Q&A Hero

Q: The nurse knows that the best time to assess a woman's blood pressure during an initial prenatal visit is: a. At the end of the examination when she will be the most relaxed. b. At the beginning of the interview as a nonthreatening method of gaining rapport. c. During the middle of the physical examination when she is the most comfortable. d. Before beginning the pelvic examination because her blood pressure will be higher after the pelvic examination.

Q: When assessing a woman who is in her third trimester of pregnancy, the nurse looks for the classic symptoms associated with preeclampsia, which include: a. Edema, headaches, and seizures. b. Elevated blood pressure and proteinuria. c. Elevated liver enzymes and high platelet counts. d. Decreased blood pressure and edema.

Q: A woman who is 28 weeks' pregnant has bilateral edema in her lower legs after working 8 hours a day as a cashier at a local grocery store. She is worried about her legs. What is the nurse's best response? a. "You will be at risk for development of varicose veins when your legs are edematous." b. "I would like to listen to your heart sounds. Edema can indicate a problem with your heart." c. "Edema is usually the result of too much salt and fluids in your diet. You may need to cut down on salty foods." d. "As your baby grows, it slows blood return from your legs, causing the swelling. This often occurs with prolonged standing."

Q: The nurse auscultates a functional systolic murmur, grade II/IV, on a woman in week 30 of her pregnancy. The remainder of her physical assessment is within normal limits. The nurse would: a. Consider this finding abnormal, and refer her for additional consultation. b. Ask the woman to run briefly in place and then assess for an increase in intensity of the murmur. c. Know that this finding is normal and is a result of the increase in blood volume during pregnancy. d. Ask the woman to restrict her activities and return to the clinic in 1 week for re-evaluation.

Q: A patient who is 20 weeks' pregnant tells the nurse that she feels more shortness of breath as her pregnancy progresses. The nurse recognizes which statement to be true? a. High levels of estrogen cause shortness of breath. b. Feelings of shortness of breath are abnormal during pregnancy. c. Hormones of pregnancy cause an increased respiratory effort. d. The patient should get more exercise in an attempt to increase her respiratory reserve.

Q: A woman in her second trimester of pregnancy complains of heartburn and indigestion. When discussing this with the woman, the nurse considers which explanation for these problems? a. Tone and motility of the gastrointestinal tract increase during the second trimester. b. Sluggish emptying of the gallbladder, resulting from the effects of progesterone, often causes heartburn. c. Lower blood pressure at this time decreases blood flow to the stomach and gastrointestinal tract. d. Enlarging uterus and altered esophageal sphincter tone predispose the woman to have heartburn.

Q: During the examination of a woman in her second trimester of pregnancy, the nurse notices the presence of a small amount of yellow drainage from the nipples. The nurse knows that this is: a. An indication that the woman's milk is coming in. b. A sign of possible breast cancer in a pregnant woman. c. Most likely colostrum and considered a normal finding at this stage of the pregnancy. d. Too early in the pregnancy for lactation to begin and refers the woman to a specialist.

Q: A patient who is in her first trimester of pregnancy tells the nurse that she is experiencing significant nausea and vomiting and asks when it will improve. The nurse should reply: a. "Did your mother have significant nausea and vomiting?" b. "Many women experience nausea and vomiting until the third trimester." c. "Usually, by the beginning of the second trimester, the nausea and vomiting improve." d. "At approximately the time you begin to feel the baby move, the nausea and vomiting will subside."

Q: A patient is being seen at the clinic for her 10-week prenatal visit. She asks when she will be able to hear the baby's heartbeat. The nurse should reply: a. "The baby's heartbeat is not usually heard until the second trimester." b. "The baby's heartbeat may be heard anywhere from the ninth to the twelfth week." c. "It is often difficult to hear the heartbeat at this point, but we can try." d. "It is normal to hear the heartbeat at 6 weeks. We may be able to hear it today."

