A patient describes a recent onset of frequent and severe .

unilateral headaches that last about 1 hour. Based on

these symptoms, the nurse suspects which type of

?headache

Cluster headaches .1

Migraine headaches .2

Tension headache .3

Sinus headache .4

During a physical examination the nurse is unable to feel .2

the patients thyroid gland with palpation. What is the

?appropriate action of the nurse at this time

.Recognize that this is an expected finding .1

.Auscultate the thyroid area .2

.Percuss the anterior neck for thyroid span .3

Refer the patient for follow-up with an .4

.endocrinologist

A 24-year-old female patient has a 2-day history of clear .3

nasal drainage. Based on these data, which question is the

?most logical for the nurse to ask

?Is there a foul odor coming from your nose .1

?Have you recently had nosebleeds .2

?Do you snore when sleeping .3

?Do you have allergies .4

A 32-year-old woman has a 4-day history of sore throat .4

and difficulty swallowing. The nurse observes tonsils

covered with yellow patches. The tonsils are so large that

.they fill the entire oropharynx and appear to be touching

?How does the nurse document these findings

 .Tonsils yellow and swollen .1

.Enlarged tonsils 4+ with yellow exudate .2

.Strep infection to tonsils with 3+ swelling .3

.edema of tonsils with pus +1 .4

A nurse is obtaining a health history from a 52-year-old .5

.male patient with a red lesion at the base of the tongue

What additional data does the nurse specifically collect

?about this patient

Alcohol and tobacco use .1

The date of his last dental examination .2

The presence of dentures .3

A history of pyorrhea .4

While talking with a patient, the nurse suspects that he .6

has hearing loss. Which examination technique is most

?accurate for assessing hearing loss

Whispered voice test .1

Rinne test .2

Webers test .3

Audiometry test .4

Which data from the health history of a 42-year-old man .7

should be evaluated further as a possible risk for hearing

?loss

I watch TV in the evenings with my wife and .1

.children

.When I was younger, I wore an earring .2

.My primary hobby is carpentry work .3

-I have been an accountant for 16 years for an insur .4

.ance agency
-The nurse examines a patients auditory canal and tym .8

-panic membrane with an otoscope. Which finding is con

?sidered abnormal

Presence of cerumen .1

Yellow or amber color to the tympanic membrane .2

Presence of a cone of light .3

Shiny, translucent tympanic membrane .4

During the history the patient indicates that her eyes .9

have been red and itching. Which additional question

?does the nurse ask

?Have you ever had a detached retina .1

?Have you had the pressure in your eyes checked .2

?Do you have seasonal allergies .3

?Do you also have double vision .4

How does the nurse assess a patients consensual .10

?reaction

By touching the cornea with a small piece of sterile .1

cotton and observing the change in the pupil size

By observing the patients pupil size when she or he .2

looks at an object 2 to 3 feet away and then looks at

an object 6 to 8 inches away

By shining a light into the patients right eye and .3

observing the pupillary reaction of the left eye

By covering one eye with a card and observing the .4

pupillary reaction when the card is removed

What are the characteristics of lymph nodes in patients .11

?who have an acute infection

.They are enlarged and tender .1

 .They are round, rubbery, and mobile .2

.They are hard, fixed, and painless .3

.They are soft, mobile, and painless .4

?Which technique is used for palpating lymph nodes .12

Apply firm pressure over the nodes with the pads of .1

.the fingers

Apply gentle pressure over the nodes with the tips of .2

.the fingers

Apply firm pressure anterior to the nodes with the tips .3

.of the fingers

Apply gentle pressure over the nodes with the pads of .4

.the fingers

CASE STUDY

Trudy Neinto is a 25-year-old Native American (Navajo)

-female who was brought to the clinic by her sister. The fol

lowing data are collected by the nurse during an interview

.and assessment

Interview Data

The patient tells the nurse, My ear is hurting very badly, and

Im hot. She adds, I wanted to go to the clinic yesterday, but

,my grandmother told me I shouldnt. Trudy tells the nurse

I have been treated many times for this problem over the last
 : Chest

A nurse suspects a viral infection or .1

upper respiratory
allergies when the patient describes the
sputum as being
?which color
White .1
Clear .2
Yellow .3
Pink tinged .4
During inspection of the respiratory .2
system the nurse
?documents which finding as abnormal
Skin color consistent with patients .1
ethnicity
ratio of anteroposterior to lateral 2 : 1 .2
diameter
Anterior costal angle is 85 degrees .3
 Patient leaning forward with arms .4
braced against the
knees
A patient has an infection of the .3
terminal bronchioles
and alveoli that involves the right lower
.lobe of the lung
?Which abnormal findings are expected
Dyspnea with diminished breath .1
sounds bilaterally
Asymmetric chest expansion on the .2
right side
Fever and tachypnea with crackles .3
over the right lower
lobe
Prolonged expiration with an .4
occasional wheeze in
the right lower lobe
On auscultation of a patients lungs, .4
the nurse hears
 a low-pitched, coarse, loud, and low
.snoring sound
Which term does the nurse use to
document this
?finding
Rhonchi .1
Wheeze .2
Crackles .3
Pleural friction rub .4
Which question gives the nurse further .5
information
about the patients complaint of chest
?pain
Have you had your influenza .1
immunization this
?year
Are there environmental conditions .2
that may affect
?your breathing at home
How would you describe the chest .3
?pain
 Has the chest pain been interrupting .4
?your sleep
Which finding does the nurse expect .6
when performing
?tactile fremitus
A vibration of sounds that are equal .1
bilaterally
A change in muscle tone when the .2
patient inhales and
exhales, indicating weakness
The symmetric rise of the thorax as .3
,the patient speaks
indicating equal expansion
Coughing triggered by patient speech, .4
indicating
bronchial irritation
How does the nurse palpate the chest .7
,for tenderness
?bulges, and symmetry
Uses the fist of the dominant hand to .1
gently tap the
 anterior, lateral, and posterior chest,
comparing one
side with another
Uses the ulnar surface of one hand to .2
palpate the
anterior, posterior, and lateral chest,
comparing one
side with another
With the tips of the fingers, palpates .3
the skin over the
chest and the alignment of vertebrae
With the palmar surface of fingers of .4
both hands, feels
the consistency of the skin over the
chest and the
alignment of vertebrae
Which breath sounds are expected .8
over the posterior
?chest of an adult
Vesicular .1
Bronchovesicular .2
 Bronchial .3
Bronchoalveolar .4
Narrowing of the bronchi creates .9
which adventitious
?sound
Wheeze .1
Crackles .2
Rhonchi .3
Pleural friction rub .4
Which finding may indicate abnormal .10
thoracic
?expansion
A 4-cm diaphragmatic excursion .1
A 1 : 2 ratio anteroposterior to lateral .2
diameter
An S -shaped curvature of the spine .3
A costal angle of 85 degrees .4