather more comprehensive information about the client's cardiovascular status and make appropriate interventions.

46. During an assessment, the client reports pain in the internal rotation of her right shoulder. This will most likely affect which of the following activities?.

Brushing the back of her hair

Fastening her bra behind her back

Reaching for something in a cabinet above the sink

Mopping the floor

Fastening a bra from behind requires internal rotation of the shoulder. Brushing the back of the hair and reaching for something up high require external rotation of the shoulder. Mopping the floor requires flexion and extension of the shoulder

Explanation

Fastening a bra from behind requires internal rotation of the shoulder. Brushing the back of the hair and reaching for something up high require external rotation of the shoulder. Mopping the floor requires flexion and extension of the shoulder

47. A 4-year-old child was brought to a clinic by her father. According to the father, she goes to bed at 8:30 pm every night and wakes up at about 7:30 in the morning, but she often lays in bed talking to herself or gets up a couple of times before falling asleep 40 minutes later. In the pre-school where she goes, children take a 2-hour afternoon nap. Which of the following could help improve the child's sleep behavior?

Offer the child a snack of her favorite treat right before bedtime

Allow the child to watch an extra 30 min of TV in the evening

Change the child's bedtime to 9 pm on days she takes an afternoon nap

Request the pre-school to limit her nap to 1 hour.

A preschool age child may start to need less sleep, so putting the child to bed 30 minutes later will be the least disruptive way to improve the child's behavior. Eating a snack, especially one with a high sugar content, and watching TV will provide stimulation that will make it more difficult for the child to fall asleep. It is impractical to ask the preschool to limit the child's nap as this may be disruptive as all of the children are probably required to nap for that amount of time. Also, if the child is napping for that amount of time, it is most likely the child needs that rest during the day.

Explanation

A preschool age child may start to need less sleep, so putting the child to bed 30 minutes later will be the least disruptive way to improve the child's behavior. Eating a snack, especially one with a high sugar content, and watching TV will provide stimulation that will make it more difficult for the child to fall asleep. It is impractical to ask the preschool to limit the child's nap as this may be disruptive as all of the children are probably required to nap for that amount of time. Also, if the child is napping for that amount of time, it is most likely the child needs that rest during the day.

48. Match each of the following practices to the best example.

medical asepsis

standard precuation

sterile field mainenance

contamination

Submit

49. Based on the type of client on the left, match the appropriate site for temperature assessment together with the rationale.

a newborn

a 6-month old infant

a healthy 60-year old woman

a confused 82-year old man

Submit

50. Which of the following should be asked to assess a patient's cerebral function during a health history?

"Do your fingers feel numb and tingly?"

"Do you have difficulty remembering things?"

"Do you have any problems keeping your balance?"

"Do you have nay difficulties with your sense of taste?"

Memory is tested during the mental status examination, which evaluates cerebral function. Numbness and tingling are abnormal findings of the sensory system. Balance is a test for muscle function, and the sense of taste is controlled by cranial nerves VII and IX.

Explanation

Memory is tested during the mental status examination, which evaluates cerebral function. Numbness and tingling are abnormal findings of the sensory system. Balance is a test for muscle function, and the sense of taste is controlled by cranial nerves VII and IX.

51. A 21-year old male client comes to a health clinic with a sore throat. The client tells the nurse he did not see a doctor more than 4 years ago. Which of the following health screenings should the nurse anticipate will be performed for this client?

Testicular cancer

Blood glucose

Fecal occult blood

Prostate specific antigen (PSA)

The nurse can expect that the client will be screened for testicular cancer. The nurse can also anticipate that the client's blood pressure will be checked along with his BMI and blood cholesterol. Blood glucose testing begins at 45, and testing for fecal occult blood and prostate specific antigen usually begins at age 50.

Explanation

The nurse can expect that the client will be screened for testicular cancer. The nurse can also anticipate that the client's blood pressure will be checked along with his BMI and blood cholesterol. Blood glucose testing begins at 45, and testing for fecal occult blood and prostate specific antigen usually begins at age 50.

52. When performing percussion, which of the following sounds should be heard over most of the abdomen?

Dullness

Tympany

Grating

Gurgling

The abdomen is primarily filled with air, and tympany is the sound that will predominate. Dullness is heard over the liver or a distended bladder. A grating sound may indicate a friction rub. Gurgling sounds are heard through a stethoscope and indicate peristalsis.

Explanation

The abdomen is primarily filled with air, and tympany is the sound that will predominate. Dullness is heard over the liver or a distended bladder. A grating sound may indicate a friction rub. Gurgling sounds are heard through a stethoscope and indicate peristalsis.