Q: A woman who is 8 weeks' pregnant is visiting the clinic for a checkup. Her systolic blood pressure is 30 mm Hg higher than her prepregnancy systolic blood pressure. The nurse should: a. Consider this a normal finding. b. Expect the blood pressure to decrease as the estrogen levels increase throughout the pregnancy. c. Consider this an abnormal finding because blood pressure is typically lower at this point in the pregnancy. d. Recommend that she decrease her salt intake in an attempt to decrease her peripheral vascular resistance.

Q: A female patient has nausea, breast tenderness, fatigue, and amenorrhea. Her last menstrual period was 6 weeks ago. The nurse interprets that this patient is experiencing __________ signs of pregnancy. a. Positive b. Possible c. Probable d. Presumptive

Q: Which of these statements best describes the action of the hormone progesterone during pregnancy? a. Progesterone produces the hormone human chorionic gonadotropin. b. Duct formation in the breast is stimulated by progesterone. c. Progesterone promotes sloughing of the endometrial wall. d. Progesterone maintains the endometrium around the fetus.

Q: The nurse is completing an assessment on a patient who was just admitted from the emergency department. Which assessment findings would require immediate attention? Select all that apply. a. Temperature: 38.6o C b. Systolic blood pressure: 150 mm Hg c. Respiratory rate: 22 breaths per minute d. Heart rate: 130 beats per minute e. Oxygen saturation: 95% f. Sudden restlessness

Q: The nurse is assessing the IV infusion at the beginning of the shift. Which factors should be included in the assessment of the infusion? Select all that apply. a. Proper IV solution is infusing, according to the physician's orders. b. The IV solution is infusing at the proper rate, according to physician's orders. c. The infusion is proper, according to the nurse's assessment of the patient's needs. d. Capillary refill in the fingers is checked and noted. e. The IV site date is noted. f. Whether the patient is sufficiently voiding is noted.

Q: The nurse is giving report to the next shift and is using the situation, background, assessment, recommendation (SBAR) framework for communication. Which of these statements reflects the Background portion of the report? a. "I"m worried that his gastrointestinal bleeding is getting worse." b. "We need an order for oxygen." c. "My name is Ms. Smith, and I"m giving the report on Mrs. X in room 1104." d. "He is 4 days postoperative, and his incision is open to air."

Q: When assessing a patient in the hospital setting, the nurse knows which statement to be true? a. The patient will need a brief assessment at least every 4 hours. b. The patient will need a consistent, specialized examination every 8 hours that focuses on certain parameters. c. The patient will need a complete head-to-toe physical examination every 24 hours. d. Most patients require a minimal examination each shift unless they are in critical condition.

Q: When assessing a patient's general appearance, the nurse should include which question? a. Is the patient's muscle strength equal in both arms? b. Is ptosis or facial droop present? c. Does the patient appropriately respond to questions? d. Are the pupils equal in reaction and size?

Q: When assessing the neurologic system of a hospitalized patient during morning rounds, the nurse should include which of these during the assessment? a. Blood pressure b. Patient's rating of pain on a scale of 1 to 10 c. Patient's ability to communicate d. Patient's personal hygiene level

Q: During an assessment of a hospitalized patient, the nurse pinches a fold of skin under the clavicle or on the forearm to test the: a. Mobility and turgor. b. Patient's response to pain. c. Percentage of the patient's fat-to-muscle ratio. d. Presence of edema.

Q: The nurse has administered a pain medication to a patient by an IV infusion. The nurse should reassess the patient's response to the pain medication within _____ minutes. a. 5 b. 15 c. 30 d. 60

Q: What should the nurse assess before entering the patient's room on morning rounds? a. Posted conditions, such as isolation precautions b. Patient's input and output chart from the previous shift c. Patient's general appearance d. Presence of any visitors in the room

Q: During a morning assessment, the nurse notices that a patient's urine output is below the expected amount. What should the nurse do next? a. Obtain an order for a Foley catheter. b. Obtain an order for a straight catheter. c. Perform a bladder scan test. d. Refer the patient to an urologist.

