PRELIMS EXAM

NCM_101 - HEALTH ASSESSMENT

Preliminary Examination
1. The result of a nursing assessment is the 14. The student nurse identifies the different factors that
d. Formulation of nursing diagnosis contribute to the occurrence of diseases. The reasons
obtained thru interview as to the cause of origin of the
2. A comprehensive nursing examination differs from a manifestations is:
medical examination in that the comprehensive nursing c.Etiology
examination focuses primarily on client’s
b. Holistic wellness status 15. Upon admission in the ER, the nurse performs physical
examination to Mrs. Gajelonia to establish a complete
3. Although the assessment phase of the nursing process data base. This type of assessment is:
precedes the other phases, the assessment phase is a. Initial assessment
a. Continuous
16. Which of the following statements describe a subjective
4. To prepare for the assessment of the client visiting data?
neighborhood health care clinic, the nurse should FIRST b. Subjective data can be verified only by the client
c. review the client’s health record
17. The following EXCEPT ONE are examples of independent
5. When a client first enters the hospital for an elective nursing interventions:
surgical procedure, the nurse should perform an a. “May ambulate as tolerated”, dangle the feet
assessment termed: for 5 minutes, 12-hour post-operative, stand at
d. Initial comprehensive assessment bedside 24 post-operative and observe for
dizziness
6. During an interview, the nurse collects both subjective
and objective data from an adult client. Subjective data 18. The student nurse obtained a subjective cue “mainit ang
would include the client’s aking pakiramdam (I feel hot).” Such statement can be
a. Perception of pain validated / verified thru:
b. The the patient’s body temperature with the
7. The nurse is interviewing a client in the clinic for the first use of the thermometer
time. The client appears to have a very limited vocabulary.
The nurse should plan to 19. During a client interview, the nurse asks questions about
a. Use very basic lay terminology the client past health history. The primary purpose of
asking about the past health problems is to
8. During the client interview, the nurse uses nonverbal a.Determine whether genetic conditions are
expressions appropriately when the nurse present
a. Avoids excessive eye contact with the client
20. While interviewing an adult client about her nutrition
9. While interviewing a client for the first time, the nurse is habits, the nurse should?
issuing a standardized nursing history form. The nurse a. Ask the client for a 24-hour recall food intake
should
a. Maintain eye contact while asking questions 21. Data are gathered through interview, physical
from the form examination, research, and review of records
a. ASSESSMENT
10. During an interview between the nurse and the client,
the nurse and the client collaborate to identify problems 22. Critical step as it is used to determine course of
and goals. This occurs during the phase of the interview treatment:
termed c.DIAGNOSIS
c. working
23. A statement about a health problem that the client has
11. A client does not have any past medical records from and could benefit from nursing care
your hospital and you would like to know / understand c.Actual Diagnosis
the medications used and hospital confinement from the
past. This data should have to be present on what part of 24. Formulation of the nursing care plan on which the nurse
the nursing health history? works with the client to set goals and objectives and
d.History of Past/Personal Illness predict outcome
b. PLANNING
12. A three-part nursing diagnostic statement should
contain the following details in proper order: 25. During which of the five steps in the nursing process
c.The Problem derived from the NANDA Label, The does the nurse determine whether outcomes of care are
Etiology and the Manifestations achieved
b.Evaluation
13. Mrs. Alisot was brought to the hospital’s emergency
room because of stabbed wounds. The student nurse 26. Which statement is related to the concept that is central
assisted the attending physician to determine the to the nursing process?
patient’s condition. The applied assessment with this kind a. It is dynamic rather than static
of health crisis is:
d. Emergency assessment 27. Which word is mostly closely associated with scientific
principles?
c.Rationale

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28. A pebble dropped into a pond causes ripples on the 44. During palpation of client’s organs, the nurse palpitates
surface of the water. Which part of the nursing diagnosis the spleen by applying pressure between 2.5cm and 5cm.
is directly is directly related to this concept? The nurse is performing?
c. Etiology c.deep palpation