53. Match the following lung sounds with its correct description

pleural friction rub

wheezes

resonance

hyperresonance

Submit

54. A nurse is teaching a new mother about infant safety. Which of the following statements by the mother indicates an understanding of safety for the infant?

"My baby loved to play with his crib gym but I took it away from him

"I just bought a soft mattress so my baby will sleep better."

"My baby really likes riding in the car now that he can sit facing forward."

"I just bought a child-safety gate that folds like an accordion

Crib gyms and mobiles should be removed by 4 months, as injury can occur from choking or strangulation. The infant's crib mattress should be firm and fit tightly to prevent suffocation. The infant needs to remain in the backwards facing position until 1 year of age and weight 20 lb. Child safety gates should expand by a horizontal mechanism and not like an accordion to prevent injury to hands and arms.

Explanation

Crib gyms and mobiles should be removed by 4 months, as injury can occur from choking or strangulation. The infant's crib mattress should be firm and fit tightly to prevent suffocation. The infant needs to remain in the backwards facing position until 1 year of age and weight 20 lb. Child safety gates should expand by a horizontal mechanism and not like an accordion to prevent injury to hands and arms.

55. What part of the eye examination should occur first?

Extraocular movements

Internal structures

Visual acuity

Visual fields

Visual acuity should be assessed first during an eye examination. Assessing extraocular movements, internal structures and visual fields may interfere with the ability of the client to read and demonstrate accurate visual acuity

Explanation

Visual acuity should be assessed first during an eye examination. Assessing extraocular movements, internal structures and visual fields may interfere with the ability of the client to read and demonstrate accurate visual acuity

56. Match the location on the right where the following percussion sounds on the left are normally produced in the body.

tympany

resonance

dull

flat

Submit

57. The proper placement of a stethoscope for auscultating the aortic valve is the

Second ICS just left of the sternum

Second ICS just right of the sternum

Fourth ICS just left of the sternum

Fourth ICS just right of the sternum

The aortic valve is best auscultated at the second intercostal space (ICS) just right of the sternum. This is because the aortic valve is located in the second intercostal space on the right side of the sternum. Placing the stethoscope at this location allows for optimal sound transmission and detection of any abnormalities or murmurs associated with the aortic valve.

Explanation

The aortic valve is best auscultated at the second intercostal space (ICS) just right of the sternum. This is because the aortic valve is located in the second intercostal space on the right side of the sternum. Placing the stethoscope at this location allows for optimal sound transmission and detection of any abnormalities or murmurs associated with the aortic valve.

58. Which of the following is an expected psychosocial assessment from a healthy middle-aged adult?

Develop an acceptance of diminished strength and increased dependence on others.

Feel frustrated that time is too short for attempting to start another life

Accept one's life as creative and productive

Find someone to share one's life with

Healthy middle adults accept the life they have created for themselves and have a sense of social responsibility. Acceptance of diminished strength and increased dependence on others is true of older adults. Feeling frustrated that time is too short is true of adults who are having difficulties with the developmental tasks of middle age. Finding someone to share life with is applicable to young adults.

Explanation

Healthy middle adults accept the life they have created for themselves and have a sense of social responsibility. Acceptance of diminished strength and increased dependence on others is true of older adults. Feeling frustrated that time is too short is true of adults who are having difficulties with the developmental tasks of middle age. Finding someone to share life with is applicable to young adults.

59. When performing a skin assessment, which of the following are normal findings? Select all that apply:

No clubbing noted

Capillary refill less than 2 seconds

3+ pitting edema in feet bilaterally

Numerous light brown macules, less than 3 mm in size, located on nose and cheeks

Shiny and thin skin without hair on shins

Expected skin findings include no clubbing, capillary refill less than 2 seconds, and light brown macules noted on the nose and cheeks. No edema should be present, and the skin should have a dull, opaque appearance with some hair present

Explanation

Expected skin findings include no clubbing, capillary refill less than 2 seconds, and light brown macules noted on the nose and cheeks. No edema should be present, and the skin should have a dull, opaque appearance with some hair present

Submit

60. Which of the following should be assessed when examining the face?

Lymph nodes

Perception of light touch of the face

Symmetry of facial features

ROM of the neck

Presence of involuntary movements

Assessment of the perception of light touch to the face indicates that the sensory portion of the trigeminal nerve (CN V) is intact. symmetry of facial movements and presence of involuntary movements of the face are also assessed. Lymph nodes and ROM of the neck are assessed while examining the neck.