Q: During an assessment, the nurse is unable to palpate pulses in the left lower leg. What should the nurse do next? a. Document that the pulses are nonpalpable. b. Reassess the pulses in 1 hour. c. Ask the patient turn to the side, and then palpate for the pulses again. d. Use a Doppler device to assess the pulses.

Q: At the beginning of rounds when entering the room, what should the nurse do first? a. Check the intravenous (IV) infusion site for swelling or redness. b. Check the infusion pump settings for accuracy. c. Make eye contact with the patient, and introduce him or herself as the patient's nurse. d. Offer the patient something to drink.

Q: Which of these actions is most appropriate to perform on a 9-month-old infant at a well-child checkup? a. Testing for Ortolani sign b. Assessment for stereognosis c. Blood pressure measurement d. Assessment for the presence of the startle reflex

Q: The nurse is documenting the assessment of an infant. During the abdominal assessment, the nurse noticed a very loud splash auscultated over the upper abdomen when the nurse rocked her from side to side. This finding would indicate: a. Epigastric hernia. b. Pyloric obstruction. c. Hypoactive bowel sounds. d. Hyperactive bowel sounds.

Q: A female patient tells the nurse that she has four children and has had three pregnancies. How should the nurse document this? a. Gravida 3, para 4 b. Gravida 4, para 3 c. This information cannot be documented using the terms gravida and para. d. "The patient seems to be confused about how many times she has been pregnant."

Q: When assessing the neonate, the nurse should test for hip stability with which method? a. Eliciting the Moro reflex b. Performing the Romberg test c. Checking for the Ortolani sign d. Assessing the stepping reflex

Q: Which statement is true regarding the recording of data from the history and physical examination? a. Use long, descriptive sentences to document findings. b. Record the data as soon as possible after the interview and physical examination. c. If the information is not documented, then it can be assumed that it was done as a standard of care. d. The examiner should avoid taking any notes during the history and examination because of the possibility of decreasing the rapport with the patient.

Q: A 5-year-old child is in the clinic for a checkup. The nurse would expect him to: a. Need to be held on his mother's lap. b. Be able to sit on the examination table. c. Be able to stand on the floor for the examination. d. Be able to remain alone in the examination room.

Q: While examining a 48-year-old patient's eyes, the nurse notices that he had to move the handheld vision screener farther away from his face. The nurse would suspect: a. Myopia. b. Omniopia. c. Hyperopia. d. Presbyopia.

Q: While recording in a patient's medical record, the nurse notices that a patient's Hematest results are positive. This finding means that there is(are): a. Crystals in his urine. b. Parasites in his stool. c. Occult blood in his stool. d. Bacteria in his sputum.

Q: After assessing a female patient, the nurse notices flesh-colored, soft, pointed, moist, papules in a cauliflower-like patch around her introitus. This finding is most likely: a. Urethral caruncle. b. Syphilitic chancre. c. Herpes simplex virus. d. Human papillomavirus.

Q: After the examination of an infant, the nurse documents opisthotonos. The nurse recognizes that this finding often occurs with: a. Cerebral palsy. b. Meningeal irritation. c. Lower motor neuron lesion. d. Upper motor neuron lesion.

Q: During examination, the nurse finds that a patient is unable to distinguish objects placed in his hand. The nurse would document: a. Stereognosis. b. Astereognosis. c. Graphesthesia. d. Agraphesthesia.

Q: During the examination of a patient's mouth, the nurse observes a nodular bony ridge down the middle of the hard palate. The nurse would chart this finding as: a. Cheilosis. b. Leukoplakia. c. Ankyloglossia. d. Torus palatinus.

Q: If the nurse records the results to the Hirschberg test, the nurse has: a. Tested the patellar reflex. b. Assessed for appendicitis. c. Tested the corneal light reflex. d. Assessed for thrombophlebitis.

Q: The nurse will measure a patient's near vision with which tool? a. Snellen eye chart with letters b. Snellen "E" chart c. Jaeger card d. Ophthalmoscope

Q: The nurse has just recorded a positive iliopsoas test on a patient who has abdominal pain. This test is used to confirm a(n): a. Inflamed liver. b. Perforated spleen. c. Perforated appendix. d. Enlarged gallbladder.

