NTK

A patient visits the clinic and complains of wrist pain. To perform Phalen's test for carpal tunnel syndrome, the nurse should ask the client to:
a. move the hand inward with the wrists straight
b. place both palms on the examination table
c. dorsiflex the carpal
d. place the backs of both hands against each other
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Terms in this set (96)
A patient visits the clinic and complains of wrist pain. To perform Phalen's test for carpal tunnel syndrome, the nurse should ask the client to:
a. move the hand inward with the wrists straight
b. place both palms on the examination table
c. dorsiflex the carpal
d. place the backs of both hands against each other
d. place the backs of both hands against each other
The nurse needs to assess the right middle lobe of the lung. Where should the nurse place the stethoscope?
a. posterior thoracic wall, right of mid-scapular line
b. right tenth intercostal space posteriorly
c. right sixth intercostal space anteriorly at the mid-clavicular line
d. left second intercostal space, right of mid-axillary line
c. right sixth intercostal space anteriorly at the mid-clavicular line
The patient is admitted with right-sided hemiparesis. Which of the following would be the most appropriate episodic assessment?
a. taking vital signs on the left side
b. testing the strength of hands
c. checking the left patellar reflex
d. asking the patient what year it is
b. testing the strength of hands
When palpating the pulses in the feet, the nurse notices that her fingers leave a lasting depression in the skin. This is called:
a. pitting edema
b. lymphodema
c. orthostatic edema
d. 4+ edema
a. pitting edema
The pimple like lesions across the chin of an adolescent are called:
a. cysts
b. papules
c. pustules
d. vesicles
c. pustules
During the musculoskeletal examination, the person is asked to bend forward at the waist to evaluate which condition:
a. lordosis
b. kyphosis
c. gibbus
d. scoliosis
d. scoliosis
When you ask the patient to push his feet against your hands, you are assessing which of the following:
a. homan's sign
b. length of feet
c. range of motion
d. muscle strength
d. muscle strength
An adolescent asks the nurse about a "bump" on his neck. The nurse observes a raised, red, solid mass, 0.3 cm (1/8") by 0.2 cm(7/16"). The nurse should record this as which skin lesion:
a. papule
b. macule
c. nodule
d. pustule
a. papule
The nurse hears a low-pitch, dry, grating sound at the lung bases during inspiration and expiration of a patient with pneumonia. The nurse would document what type of lung sound:
a. vesicular
b. wheeze
c. friction rub
d. fine crackles
c. friction rub
Mr. J says "I have to get up 3-4 times a night to urinate in the bathroom." This is called:
a. enuresis
b. bradyuria
c. nocturia
d. dysuria
c. nocturia
In teaching a patient how to determine total body fat at home, the nurse includes instructions to obtain measurements of: a. height and weight b. frame size and weight c. waist and hip circumferences d. mid upper arm circumferences and arm spana. height and weightFollowing self-testicular examination, the client should report which of the following findings to a health professional: a. one testicle being lower than the other b. any non-tender mass c. periodic non sexual erections d. palpation of the epididymisb. any non-tender massPapanicolaou (Pap) smear is screening test for which condition: a. abdominal aneurysm b. cervical cancer c. gonorhea d. ovarian cancerb. cervical cancerDuring the assessment of the neck you determine that the lymph nodes are soft, move from side to side, and are non-tender. Your evaluation is which of the following: a. it is normal b. it may represent malignancy c. it is a result of aging d. it is a sign of a chronic infectiona. it is normalHow do you test for stereognosis? With patient's eyes closed: a. place a familiar object in hand and ask patient to identify it b. write a number on the palm of the hand and ask patient to identify it c. touch the patient in the same area on both side of the body and ask patient to identify locations d. move toes or fingers up or down ask the patient to tell you the direction of movementa. place a familiar object in hand and ask patient to identify itDuring an interaction with the family of a critically ill patient, the nurse uses silence as a therapeutic technique. This technique allows the family to: a. communicate with the patient b. regain composure c. organize their thoughts d. decrease anxietyc. organize their thoughtsAn