29. A nurse teaches a patient to use visualization to cope 45. The most commonly used method of percussion
with chronic pain. Which step of the nursing process is c. Indirect percussion
associated with this nursing intervention?
d. Implementation 46. During a comprehensive assessment of the lungs of an
adult client with a diagnosis of emphysema, the nurse
30. Which action reflects the assessment step of the nursing anticipates that during percussion the client will exhibit
process? a. Hyperresonance
c.Examining a patient for injury after a patient falls
in the bathroom 47. While percussing an adult client during a physical
examination, the nurse can expect to hear flatness over
31. Before beginning a physical assessment of a client, the the client’s
nurse should FIRST? b. Bone
a. Wash both hands with soap and water
48. During a comprehensive assessment of an adult client,
32. To alleviate client’s anxiety during a comprehensive the nurse can best hear high pitched sounds by using a
assessment, the nurse should? stethoscope with a?
b. Explain each procedure being performed and b. 1 ½ inch diaphragm
the reason for the procedure
49. When the nurse places one hand flat on the body
33. During a comprehensive assessment, the primary surface and uses the fist of the other hand to strike the
technique used by the nurse throughout the examination back of the hand flat on the body surface, the nurse is
is? using
d. Inspection d. blunt percussion

34. It involves tapping your fingers or hands quickly and 50. Part of the hand that are sensitive to vibrations, fremitus
sharply against parts of the patient’s body to help locate and thrills
organ borders b. ulnar/palmar surface
d. Percussion
51. Select the following nursing diagnosis that is correctly
35. The nurse is assessing a client’s abdomen. Which stated:
examination technique should the nurse use after the first c. Risk for impaired skin integrity related to
technique? immobility secondary to right sided paralysis and
d. Auscultation dehydration as evidenced by reddened coccyx and
very dry skin
36. Which of the following is an assessment finding?
c. Pupils equally round and reactive to light and 52. Pain assessment (PQRST) involves all of the following
accommodations except:
d. Turning point
37. The nurse notices ecchymotic areas on the client’s skin.
This is an example of which physical examination 53. An ongoing or partial assessment of a client:
technique? d. include a brief reassessment of the client’s
a. Inspection normal body system

38. Which physical assessment method uses short, tapping 54. The measurement of the balance between heat
strokes on the surface of the skin to create vibrations of produced and lost is:
underlying organs? b. temperature
b. Percussion
55. The most accurate method for taking a temperature is:
39. When percussing over the stomach, the nurse notes a a. Rectal
loud, drum-like sound. The term used to document this
percussion note is: 56. A nursing assistant notes a patient’s temperature to be
c. Tympany 101.2 which is the BEST action the assistant can take
b. Report the temperature to the patient’s nurse
40. The bell of the stethoscope is used to hear:
d. Low pitched sounds 57. The least accurate route for measuring temperature is?
b. Axillary
41. Sounds (tone) elicited thru percussion and best heard in
normal lungs is called? 58. How long should a clinical thermometer be left in the
b. Resonance axillary site?
b. 5-7 minutes
42. While examining a client, the nurse plans to palpate the
temperature of the skin by using the 59. A normal pulse pressure range for an adult client
c. Dorsal surface of the hand typically:
c. 40-60 mmHg
43. It requires to touch the patient with different parts of
your hands, using varying degrees of pressure 60. What does pulse indicate?
a. Palpation a. Heartbeat

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61. What is the term for slow breathing? 80. Which among these statements regarding lesions is true
b. Bradypnea b. Some secondary lesions are initially from
Primary lesions
62. The nurse notes which of the following vital signs
findings as an abnormal finding in 88-year-old client? 81. All except one of these following findings could be
c. Oral temp of 100 F assessed via observation:
d. moist skin
63. During an intermittent fever:
d. The body temp alternates regular intervals 82. Jeremy, a first-year nursing student is doing an
between periods of fever and periods of normal or assessment of the skin. He was able to note some
subnormal temps pigmentation in his client’s skin. He remembered their
discussion regarding signs to consider malignant
64. What are the four major vital signs? pigmentation. Which among these statements is true
c. Blood pressure, PR, Respiratory rate, temp regarding signs of malignancy in pigmentation?
b. the pigmentation is asymmetrical, border is
65. It is the dispersion of heat by air currents irregular and there is noted enlargement of the
b. convection pigment