Explanation

Assessment of the perception of light touch to the face indicates that the sensory portion of the trigeminal nerve (CN V) is intact. symmetry of facial movements and presence of involuntary movements of the face are also assessed. Lymph nodes and ROM of the neck are assessed while examining the neck.

Submit

61. Which of the following are appropriate activities for a toddler? Select all that apply:

Building simple models

Playing with a team

Filling and emptying containers

Playing with blocks

Looking at books

Building simple models and playing with a team are more appropriate for a school-age child. Playing with blocks, looking at books and filling and emptying containers are appropriate for toddlers

Explanation

Building simple models and playing with a team are more appropriate for a school-age child. Playing with blocks, looking at books and filling and emptying containers are appropriate for toddlers

Submit

62. Which of the following positions promotes drainage from the mouth for clients with throat or oral surgery but inhibits chest expansion?

Fowler's position

Semi-Fowler's position

Prone position

Reverse Trendelenburg

The prone position promotes drainage from the mouth for clients with throat or oral surgery, but it inhibits chest expansion. Fowlers and semi-Fowlers positions promote chest expansion. Reverse Trendelburg promotes gastric emptying and prevents esophageal reflux.

Explanation

The prone position promotes drainage from the mouth for clients with throat or oral surgery, but it inhibits chest expansion. Fowlers and semi-Fowlers positions promote chest expansion. Reverse Trendelburg promotes gastric emptying and prevents esophageal reflux.

63. A patient just had a knee arthroplasty. Which of the following should be examined to assess the peripheral vascular system of the affected extremity? Select all that apply

Range of motion

Skin color

Skin temperature

Presence of skin lesions

Capillary refill

Edema

Assessment of peripheral vascular system should include skin color, skin temperature, capillary refill and edema. Determining range of motion will assess joint function. Inspecting for skin lesions is a routine included in the skin assessment

Explanation

Assessment of peripheral vascular system should include skin color, skin temperature, capillary refill and edema. Determining range of motion will assess joint function. Inspecting for skin lesions is a routine included in the skin assessment

Submit

64. Match the critical thinking attitude with the appropriate example

confidence

discipline

perseverance

integrity

humility

Submit

65. The formal operations stage of development is described by which of the following theorists?

Piaget

Erikson

Freud

Kohlberg

Piaget describes formal operations as the phase of his cognitive development theory that is applicable to adolescents and young adults. Erikson describes intimacy vs. isolation (age 18 to 25) and generativity vs stagnation (25 to 65) as the phases of his psychosocial development theory that are applicable to young adults. Freud describes genital as the stage of his psychosocial development theory that is applicable to young adults. Kohlberg describes law and order orientation as the stage of his moral development theory that is applicable to young adults.

Explanation

Piaget describes formal operations as the phase of his cognitive development theory that is applicable to adolescents and young adults. Erikson describes intimacy vs. isolation (age 18 to 25) and generativity vs stagnation (25 to 65) as the phases of his psychosocial development theory that are applicable to young adults. Freud describes genital as the stage of his psychosocial development theory that is applicable to young adults. Kohlberg describes law and order orientation as the stage of his moral development theory that is applicable to young adults.

66. Which of the following are expected findings in regard to changes associated with aging? Select all that apply:

Increased insulin resistance

Increased constipation

Increased saliva production

Decrease in subcutaneous fat

Increase in bladder capacity

Aging leads an increase insulin resistance. A decrease in GI motility can lead to constipation. A decrease in subcutaneous fat occurs in aging. Saliva production is decreased with aging. The capacity of the bladder decreases with aging.

Explanation

Aging leads an increase insulin resistance. A decrease in GI motility can lead to constipation. A decrease in subcutaneous fat occurs in aging. Saliva production is decreased with aging. The capacity of the bladder decreases with aging.

Submit

67. A nurse is contributing to the plan of care for a client who is being admitted to the facility with a suspected diagnosis of pertussis. Which of the following should be included in the plan of care?

Place the client in a room that has negative pressure of at least six exchanges per hour

Wear a mask when providing care within 3 feet of the client

Place a surgical mask on the client if transportation to another department is unavoidable

Use sterile gloves when handling soiled linen

Wear a gown when performing care that may result in contamination from secretions

A client with known or suspected pertussis is placed on droplet precaution. A private room is required but a room with a negative air pressure is not required. A mask is worn when the nurse is within 3 ft of the client. A surgical mask is placed on the client during transport to another area of the facility. Gloves (clean) are worn when handling soiled linen, but sterile gloves are not necessary. A gown should be worn if the nurse's clothing or skin may be contaminated with body secretions or excretions.