older woman visits the clinic complaining of dysuria. The woman says "what is wrong with me?" The nurse should explain to her that this is most likely due to which of the following: a. atrophy of the vaginal mucosa b. bladder infection c. decreased volume of urine d. change in vaginal pHb. bladder infectionWhich of the following is not one of the Ohio Board of Nursing (OBN) Standards for promoting patient safety: a. name tags b. communicate and document properly c. maintain personal boundaries d. promote a safe environmentc. maintain personal boundariesIt is recommended that males do a self testicular exam by monthly. Testicular cancer is most common for which age group: a. 10 to 15 years b. 15 to 39 years c. 40 to 55 years d. over 50b. 15 to 39 yearsWhen the nurse was interviewing a patient, she asked these questions. Which is an example of a "close-ended" question/statement: a. "describe your relationship with your children" b. "tell me what you eat in a normal day" c. "are you allergic to any medications" d. "what is your typical day like"c. "are you allergic to any medications"The apex of each lung is located at the: a. area slightly above the clavicle b. area below the diaphragm c. level of the sixth rib d. left oblique fissurea. area slightly above the clavicleWhich is the best position for listening to a patient's breath sounds: a. prone b. supine c. left lateral d. sitting uprightd. sitting uprightWhich of the following questions should be used to assess whether a patient is experiencing hesitancy: a. do you have difficulty starting your stream of urine? b. how often do you void? c. do you experience the need to void immediately? d. do you have difficulty controlling your urine?a. do you have difficulty starting your stream of urine?The American Nurses Association (ANA) Standards of Care address which of the following: a. the nursing process b. code of ethics c. professional behavior d. social policy statementa. the nursing processWhen asking the patient "a rolling stone catches no moss" you are assessing which of the following: a. concentration b. judgement c. abstract reasoning d. perceptual abilityc. abstract reasoningThe OBN states that "a registered nurse shall maintain the confidentiality of patient information." This means which of the following: a. will discuss only with health care team members b. will share only with the nursing stand and instructor c. will not tell anyone d. will not discuss unless directly asked by othersa. will discuss only with health care team membersWhen auscultating the heart of a normal adult, how many heart sounds would the nurse expect to hear: a. one b. two c. three d. fourb. twoDyspareunia associated with menopause is related to which of the following: a. decrease in libido b. decrease in vaginal secretions c. increase in size of clitoris d. increase expansion of the vaginal vaultb. decrease in vaginal secretionsWhich data collected by the nurse is documented under objective data: a. religion b. occupation c. appearance d. ethnicityc. appearanceA patient's weekly blood pressure readings for 2 months have ranged between 124/84 and 136/88 mm Hg. The nurse knows that this blood pressure falls within which blood pressure category: a. normal blood pressure b. pre-hypertension c. stage I hypertension d. stage II hypertensionb. pre-hypertensionOrthostatic hypertension is best described as: a. a drop of 20 mm of pressure from prone to supine position b. an increase in at least 10 mm in systolic pressure when standing c. a drop of 20 mm of Hg from supine to standing position d. an increase of 10 mm in the pulse deficitc. a drop of 20 mm of Hg from supine to standing positionWhen using alcohol-based hand rub for hand hygiene, it is important to remember which of the following: a. it can be used in all situations just like soap and water b. you need to apply about 10-20 ml (about 1 tablespoon) of the product c. you need to rub your hands until they are completely dry d. wipe any excess product with a dry paper towelc. you need to rub your hands until they are completely dryThe nurse preparing to interview a client knows it is important to do which of the following first: a. make inferences b. determine client strengths c. identify health problems d. establish rapportd. establish rapportBefore beginning the physical assessment of a patient, the nurse should first: a. wash hands with soap and water b. determine whether the client is anxious c. ask the client to remove all clothing d. request a family member to be presenta. wash hands with