66. It is the most reliable indicator of cardiac output 83. An adult client visits the outpatient center and tells the
c. urine output nurse that he has been experiencing patchy hair loss. The
nurse should assess the client for:
67. Pulse site that used in physiological shock and cardiac a. Symptoms of stress
arrest, used to determine circulation in the brain?
d. carotid 84. A female client visits the clinic and complains to the
nurse that her skin feels dry. The nurse should instruct the
68. When assessing the client for pain, the nurse should? client that the skin elasticity is related to adequate:
c. believe the client when he or she claims to be in d. fluid intake
pain
85. An adult white client visits the clinic for the first time.
69. Which of the following is considered in most health care During assessment of the client’s skin, the nurse should
agencies as the 5th vital signs assess for central cyanosis by:
d. pain b. Oral mucosa

70. By definition, hypothermia has a core temp of? (bonus) 86. The nurse assesses an older adult bedridden client in her
c. 96.8 and below home. While assessing the client’s buttocks, the nurse
observes that a small area of the skin is broken and
71. Connecting the skin to underlying tissue is/are the? resembles an erosion. The nurse should document the
d. Subcutaneous tissue client’s pressure ulcer as?
b. stage II
72. The skin plays a vital role in temperature maintenance,
fluid and electrolyte balance and synthesis of vitamin? 87. To assess an adult client’s skin turgor, the nurse should?
d. D d. use two fingers to pinch the skin under the
clavicle
73. The only layer of the skin that undergoes cell division
a. Innermost layer of the epidermis 88. While assessing the nails of an adult client, the nurse
observes Beau’s lines. The nurse should ask the client if he
74. A client’s skin color depends on melanin and carotene has had
contained in the skin and the c. Recent illness
b. Volume of blood circulating in the dermis
89. While assessing an adult client, the nurse observes
75. A nurse is assessing for the capillary refill time (CRT) of freckles on the client’s face. The nurse should document
the patient. Three to four seconds after releasing pressure, the presence of
the nail returned to its original tone. This result would a. Macules
suggest:
d. cardiovascular disease 90. An adult male client visits the clinic and tells the nurse
that he believes he has athlete’s foot. The nurse observes
76. Sweat glands that are concentrated in the axillae, that the client has linear cracks in the skin on both feet.
perinuem, and areolae of the breast and are usually open The nurse should document the presence of?
through a hair follicle d. Fissures
d. apocrine
91. An African-American female client visits the clinic. She
77. A nurse who is to conduct physical assessment of the tells the nurse that she had her ears pierced several
integumentary system is aware that the following weeks ago, and an elevated, irregular, reddened mass has
techniques are used: now developed at the earlobe. The nurse should
d. inspection, palpation document a?
d. Keloid
78. Assessing for skin turgor means assessing for the skin’s:
b. mobility and elasticity 92. A dark-skinned client visits the clinic because he hasn’t
been feeling well. To assess the client’s skin for jaundice,
79. One abnormality a nurse might encounter in assessment the nurse should inspect the clients:
of the nails is clubbing of the nails. Clubbing of the nails is d. sclera
due to:
a. Chronic hypoxia
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 93. Connecting the skin to underlying structures is the?
d. subcutaneous tissue

94. The only layer of the skin that undergoes cell division is
the?
a. Innermost layer of the epidermis

95. A client’s skin color depends on melanin and carotene

contained in the skin, and the:
b. Volume of blood circulating in the dermis

96. Hair follicle, sebaceous glands, and sweat glands

originate from the:
d. dermis

97. The apocrine glands are dormant until puberty and are
concentrated in the axillae, the perinuem, and the:
a. Areola of the breast