Explanation

A client with known or suspected pertussis is placed on droplet precaution. A private room is required but a room with a negative air pressure is not required. A mask is worn when the nurse is within 3 ft of the client. A surgical mask is placed on the client during transport to another area of the facility. Gloves (clean) are worn when handling soiled linen, but sterile gloves are not necessary. A gown should be worn if the nurse's clothing or skin may be contaminated with body secretions or excretions.

Submit

68. Which of the following decreases the pulse rate? Select all that apply:

Calcium channel blockers

Acute pain

Anxiety

Blood loss

Hypothermia

Calcium channel blockers are medications that work by blocking the entry of calcium into the smooth muscle cells of the heart and blood vessels, leading to relaxation and dilation of the blood vessels. This ultimately results in a decrease in the pulse rate. Hypothermia, on the other hand, refers to a decrease in body temperature. This decrease in temperature can slow down the body's metabolic processes, including the heart rate, leading to a decrease in the pulse rate.

Explanation

Calcium channel blockers are medications that work by blocking the entry of calcium into the smooth muscle cells of the heart and blood vessels, leading to relaxation and dilation of the blood vessels. This ultimately results in a decrease in the pulse rate. Hypothermia, on the other hand, refers to a decrease in body temperature. This decrease in temperature can slow down the body's metabolic processes, including the heart rate, leading to a decrease in the pulse rate.

Submit

69. Which of the following decreases blood pressure? Select all that apply:

Cocaine

Brisk walk on a treadmill

Antihypertensive

Acute gallbladder attack

Postoperative pain

Both a brisk walk on a treadmill and antihypertensive medications can decrease blood pressure. Exercise, such as walking, helps to improve cardiovascular health and can lower blood pressure. Antihypertensive medications are specifically designed to lower blood pressure and are commonly prescribed to individuals with hypertension.

Explanation

Both a brisk walk on a treadmill and antihypertensive medications can decrease blood pressure. Exercise, such as walking, helps to improve cardiovascular health and can lower blood pressure. Antihypertensive medications are specifically designed to lower blood pressure and are commonly prescribed to individuals with hypertension.

Submit

70. Which of the following developmental task should a school-age child be expected to accomplish?

Trust vs mistrust

Autonomy vs shame

Initiative vs guilt

Industry vs inferiority

The developmental task of industry should be accomplished during school age years. The developmental task of trust should be accomplished during infancy, autonomy during the toddler years, and initiative during the preschool years

Explanation

The developmental task of industry should be accomplished during school age years. The developmental task of trust should be accomplished during infancy, autonomy during the toddler years, and initiative during the preschool years

71. Place the following steps of mobility assessments in the correct sequence by matching the assessment with its numbered order

exercise tolerance

moving from supine to sitting on the side of the bed

gait

range of motion

Submit

72. Behaviors of active listening. Select all that apply:

Responding positively when giving feedback

Writing down what the client says so that details are not forgotten

Maintaining an open posture

Establishing and maintaining an eye contact

Nodding in agreement with the client throughout the conversation

Having an open posture and leaning forward, establishing and maintaining eye contact, and responding positively when giving feedback are ways the nurse can demonstrate active listening. Writing down everything the client says will interfere with the nurse's ability to maintain eye contact and an open posture. Nodding in agreement throughout the conversation may be interpreted as agreement with what the client is saying when it was only intended to indicate attending to what was being said.

Explanation

Having an open posture and leaning forward, establishing and maintaining eye contact, and responding positively when giving feedback are ways the nurse can demonstrate active listening. Writing down everything the client says will interfere with the nurse's ability to maintain eye contact and an open posture. Nodding in agreement throughout the conversation may be interpreted as agreement with what the client is saying when it was only intended to indicate attending to what was being said.

Submit

73. Which of the following increases blood pressure? Select all that apply

Cocaine

Brisk walk on a treadmill

Antihypertensive

Acute gallbladder attack

Postoperative pain

Cocaine is a stimulant drug that increases blood pressure by constricting blood vessels and stimulating the release of adrenaline. An acute gallbladder attack can cause an increase in blood pressure due to the intense pain and stress on the body. Postoperative pain can also lead to an increase in blood pressure as a result of the body's response to pain and stress. Antihypertensive medications, on the other hand, are used to lower blood pressure, so they do not increase it. A brisk walk on a treadmill can temporarily raise blood pressure during exercise, but it is not a long-term increase.