Q: The nurse notices that a patient has ulcerations on the tips of the toes and on the lateral aspect of the ankles. This finding indicates: a. Lymphedema. b. Raynaud disease. c. Arterial insufficiency. d. Venous insufficiency.

Q: The nurse documents that a patient has coarse, thickened skin and brown discoloration over the lower legs. Pulses are present. This finding is probably the result of: a. Lymphedema. b. Raynaud disease. c. Chronic arterial insufficiency. d. Chronic venous insufficiency.

Q: During an examination, the nurse notices that a patient's legs turn white when they are raised above the patient's head. The nurse should suspect: a. Lymphedema. b. Raynaud disease. c. Chronic arterial insufficiency. d. Chronic venous insufficiency.

Q: During the examination of a patient, the nurse notices that the patient has several small, flat macules on the posterior portion of her thorax. These macules are less than 1 cm wide. Another name for these macules is: a. Warts. b. Bullae. c. Freckles. d. Papules.

Q: A patient tells the nurse, "Sometimes I wake up at night and I have real trouble breathing. I have to sit up in bed to get a good breath." When documenting this information, the nurse would note: a. Orthopnea. b. Acute emphysema. c. Paroxysmal nocturnal dyspnea. d. Acute shortness of breath episode.

Q: During an examination, the patient tells the nurse that she sometimes feels as if objects are spinning around her. The nurse would document that she occasionally experiences: a. Vertigo. b. Tinnitus. c. Syncope. d. Dizziness.

Q: During inspection of the posterior chest, the nurse should assess for: a. Symmetric expansion. b. Symmetry of shoulders and muscles. c. Tactile fremitus. d. Diaphragmatic excursion.

Q: During an inspection of a patient's face, the nurse notices that the facial features are symmetric. This finding indicates which cranial nerve is intact? a. VII b. IX c. XI d. XII

Q: The nurse should use which location for eliciting deep tendon reflexes? a. Achilles b. Femoral c. Scapular d. Abdominal

Q: The nurse should wear gloves for which of these examinations? a. Measuring vital signs b. Palpation of the sinuses c. Palpation of the mouth and tongue d. Inspection of the eye with an ophthalmoscope

Q: Which of these is included in an assessment of general appearance? a. Height b. Weight c. Skin color d. Vital signs

Q: Which statement is true regarding the complete physical assessment? a. The male genitalia should be examined in the supine position. b. The patient should be in the sitting position for examination of the head and neck. c. The vital signs, height, and weight should be obtained at the end of the examination. d. To promote consistency between patients, the examiner should not vary the order of the assessment.

Q: When the nurse performs the confrontation test, the nurse has assessed: a. Extraocular eye muscles (EOMs). b. Pupils (pupils equal, round, reactive to light, and accommodation [PERRLA]). c. Near vision. d. Visual fields.

Q: During an examination, a patient has just successfully completed the finger-to-nose and the rapid-alternating-movements tests and is able to run each heel down the opposite shin. The nurse will conclude that the patient's __________ function is intact. a. Occipital b. Cerebral c. Temporal d. Cerebellar

Q: A patient is unable to shrug her shoulders against the nurse's resistant hands. What cranial nerve is involved with successful shoulder shrugging? a. VII b. IX c. XI d. XII

Q: During an examination, the nurse notices that a patient is unable to stick out his tongue. Which cranial nerve is involved with the successful performance of this action? a. I b. V c. XI d. XII

Q: A patient's uvula raises midline when she says "ahh," and she has a positive gag reflex. The nurse has just tested which cranial nerves? a. IX and X b. IX and XII c. X and XII d. XI and XII

Q: The nurse has just completed an examination of a patient's extraocular muscles. When documenting the findings, the nurse should document the assessment of which cranial nerves? a. II, III, and VI b. II, IV, and V c. III, IV, and V d. III, IV, and VI

Q: A patient states, "Whenever I open my mouth real wide, I feel this popping sensation in front of my ears." To further examine this, the nurse would: a. Place the stethoscope over the temporomandibular joint, and listen for bruits. b. Place the hands over his ears, and ask him to open his mouth "really wide." c. Place one hand on his forehead and the other on his jaw, and ask him to try to open his mouth. d. Place a finger on his temporomandibular joint, and ask him to open and close his mouth.