soap and waterThe normal response for capillary refill test is: a. less than 1 second b. greater than 4 seconds c. greater than 2 seconds d. less than 3 secondsd. less than 3 secondsThe nurse can best encourage a patient's verbalization of a topic by using which technique: a. sharing own experiences b. direct questions c. open-ended questions d. active listeningc. open-ended questionsWhen inspecting the breasts which finding would be reason for further evaluation: a. areolas that are dark brown b. retracted left nipple c. smooth breast tissue d. linear striae on outer aspectsb. retracted left nippleTo test for back and leg pain, you should do which of the following: a. in supine position with leg raised to point of pain, dorsiflex the foot b. in prone position, deeply palpate the lower back c. in side lying position, bend the knee on the affected side d. standing, have the patient bend over to the point of paina. in supine position with leg raised to point of pain, dorsiflex the footThe OBN states that the nurse shall not engage in seductive or sexual behavior with a patient. The basis of this is that the patient is presumed to be: a. married b. not interested in sex since he is sick c. infected d. incapable of giving free and full consentd. incapable of giving free and full consentAn African American client has areas of raised and enlarged scar tissue. The nurse recognizes this as: a. crusts b. vitiligo c. birthmark d. keloidsd. keloidsThe nurse is preparing to perform a musculoskeletal examination on an adult patient. The patient tells you, the nurse, that he has a limitation in ROM of his left elbow. To further assess you should do which of the following: a. go through all ROM quickly to minimize pain b. firmly move the joint to the point of pain then take it just beyond to stretch the muscle c. instruct the patient to take the joint as far as he can, then you move it to the normal position d. anchor the joint with one hand while the other slowly moves it to its limitc. instruct the patient to take the joint as far as he can, then you move it to the normal positionWhen performing the Romberg test, it is important to place your arms around the person without touching in order to: a. prevent a fall b. test peripheral vision c. determine presence of tinnitus d. assess body circumferencea. prevent a fallIn percussing the thorax, the sound representing normal lung tissue is: a. hyperresonance b. resonance c. dull d. flatb. resonanceIn preparing a woman for pelvic exam, which position is she placed in: a. supine b. prone c. sim's d. lithotomyd. lithotomyThe proper technique for washing hands includes which of the following: a. washing with hot water b. keep the hands higher than wrists c. start with the right hand, then do the left d. washing for at least 15 secondsd. washing for at least 15 secondsWhen the examiner asks the person to repeat a series of unrelated numbers, what is being evaluated: a. judgement b. ability to learn c. computation d. memoryd. memoryWhich of the following is likely to cause dullness in the abdomen: a. kidney stones b. feces c. flatus d. bruitsb. fecesWhen the nurse asks the question "have you ever been hospitalized for a serious illness of injury?" The nurse should document this under which heading: a. biographic data b. past health history c. family health history d. review of systemsb. past health historyAccording to the Ohio Board of Nursing, a student in an RN program is held to which standard: a. higher standard than an RN b. same standard as an RN c. lower standard than an RN d. there is no standard for student nursesb. same standard as an RNThe nurse can best encourage a patient's verbalization by using which technique: a. sharing own experiences b. direct quotations c. open ended questions d. active listeningc. open ended questionsA patient has tested 20/40 on the distant visual acuity test using a Snellen chart. The nurse knows that the : a. 20 means the distance the person is standing from the chart b. 20 means the number of choices c. 40 means the distance the chart is from the person d. 40 means the 4th line from the top of the charta. 