Explanation

Cocaine is a stimulant drug that increases blood pressure by constricting blood vessels and stimulating the release of adrenaline. An acute gallbladder attack can cause an increase in blood pressure due to the intense pain and stress on the body. Postoperative pain can also lead to an increase in blood pressure as a result of the body's response to pain and stress. Antihypertensive medications, on the other hand, are used to lower blood pressure, so they do not increase it. A brisk walk on a treadmill can temporarily raise blood pressure during exercise, but it is not a long-term increase.

Submit

74. Which of the following is a priority nursing intervention for a family with a history of violence?

Educating the family about anger management

Refining the family's communication skills

Viewing the family in context

Using the family's strengths to define them

The priority intervention is to collect more data to determine which family member (s) is a victim of abuse and needs assistance to be protected. Teaching anger management is a good strategy, but first there must be a family assessment to determine if there are anger and safety issues. Refining communication skills and using family strengths are not the priorities if the safety of a family member is at risk

Explanation

The priority intervention is to collect more data to determine which family member (s) is a victim of abuse and needs assistance to be protected. Teaching anger management is a good strategy, but first there must be a family assessment to determine if there are anger and safety issues. Refining communication skills and using family strengths are not the priorities if the safety of a family member is at risk

75. Which of the following are expected changes in the breast tissue after menopause? Select all that apply

Clear discharge from nipples

More pendulous

Breast tissue replaced by adipose tissue

Firmer

Nodular

The breast becomes more pendulous, replaced by adipose tissue, and may feel softer. Discharge from nipples is an abnormal finding

Explanation

The breast becomes more pendulous, replaced by adipose tissue, and may feel softer. Discharge from nipples is an abnormal finding

Submit

76. Match the type of lesion commonly seen on a skin assessment with its correct assessment terminology.

freckle

wart

blister

acne

psoriasis

insect bit

Submit

77. In which of the following scenarios would the use of the apical site be appropriate to assess the pulse rate? Select all that apply:

A 2-month old infant during a routing check-up

A 20-yeard patient in the ER with a hand laceration

A 16-year old patient who has been stable for 3 hours following an appendectomy

A 56-year old patient with an order to receive a stat dose of Digoxin

The apical site is appropriate to assess the pulse rate in a 2-month old infant during a routine check-up because it is more accurate in infants and young children. It is also appropriate to use the apical site in a 56-year old patient with an order to receive a stat dose of Digoxin because Digoxin can affect the electrical conduction of the heart, and the apical site provides a more accurate assessment of the heart's rhythm in such cases.

Explanation

The apical site is appropriate to assess the pulse rate in a 2-month old infant during a routine check-up because it is more accurate in infants and young children. It is also appropriate to use the apical site in a 56-year old patient with an order to receive a stat dose of Digoxin because Digoxin can affect the electrical conduction of the heart, and the apical site provides a more accurate assessment of the heart's rhythm in such cases.

Submit

78. Match the following respiratory sounds with their correct description

Bronchial sounds

Bronchovesicular sounds

Vesicular sounds

Crackles and rales

Submit

79. Which of the following types of stress is being experienced by a middle adult client who is stressed by the concerns of caring for young adults still in the home and her aging parents?

Situational

Developmental

Social

Cultural

Developmental stress is related to the stages of life. Situational stress is an unexpected, sudden stressor, such as a job loss. Social and cultural stresses are widespread problems, such as poverty that affects a community as a whole

Explanation

Developmental stress is related to the stages of life. Situational stress is an unexpected, sudden stressor, such as a job loss. Social and cultural stresses are widespread problems, such as poverty that affects a community as a whole

80. Which of the following is an age-appropriate activity for a 7-year old child? Select all that apply:

Playing a card game

Assuming responsibility for a pet

Collecting coins

Participating in a soccer team

Solving a puzzle

Playing a card game, collecting coins, participating in a soccer team and solving puzzles are all appropriate for a 7-year old child. Assuming responsibility for a pet is an appropriate activity for an adolescent

Explanation

Playing a card game, collecting coins, participating in a soccer team and solving puzzles are all appropriate for a 7-year old child. Assuming responsibility for a pet is an appropriate activity for an adolescent

Submit

81. An 85-year old man was admitted to the ER with an oral body temperature of 101 F, a pulse rate of 114 / min, and a respiratory rate of 22 / min. He is restless with warm skin. Which of the following interventions are appropriate for him? Select all that apply:

