The nurse has palpated a lump in a female patient's right breast. The nurse documents this as a small, round, firm, distinct, lump located at 2 o'clock, 2 cm from the nipple. It is nontender and fixed. No associated retraction of the skin or nipple, no erythema, and no axillary lymphadenopathy are observed. What information is missing from the documentation?
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Question 2 of 63
You are assessing a patient for peripheral vascular disease in the arms, secondary to a complaint of increased weakness and a history of coronary artery disease and diabetes. You assess the brachial and radial pulses and note that they are bounding. What does that translate to on a scale of 0 to 3?
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Question 3 of 63
The nurse is assessing a patient's cranial nerve function and asks the patient to close their eyes and smile. Which cranial nerve is being tested?
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Question 4 of 63
When obtaining an oral temperature, after requesting the patient to open the mouth, the probe is gently inserted into:
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Question 5 of 63
Variations in body temperature can be caused by...
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Question 6 of 63
During a mental status assessment, which question by the nurse would best assess a person's judgment?
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Question 7 of 63
Which of these patients in the neurologic ICU will be best to assign to an RN who has floated from the medical unit?
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Question 8 of 63
The nurse needs to obtain an accurate respiratory rate from a patient who is talking with visitors. What will the nurse do?
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Question 9 of 63
A physical therapist evaluates a patient with multiple sclerosis (MS) experiencing fatigue. Which intervention is MOST appropriate to improve endurance?
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Question 10 of 63
A physical therapist assesses the functional strength of a patient's hip extensors while observing the patient move from standing to sitting. What type of contraction occurs in the hip extensors during this activity?
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Question 11 of 63
When assessing a patient with significant shortness of breath, the nurse should:
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Question 12 of 63
Which of the following is a physiologic result of wound treatment with ultraviolet radiation?
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Question 13 of 63
Which of the following can a nurse assess by palpation?
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Question 14 of 63
During an eye examination, the nurse observes a white arc around the corneal margin. What does this finding indicate?
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Question 15 of 63
The nurse is assessing a patient's abdomen and notes generalized tenderness on deep palpation. What is the most likely diagnosis?
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Question 16 of 63
Of the following patients, which one is the best candidate to have his temperature taken orally?
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Question 17 of 63
The nurse is preparing to assess the ankle-brachial index (ABI) of a patient. Which statement about the ABI is true?
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Question 18 of 63
A client admitted to the hospital with a neurological problem requires magnetic resonance imaging. The nurse understands that the client may be ineligible for this diagnostic procedure based on the client's history of:
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Question 19 of 63
To assess a rectal temperature accurately in an adult, the nurse would:
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Question 20 of 63
Which respiratory disease causes a restrictive, parenchymal pattern of illness?
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Question 21 of 63
During a cardiovascular assessment, the nurse notes jugular vein distension (JVD) in a patient sitting at a 45-degree angle. What does this finding indicate?
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Question 22 of 63
A 40-year-old man presents with shortness of breath and a dry cough. He has a history of frequent sinus infections. His chest X-ray shows bilateral hilar lymphadenopathy. Which of the following is the most likely diagnosis?
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Question 23 of 63
The patient is restless with a temperature of 102.2°F (39°C). One of the first things the nurse should do is
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Question 24 of 63
The nurse is assessing a patient's cranial nerve function and asks the patient to shrug both shoulders against resistance. Which cranial nerve is being tested?
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Question 25 of 63
Jim is a 60-year-old man who presents with vomiting. He denies seeing any blood with emesis, which has been occurring for 2 days. He does note a dark, granular substance resembling the coffee left in the filter after brewing. What do you suspect?
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Question 26 of 63
On assessment, a nurse notes that a patient's pulse is weak and applying light pressure causes it to disappear. What pulse amplitude would the nurse document on the flow chart?
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Question 27 of 63
A physical therapist observes the gait of a patient rehabilitating from a traumatic brain injury. The patient has significant spasticity in the lower extremities and demonstrates a scissoring gait pattern. The MOST likely cause of the gait deviation is increased tone in the:
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Question 28 of 63
A client, age 22, is admitted with bacterial meningitis. Which hospital room would be the best choice for this client?
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Question 29 of 63
The nurse is assessing a patient's carotid arteries. Which technique is most appropriate?