20 means the distance the person is standing from the chartWhat is the correct sequence of the four assessments techniques when examining the abdomen: a. inspect, percuss, palpate, auscultate b. auscultate, inspect, palpate, percuss c. inspect, auscultate, percuss, palpate d. palpate, inspect, auscultate, percussc. inspect, auscultate, percuss, palpateThe Romberg test evaluates: a. equilibrium b. bone conduction c. air conduction d. swallowinga. equilibriumDuring an interview, a woman says, "I have decided that I can no longer allow my children to live with their father's violence. I just can't seem to leave him though." Which response is the least nonjudgmental: a. "that's too bad -- children need both parents" b. "if you're afraid for your children, why can't you leave?" c. "it sounds as if you might be afraid of how your husband will respond" d. "it sounds as though you have made your decision. I think it is a good one"c. "it sounds as if you might be afraid of how your husband will respond"When evaluating lymph nodes in the neck, you note that they are soft bilateral. "Soft" is describing what characteristic of lymph nodes" a. consistency b. delimitation c. mobility d. shapea. consistencyIdentify the correct order for using the physical assessment skills in most cases: a. auscultation, percussion, inspection, palpation b. percussion, inspection, auscultation, palpation c. inspection, palpation, auscultation, percussion d. inspection, palpation, percussion, auscultationd. inspection, palpation, percussion, auscultationYou are discussing the need for a flu shot with a woman who is 30 years old. She says "I really think it is important for everyone who can to get flu shots in order to prevent needless deaths." This reflects which time orientation: a. past b. current c. future d. presentc. futureYou are planning to teach Mary Doe, a 20-year-old college student how to perform self-breast examination. Which of the following will assist the palpation: a. palpating the breasts in a circular pattern b. squeezing the nipple of each breast with thumb and forefinger c. keeping a bra on d. start in a sitting positiond. start in a sitting positionWhile assessing the breasts of a female patient, the nurse should explain to the patient that most breast tumors occur in which quadrant: a. upper outer b. lower inner c. upper inner d. lower outera. upper outerWhich action by the nurse correctly applies the principles of standard precautions: a. washing the hands between examination of each body part b. discarding a safety pin used to assess sensory perception in the trash can c. wearing gloves to palpate the tongue and buccal membranes d. wearing gown, gloves, and mask during the physical examc. wearing gloves to palpate the tongue and buccal membranesIf the thyroid is palpable, where is it located: a. above the thyroid cartilage b. over the thyroid cartilage c. lateral to the sternomastoid muscle d. below the cricoid cartilaged. below the cricoid cartilageWhen considering a nutritional assessment, the nurse is aware that the most common anthropometric measurements include: a. height and weight b. leg circumference c. biceps skinfold thickness d. hip and waist measurementa. height and weightAs one ages the systolic and diastolic readings both increase. This is due to: a. decreased peripheral vascular resistance b. increased cardiac output c. increased blood viscosity d. decreased elasticity in the arteriesd. decreased elasticity in the arteriesWhich is an important consideration in auscultating the lungs: a. listen at each site for at least one respiratory cycle b. have the patient breath quietly through the nose c. listen to the bases of the lungs first d. listen to the anterior thorax firsta. listen at each site for at least one respiratory cycleWhile auscultating for bowel sounds in a 35 year old man, you note a series of intermittent, soft clicks and gurgles that occur at a rate of 5-30/minute. These findings are: a. within normal limits b. minor variations but abnormal c. age related variations d. an abnormal situationa. within normal limitsWhich non-verbal behavior by the nurse facilitates communication: a. sitting when the patient is in the bed b. reading the interview questions c. maintaining physical distance d. note takinga. sitting when the patient is in the bedThe rationale for standard precautions is that: a. one does not want to discriminate between patients b. it is the law c. all patients are considered infected d. it reduces nosocomial infectionsc. all patients are considered infectedWhen testing shoulder abduction, ask the patient to: a. lift both arms out to the side b. extend hands behind back c. put hands on waist d. contract forearmsa. lift both arms out to the sideWhich is the back-lying position used for examination of the abdomen (with small pillow under head and one under knees): a. supine position b. sitting position c. sim's position d. prone positiona. supine