Q: During a complete health assessment, how would the nurse test the patient's hearing? a. Observing how the patient participates in normal conversation b. Using the whispered voice test c. Using the Weber and Rinne tests d. Testing with an audiometer

Q: After the health history has been obtained and before beginning the physical examination, the nurse should first ask the patient to: a. Empty the bladder. b. Completely disrobe. c. Lie on the examination table. d. Walk around the room.

Q: The nurse is performing a vision examination. Which of these charts is most widely used for vision examinations? a. Snellen b. Shetllen c. Smoollen d. Schwellon

Q: An 85-year-old man has come in for a physical examination, and the nurse notices that he uses a cane. When documenting general appearance, the nurse should document this information under the section that covers: a. Posture. b. Mobility. c. Mood and affect. d. Physical deformity.

Q: The nurse is palpating an ovarian mass during an internal examination of a 63-year-old woman. Which findings of the mass's characteristics would suggest the presence of an ovarian cyst? Select all that apply. a. Heavy and solid b. Mobile and fluctuant c. Mobile and solid d. Fixed e. Smooth and round f. Poorly defined

Q: A 35-year-old woman is at the clinic for a gynecologic examination. During the examination, she asks the nurse, "How often do I need to have this Pap test done?" Which reply by the nurse is correct? a. "It depends. Do you smoke?" b. "A Pap test needs to be performed annually until you are 65 years of age." c. "If you have two consecutive normal Pap tests, then you can wait 5 years between tests." d. "After age 30 years, if you have three consecutive normal Pap tests, then you may be screened every 2 to 3 years."

Q: During an internal examination, the nurse notices that the cervix bulges outside the introitus when the patient is asked to strain. The nurse will document this as: a. Uterine prolapse, graded first degree. b. Uterine prolapse, graded second degree. c. Uterine prolapse, graded third degree. d. A normal finding.

Q: A woman has just been diagnosed with HPV or genital warts. The nurse should counsel her to receive regular examinations because this virus makes her at a higher risk for _______ cancer. a. Uterine b. Cervical c. Ovarian d. Endometrial

Q: During an examination, the nurse would expect the cervical os of a woman who has never had children to appear: a. Stellate. b. Small and round. c. As a horizontal irregular slit. d. Everted.

Q: During an external genitalia examination of a woman, the nurse notices several lesions around the vulva. The lesions are pink, moist, soft, and pointed papules. The patient states that she is not aware of any problems in that area. The nurse recognizes that these lesions may be: a. Syphilitic chancre. b. Herpes simplex virus type 2 (herpes genitalis). c. HPV or genital warts. d. Pediculosis pubis (crab lice).

Q: A 25-year-old woman comes to the emergency department with a sudden fever of 38.3 C and abdominal pain. Upon examination, the nurse notices that she has rigid, boardlike lower abdominal musculature. When the nurse tries to perform a vaginal examination, the patient has severe pain when the uterus and cervix are moved. The nurse knows that these signs and symptoms are suggestive of: a. Endometriosis. b. Uterine fibroids. c. Ectopic pregnancy. d. Pelvic inflammatory disease.

Q: During a bimanual examination, the nurse detects a solid tumor on the ovary that is heavy and fixed, with a poorly defined mass. This finding is suggestive of: a. Ovarian cyst. b. Endometriosis. c. Ovarian cancer. d. Ectopic pregnancy.