Obtain culture specimen before initiating prescribed antimicrobials

Allow for adequate rest

Restrict fluids

Provide oral care

Only change bed linens when client requests it

Apply additional blanket if client feels chilled

Cultures may be ordered to rule out the presence of infection and the specimens for culture should be obtained prior to any antibiotic therapy to prevent any interference with infection detection. Rest helps conserve energy and decreases metabolism. Oral care provides comfort for the client's dry mucous membranes. Additional blanket will keep client warm if he feels chilly. Fluids should be encouraged because of fever. The client is likely to sweat, so bed linens should be changed as often as needed

Explanation

Cultures may be ordered to rule out the presence of infection and the specimens for culture should be obtained prior to any antibiotic therapy to prevent any interference with infection detection. Rest helps conserve energy and decreases metabolism. Oral care provides comfort for the client's dry mucous membranes. Additional blanket will keep client warm if he feels chilly. Fluids should be encouraged because of fever. The client is likely to sweat, so bed linens should be changed as often as needed

Submit

82. When caring for a school-age child, which of the following cognitive abilities should a nurse expect? Select all that apply:

Will not understand another person's point of view

Believes everything is made by humans

Understands simple analogies

Demonstrates an understanding of days and weeks

Identifies inanimate objects as living

A school-age child should understand simple analogies and demonstrate an understanding of days and weeks. A toddler is unable to see another person's point of view. A preschool child believes everything is made by humans and that inaminate objects are alive.

Explanation

A school-age child should understand simple analogies and demonstrate an understanding of days and weeks. A toddler is unable to see another person's point of view. A preschool child believes everything is made by humans and that inaminate objects are alive.

Submit

83. When doing an assessment for vibration, which part of the hand should be used?

Ulnar surface

Finger pads

Dorsal surface

Palmar surface

The ulnar surface of the hand is the most sensitive to vibration

Explanation

The ulnar surface of the hand is the most sensitive to vibration

84. A nurse is teaching an infant's mother about gross motor development. Which of the following gross motor skills are expected in the next 6 months? Select all that apply:

Rolls from back to stomach

Bears weight on legs

Walks holding into furniture

Sits unsupported

Sits down from a standing postiion

The infant should be able to roll back from back to front by 6 months, bear weight on legs by 7 months, and sit unsupported by 7 months. The infant is not expected to walk holding onto furniture until 11 months and sit down from a standing position until 12 months.

Explanation

The infant should be able to roll back from back to front by 6 months, bear weight on legs by 7 months, and sit unsupported by 7 months. The infant is not expected to walk holding onto furniture until 11 months and sit down from a standing position until 12 months.

Submit

85. In which of the following scenarios would the use of the radial site be appropriate to assess the pulse rate? Select all that apply

A 19-year old patient in the ER with a hand laceration to be sutured.

A 56 year old client with an order to receive a stat dose of digoxin

A 75-year old patient on a cardiac monitor

A 26-yeard old patient who has been stable for 3 hours following an appendectomy

The radial site is appropriate for assessing the pulse rate in a 19-year old patient with a hand laceration to be sutured because it is easily accessible and provides an accurate representation of the heart rate. Similarly, it is also appropriate for a 26-year old patient who has been stable for 3 hours following an appendectomy as they are not in a critical condition and the radial site can be easily accessed.

Explanation

The radial site is appropriate for assessing the pulse rate in a 19-year old patient with a hand laceration to be sutured because it is easily accessible and provides an accurate representation of the heart rate. Similarly, it is also appropriate for a 26-year old patient who has been stable for 3 hours following an appendectomy as they are not in a critical condition and the radial site can be easily accessed.

Submit

86. Which of the following is assessed when performing palpation of the thorax and lung? Select all that apply:

Breath sounds

Respiratory effort

Tactile fremitus

Surface characteristics

Chest excursion

Tactile fremitus, surface characteristics, and chest excursion are all assessed during palpation. Breath sounds are assessed by auscultation. Respiratory effort is assessed by inspection

Explanation

Tactile fremitus, surface characteristics, and chest excursion are all assessed during palpation. Breath sounds are assessed by auscultation. Respiratory effort is assessed by inspection

Submit

87. Based on the assessment of the client on the left, select the appropriate site for temperature assessment on the right with its corresponding rationale.

a client with hemorrhoids

a client with a stuffy nose

a client with a low platelet count due to chemotherapy

a client immediately following a mandibular surgery

Submit

88. Which of the following increases the pulse rate? Select all that apply:

Hyperthyroidism,

Walking on treadmill

Blood loss

Anxiety

Acute pain

Hyperthyroidism is a condition where the thyroid gland produces an excess amount of thyroid hormone, which can increase the pulse rate. Walking on a treadmill can increase the heart rate and pulse rate due to the physical activity involved. Blood loss leads to a decrease in blood volume, which triggers the body to compensate by increasing the heart rate. Anxiety can stimulate the release of stress hormones, such as adrenaline, which can elevate the pulse rate. Acute pain can also activate the body's stress response, leading to an increase in heart rate.