positionThe name of the position in this picture is called what: a. trendelenburg b. supine c. dorsal recumbent d. proned. proneA normal response to striking the triceps tendon with the reflex hammer is: a. forearm pronation and slight elbow flexion b. forearm extends slightly at elbow c. forearm flexes at the elbow d. plantar flexionb. forearm extends slightly at elbowWhile assessing the ankles and feet, you palpate for edema. The normal response when pressure is released is: a. instant rebound b. skin indents c. feels spongy d. one ankle is larger than the othera. instant reboundWhen documenting a normal apical impulse, how would the nurse document the location: a. 2nd intercostal space, left sternal border b. 3rd intercostal space, left axillary line c. 4th intercostal space, left sternal border d. 5th intercostal space, left mid-clavicular lined. 5th intercostal space, left mid-clavicular lineA person who is drowsy or asleep most of the time, capable of making spontaneous movements, can be aroused with gentle shaking, and responds to their name, is described as: a. lethargic b. obtunded c. stuporous d. semicomatosea. lethargicUpon inspecting the patient's skin you notice he has a rash on his arms and chest. There is a clear liquid draining from the red, raised lesions. How would you safely proceed with examination: a. apply gloves b. ask the patient to palpate his own lesions c. wash your hands immediately after palpating the lesions d. wear goggles with the gown and maska. apply glovesA woman complains that when she laughs or sneezes she leaks a little urine. This is called: a. cystitis b. dysuria c. stress incontinence d. urethral hyperplasiac. stress incontinenceA respiratory rate of 32 per minute is called: a. shortness of breath b. apnea c. tachypnea d. bradypneac. tachypneaAs the nurse palpates the radial pulse, the pulse is difficult to locate, disappears with slight pressure, is thready and irregular. The pulse would be graded as: a. 0 b. +1 c. +2 d. +3b. +1On the diagram below letter is indicating the occipital lymph node(s): a. b. c. d.c.The patient is complaining of abdominal pain in the area just below the sternum. This area is called: a. supraumbillica b. infrasternal c. epigastric d. left outer quadrantc. epigastricWith a normal Babinski response (plantar reflex) the adult individual: a. flexes toes when the other border of the sole of the foot is stroked b. blinks eyes repeatedly after being tapped on the forehead c. puckers the lips when the side of the mouth is tapped d. dorsiflexes the foota. flexes toes when the other border of the sole of the foot is strokedWhich statement made by the nurse during the health assessment implies a judgmental attitude: a. "how often do your adult children visit" b. "your husband's death must have been difficult for you" c. "how do you feel about getting older" d. "you ought to quit smoking"d. "you ought to quit smoking"Movement when pointing the toe to the ground: a. extension b. abduction c. supination d. protraction e. plantar flexione. plantar flexionLooking up at the ceiling: a. extension b. abduction c. supination d. protraction e. plantar flexiona. extensionMovement of a body part away from the midline: a. extension b. abduction c. supination d. protraction e. plantar flexionb. abductionThrusting the jaw forward: a. extension b. abduction c. supination d. protraction e. plantar flexiond. protractionWhat does PERRLA stand for:pupils equal, round, react to light, accommodationNormal range for T (ora.) in adults:96.4-99.1Normal range for P in adults:50-95Normal range for R in adults:10-20Normal range for BP in adults:<120/80What are the 2 recommended patient identifiers:full name and birth dateCreate and label the 4 quadrants of the abdomen:RU | LU -----|------ RL | LLWhat is the rationale for the sequence of the abdominal exam:inspect, auscultate, percuss, palpate Palpate last because you don't want to stimulate bowel sounds that wouldn't be there and because of pain.Write the questions that you would ask to determine if the patient is oriented:what year is it? where are you? what is your name?When doing a cardiac assessment, the nurse asks the client to assume three positions. What are these three positions? Also state the reasons for using these positions:1. supine - general exam of neck vessels including inspection, palpation, percussion and auscultation 2. sitting, leaning forward - auscultating abnormal sounds 3. left lateral - if difficulty palpating apical impulse and auscultating abnormal sounds