Q: A 46-year-old woman is in the clinic for her annual gynecologic examination. She voices a concern about ovarian cancer because her mother and sister died of it. Which statement does the nurse know to be correct regarding ovarian cancer? a. Ovarian cancer rarely has any symptoms. b. The Pap smear detects the presence of ovarian cancer. c. Women at high risk for ovarian cancer should have annual transvaginal ultrasonography for screening. d. Women over age 40 years should have a thorough pelvic examination every 3 years.

Q: When performing an external genitalia examination of a 10-year-old girl, the nurse notices that no pubic hair has grown in and the mons and the labia are covered with fine vellus hair. These findings are consistent with stage _____ of sexual maturity, according to the Sexual Maturity Rating scale. a. 1 b. 2 c. 3 d. 4

Q: A 22-year-old woman is being seen at the clinic for problems with vulvar pain, dysuria, and fever. On physical examination, the nurse notices clusters of small, shallow vesicles with surrounding erythema on the labia. Inguinal lymphadenopathy present is also present. The most likely cause of these lesions is: a. Pediculosis pubis. b. Contact dermatitis. c. HPV. d. Herpes simplex virus type 2.

Q: During a vaginal examination of a 38-year-old woman, the nurse notices that the vulva and vagina are erythematous and edematous with thick, white, curdlike discharge adhering to the vaginal walls. The woman reports intense pruritus and thick white discharge from her vagina. The nurse knows that these history and physical examination findings are most consistent with which condition? a. Candidiasis b. Trichomoniasis c. Atrophic vaginitis d. Bacterial vaginosis

Q: When assessing a newborn infant's genitalia, the nurse notices that the genitalia are somewhat engorged. The labia majora are swollen, the clitoris looks large, and the hymen is thick. The vaginal opening is difficult to visualize. The infant's mother states that she is worried about the labia being swollen. The nurse should reply: a. "This is a normal finding in newborns and should resolve within a few weeks." b. "This finding could indicate an abnormality and may need to be evaluated by a physician." c. "We will need to have estrogen levels evaluated to ensure that they are within normal limits." d. "We will need to keep close watch over the next few days to see if the genitalia decrease in size."

Q: The nurse is preparing to examine the external genitalia of a school-age girl. Which position would be most appropriate in this situation? a. In the parent's lap b. In a frog-leg position on the examining table c. In the lithotomy position with the feet in stirrups d. Lying flat on the examining table with legs extended

Q: A 65-year-old woman is in the office for routine gynecologic care. She had a complete hysterectomy 3 months ago after cervical cancer was detected. Which statement does the nurse know to be true regarding this visit? a. Her cervical mucosa will be red and dry looking. b. She will not need to have a Pap smear performed. c. The nurse can expect to find that her uterus will be somewhat enlarged and her ovaries small and hard. d. The nurse should plan to lubricate the instruments and the examining hand adequately to avoid a painful examination.

Q: The nurse is palpating a female patient's adnexa. The findings include a firm, smooth uterine wall; the ovaries are palpable and feel smooth and firm. The fallopian tube is firm and pulsating. The nurse's most appropriate course of action would be to: a. Tell the patient that her examination is normal. b. Give her an immediate referral to a gynecologist. c. Suggest that she return in a month for a recheck to verify the findings. d. Tell the patient that she may have an ovarian cyst that should be evaluated further.

Q: When performing the bimanual examination, the nurse notices that the cervix feels smooth and firm, is round, and is fixed in place (does not move). When cervical palpation is performed, the patient complains of some pain. The nurse's interpretation of these results should be which of these? a. These findings are all within normal limits. b. Cervical consistency should be soft and velvetynot firm. c. The cervix should move when palpated; an immobile cervix may indicate malignancy. d. Pain may occur during palpation of the cervix.

Q: During an examination, which tests will the nurse collect to screen for cervical cancer? a. Endocervical specimen, cervical scrape, and vaginal pool b. Endocervical specimen, vaginal pool, and acetic acid wash c. Endocervical specimen, potassium hydroxide (KOH) preparation, and acetic acid wash d. Cervical scrape, acetic acid wash, saline mount ("wet prep")