Explanation

Hyperthyroidism is a condition where the thyroid gland produces an excess amount of thyroid hormone, which can increase the pulse rate. Walking on a treadmill can increase the heart rate and pulse rate due to the physical activity involved. Blood loss leads to a decrease in blood volume, which triggers the body to compensate by increasing the heart rate. Anxiety can stimulate the release of stress hormones, such as adrenaline, which can elevate the pulse rate. Acute pain can also activate the body's stress response, leading to an increase in heart rate.

Submit

89. A school nurse is planning health promotion and primary prevention class for a group of 4th-grade students. Which of the following is appropriate to include for the parents of this age group? Select all that apply:

Obesity

Substance abuse

Scoliosis

Pregnancy prevention

Stranger awareness

Obesity, substance abuse prevention, scoliosis, and stranger awareness are all topics that are pertinent to the parents of school-aged children. Pregnancy prevention is appropriate for parents of an adolescent

Explanation

Obesity, substance abuse prevention, scoliosis, and stranger awareness are all topics that are pertinent to the parents of school-aged children. Pregnancy prevention is appropriate for parents of an adolescent

Submit

90. Identify the order of priority for completion of each of the following interventions for a newly admitted client who has a history of falls.

survey the client's belongings

complete a fall risk assessment

complete a physical assessment

make arrangements for a home safety survey

educate the client and family on the falls risk

1. The greatest risk to the client is injury from falling, therefore, the first action is to determine his risk fall. The client's fall risk assessment is used to find a safe room and guide how the client will be oriented to his room and the facility.

2. In addition to the report information from the emergency department, the physical assessment will help to identify further risks or injuries, as well as provide baseline physical data.

3. Surveying the client's belongings may provide further clues to fall risks (glasses, medications, hearing aids, canes, walkers)

4. It is important for family members and any visitors to be aware of the client's risk fir falls. Providing instructions to the family will allow them to provide safety to the client.

5. The home safety survey is very important and should be completed prior to discharge. However, this survey does not take precedence over any of the other items that may impact safety during the hospital stay.

Explanation

1. The greatest risk to the client is injury from falling, therefore, the first action is to determine his risk fall. The client's fall risk assessment is used to find a safe room and guide how the client will be oriented to his room and the facility.

2. In addition to the report information from the emergency department, the physical assessment will help to identify further risks or injuries, as well as provide baseline physical data.

3. Surveying the client's belongings may provide further clues to fall risks (glasses, medications, hearing aids, canes, walkers)

4. It is important for family members and any visitors to be aware of the client's risk fir falls. Providing instructions to the family will allow them to provide safety to the client.

5. The home safety survey is very important and should be completed prior to discharge. However, this survey does not take precedence over any of the other items that may impact safety during the hospital stay.

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91. A father tells a nurse that his child might not be ready for kindergarten yet. What developmental tasks should the child currently be doing to indicate that her growth and development are appropriate for her age (4 years old)? Select all that apply:

Demonstrates a good understanding of time

Able to skip

Able to ride a tricycle

Demonstrates good coordination

Draws copies of shapes on paper

Speaks in sentences

Able to skip, ride a tricycle, draw copies of shapes and speak in sentences are appropriate developmental tasks for a 4 year old child. A good understanding of time and good coordination are usually achieved during the school-age years

Explanation

Able to skip, ride a tricycle, draw copies of shapes and speak in sentences are appropriate developmental tasks for a 4 year old child. A good understanding of time and good coordination are usually achieved during the school-age years

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92. Which of the following increases respiratory rate? Select all that apply:

Brisk walk on treadmill

Sickle cell disease

Smoking

Acute gall bladder attack

Mountain hiking

All of the options listed can increase respiratory rate. Brisk walk on a treadmill, mountain hiking, and acute gall bladder attack can lead to an increase in respiratory rate due to increased physical activity or pain. Sickle cell disease can cause a decrease in oxygen levels, leading to compensatory increase in respiratory rate. Smoking can irritate the airways and cause shortness of breath, resulting in an increased respiratory rate.

Explanation

All of the options listed can increase respiratory rate. Brisk walk on a treadmill, mountain hiking, and acute gall bladder attack can lead to an increase in respiratory rate due to increased physical activity or pain. Sickle cell disease can cause a decrease in oxygen levels, leading to compensatory increase in respiratory rate. Smoking can irritate the airways and cause shortness of breath, resulting in an increased respiratory rate.