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Question 30 of 63
A woman who is in the second trimester of pregnancy mentions that she has had "more nosebleeds than ever" since she became pregnant. The nurse recognizes that this is a result of:
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Question 31 of 63
For the following situations, state the type of data collection you would perform (i.e., complete database, focused or problem-centered database, follow-up database, emergency database). d. recently placed on antihypertensive medication
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Question 32 of 63
A 15-year-old high school football player is brought to your office by his mother. He is complaining of severe testicular pain since exactly 8:00 this morning. He denies any sexual activity and states that he hurts so bad he can't even urinate. He is nauseated and is throwing up. He denies any recent illness or fever. His past medical history is unremarkable. He denies any tobacco, alcohol, or drug use. His parents are both in good health. On examination you see a young teenager lying on the bed with an emesis basin. He is very uncomfortable and keeps shifting his position. His blood pressure is 150/100, his pulse is 110, and his respirations are 24. On visualization of the penis he is circumcised and there are no lesions and no discharge from the meatus. His scrotal skin is tense and red. Palpation of the left testicle causes severe pain and the patient begins to cry. His prostate examination is unremarkable. His cremasteric reflex is absent on the left but is normal on the right. By catheter you get a urine sample and the analysis is unremarkable. You send the boy with his mother to the emergency room for further workup. What is the most likely diagnosis for this young man's symptoms?
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Question 33 of 63
A hospital unit has a policy that rectal temperatures may not be taken on patients who have had cardiac surgery. What rationale supports this policy?
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Question 34 of 63
In which of the following situations is it protocol for the nurse to take a patients vital signs? Select all that apply.
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Question 35 of 63
Tachycardia when an individual is at rest could indicate...
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Question 36 of 63
A nurse is assessing a client's blood pressure and finds it to be 140/90 mmHg on multiple visits. What action should the nurse take?
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Question 37 of 63
Which of the following findings during a musculoskeletal assessment suggests a possible fracture?
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Question 38 of 63
The nurse is assessing the skin of a patient who has acquired immunodeficiency syndrome (AIDS) and notices multiple patchlike lesions on the temple and beard area that are faint pink in color. The nurse recognizes these lesions as:
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Question 39 of 63
When should a woman conduct breast self-examination with respect to her menses?
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Question 40 of 63
The nurse is conducting a health fair for older adults. Which statement is true regarding vital sign measurements in aging adults?
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Question 41 of 63
A 45-year-old man presents with joint pain, especially in his knees and fingers. He reports that the pain is worse in the morning and improves with activity. He also has a history of psoriasis. What is the most likely diagnosis?
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Question 42 of 63
A 13-year-old girl is interested in obtaining information about the cause of her acne. The nurse should share with her that acne:
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Question 43 of 63
When taking a history from a newly admitted patient, the nurse notices that he often pauses and expectantly looks at the nurse. What would be the nurse's best response to this behavior?
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Question 44 of 63
Which activity will most likely aggravate patellofemoral pain syndrome?
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Question 45 of 63
While taking an adult patients pulse, a nurse finds the rate to be 140 beats/min. What should the nurse do next?
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Question 46 of 63
Debridement of burn wounds is performed for what purpose?
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Question 47 of 63
A patient with type 2 diabetes presents with signs of peripheral neuropathy. Which physical therapy intervention would be MOST appropriate?
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Question 48 of 63
The nurse is preparing to use a stethoscope for auscultation. Which statement is true regarding the diaphragm of the stethoscope?
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Question 49 of 63
The nurse knows that auscultation of fine crackles would most likely be noticed in:
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Question 50 of 63
Which of the following is consistent with good percussion technique?
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Question 51 of 63
What is Panner's disease?
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Question 52 of 63
A patient has been shown to have a sensorineural hearing loss. During the assessment, it would be important for the nurse to:
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Question 53 of 63
A 32-year-old woman is at the clinic for "little white bumps in my mouth." During the assessment, the nurse notes that she has a 0.5 cm white, nontender papule under her tongue and one on the mucosa of her right cheek. What would the nurse tell the patient?
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Question 54 of 63
A woman has just learned that she is pregnant. What are some things the nurse should teach her about her breasts?
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Question 55 of 63
During a neurological assessment, the nurse asks the patient to close their eyes and identify objects placed in their hand. Which aspect of neurological function is being tested?
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Question 56 of 63
The nurse would use bimanual palpation technique in which situation?
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Question 57 of 63
The nurse is examining a patient who has possible cardiac enlargement. Which statement about percussion of the heart is true?
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Question 58 of 63
Common or concerning symptoms to inquire about in the General Survey and vital signs include all of the following except:
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Question 59 of 63
The nurse is assessing a patient's gait and observes that the patient walks with a limp. What is the next step in the assessment?
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Question 60 of 63
The nurse is performing a neurological assessment and asks the patient to close their eyes and distinguish between sharp and dull sensations. Which cranial nerve is being tested?
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Question 61 of 63
When performing an otoscopic examination of a 5-year-old child with a history of chronic ear infections, the nurse sees that his right tympanic membrane is amber-yellow in color and that air bubbles are visible behind the tympanic membrane. The child reports occasional hearing loss and a popping sound with swallowing. The preliminary analysis based on this information is that the child:
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Question 62 of 63
When performing an assessment of a patient, the nurse notices the presence of an enlarged right epitrochlear lymph node. What should the nurse do next?
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Question 63 of 63
Which ligament is most commonly injured in lateral ankle sprains?
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