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93. Which of the following is included in the assessment of the client's cognitive processes? Select all that apply

Level of consciousness

Mood

Appearance

Knowledge

Judgment

All are components of a mental status examination. Assessment of knowledge and judgment are included in cognitive processes.

Explanation

All are components of a mental status examination. Assessment of knowledge and judgment are included in cognitive processes.

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94. Match the examination technique or tool needed to screen for the following conditions:

color blindness

myopia

nystagmus

presbyopia

strabismus

glaucoma

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95. Match the action within the heart/peripheral vascular system with the sound it produces.

rapid ventricular filling

closure of the mitral and tricuspid valve

strong atrial contraction

Obstructed blood flow in peripheral circulation

impeded blood flow in the heart

closure of the aortic and pulmonic valves

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96. Which of the following immunizations should a 4-year-old child receive from a health visitor if her immunizations are up to date? Select all that apply:

Hepatitis A, given in two doses, at least 6 months apart

Diphtheria and tetanus toxoids and pertussis (DTaP)

Inactivated Poliovirus (IPV)

Measles, Mumps and Rubella (MMR)

Varicella

Trivalent Inactivated Influenza Vaccine (TIV)

Diphtheria and tetanus toxoids and pertussis (DTaP); IPV,MMR. VAricella, and TIV or live attenuated influenza A vaccine (LAIV) by nasal spray should be given between 4 and 6 years of age. Hepatitis A (Hep A) is given in two doses at 12 to 23 months at least 6 months apart.

Explanation

Diphtheria and tetanus toxoids and pertussis (DTaP); IPV,MMR. VAricella, and TIV or live attenuated influenza A vaccine (LAIV) by nasal spray should be given between 4 and 6 years of age. Hepatitis A (Hep A) is given in two doses at 12 to 23 months at least 6 months apart.

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97. Which of the following are appropriate when assessing a client's respiration? Select all that apply:

Count the respiratory rate for 1 minute

Place the client on semi-Fowler's position

Count the respiratory rate simultaneously with the pulse

Position the stethoscope on the anterior chest

Observe one full respiratory cycle before counting the rate

The best position for the client during respiratory assessment is semi-Fowler's with the chest visible. Observing for one full respiratory cycle before starting to count assists in obtaining an accurate count. If the rate is regular, count for 30 seconds and multiply by 2. Count the rate for 1 full minute if irregular, faster than 20 / min or slower than 12 /min. It is difficult to measure either the respiratory rate or the pulse accurately if counted simultaneously. The respiratory rate is not auscultated with a stethoscope

Explanation

The best position for the client during respiratory assessment is semi-Fowler's with the chest visible. Observing for one full respiratory cycle before starting to count assists in obtaining an accurate count. If the rate is regular, count for 30 seconds and multiply by 2. Count the rate for 1 full minute if irregular, faster than 20 / min or slower than 12 /min. It is difficult to measure either the respiratory rate or the pulse accurately if counted simultaneously. The respiratory rate is not auscultated with a stethoscope

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98. Match the appropriate immunizations with the age of administration

Haemophilus influenzae type B (Hib); pneumococcal vaccine (PCV); inactivated poliovirus (IPV) (6 to 18 months); measles, mumps, and rubella (MMR); and varicella

Hepatitis A (HepA), given in two doses, at least 6 months apart

Diphtheria and tetanus toxoids and pertussis (DTaP)

Yearly trivalent inactivated influenza vaccine (TIV)

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99. Match each lymph node of the head and neck with its location for palpation

occipital lymph node

preauricular lymph node

Postauricular lymph node

submandibular lymph node

tonsillar (retropharyngeal) lymph node

Submental lymph node

Anterior cervical lymph nodes

Posterior cervical lymph nodes

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100. Which of the following are expected findings from a 50-year old patient? Select all that apply:

Decreased muscle tone in the large intestine

Decreased ability to hear high-pitched sounds.

Reduced gastric secretions

Reduced central vision

Decrease in subcutaneous fat

Decreased muscle tone of the large intestine, decrease in the ability to hear high-pitched sounds, and a decrease in gastric secretions are expected findings. Reduced central vision may be due to macular degeneration and is not an expected finding. A decrease in subcutaneous fat is an expected finding in an older adult

Explanation

Decreased muscle tone of the large intestine, decrease in the ability to hear high-pitched sounds, and a decrease in gastric secretions are expected findings. Reduced central vision may be due to macular degeneration and is not an expected finding. A decrease in subcutaneous fat is an expected finding in an older adult

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