98. Short, pale, and fine hair that is present over much of
the body is termed:
a. Vellus

99. The nails, located on the distal phalanges of the fingers

and toes, are composed of
c. keratinized epidermal cells

100. Relax. Shade Letter A.

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 MIDTERM EXAM

NCM_101 - HEALTH ASSESSMENT

Midterm Examination
1. The nurse assesses an adult client’s head and neck. While 11. When assessing an older adult client’s neck, the nurse
examining the carotid arteries, the nurse assesses each observes that the client trachea is pulled on the unaffected
artery individually to prevent a: side. All of the following are suspicions of the findings
A. Reduction of blood supply to the brain EXCEPT
C. Atelectasis
2. A client visit the outpatient center with a complaint of
sudden head and neck pain stiffness. The client’s oral 12. The nurse is plan to assess an adult client’s thyroid gland.
temperature is 37.7 degree celsius. The nurse suspects that The nurse should plan to:
the client is experiencing symptoms of? B. approach the client posteriorly
B. Meningitis
13. The nurse is preparing to assess the lymph nodes of an
3. Whiles assessing the head and neck of an adult client, the adult client. The nurse should instruct the client to?
client tells that nurse that she has been experiencing sharp D. Sit in an upright position
shooting facial pains that last from 10-20 seconds but are
occurring more frequently. The nurse should refer the client 14. A female visits the clinic and tells the nurse that she
for possible? wants to “stay healthy”. The nurse observes that the client
D. Tic Doleureaux has diffuse neck enlargement is perspiring and is quite
fidgety. The client tells the nurse that she is “hungry all the
4. A female client visits the clinic and tells the nurse that she time, but I have lost weight”. A priority nursing diagnosis for
frequently experiences severe recurring headaches that the client is?
sometimes last for several days and are accompanied by C. Health seeking behaviors related to
nausea and vomiting. The nurse determines the type of verbalization of wanting to stay healthy and
headache the client is describing is a: concerns over weight loss
A. Migraine headache
15. The nurse is preparing to assess C7 of an adult client.
5. An adult client visits the clinic and tells the nurse that she The nurse should instruct the client to:
has headaches recently that are intense and stabbing and C. Flex the neck (chin to chest)
often occur in the late evening. The nurse should suspect
the presence of? 16. A 20-year-old female is currently 8 weeks pregnant. She
A. Cluster headache had a miscarriage at 12 weeks gestation two years ago. She
has no living children. What is her GTPAL?
6. A client visits the clinic and tells the nurse that he is A. G=2, T=0, P=0, A=1. L=0
depressed because of recent job loss. He complains of dull
aching pain tight and diffuse headaches that have lasted for 17. A 26-year-old female is currently 26 weeks pregnant. She
several days. The nurse recognize that these are symptoms has a miscarriage at 10 weeks gestation five years ago. She
of: has a three-year-old who was born at 39 weeks. What is her
D. Tension headache GTPAL?
A. G=3, T=1, P=0, A=1, L=1
7. An older client visits the clinic accompanied by his
daughter. The daughter tells the nurse that her father has 18. A 35-year-old female is currently pregnant with twins.
been experiencing severe headaches that usually begin in She has 10-year-old triplets who were born at 32 weeks
the morning and become worse when he coughs. The client gestation, and a 16-year-old who was born at 41-week
tells the nurse that he feels dizzy when he has headaches. gestation. Twelve years ago she has a miscarriage at 19
The nurse refers the client for further evaluation because weeks’ gestation. What is her GTPAL?
the symptoms are characteristics of: C. G=4, T=1, P=1, A=1, L=4
B. Tumor related headache
19. A 39-year-old female is currently 18 weeks pregnant. She
8. While assessing an adult client’s skull, the nurse observes has two sets of twin daughters that were born at 38 and 39
that the client’s skull and facial bones are larger and thicker weeks gestation and an 11-year-old son who was born at 32
than usual. The nurse should assess the client for? weeks gestation. She has no history of miscarriage or
B. acromegaly abortion. What is her GTPAL?
D. G=4, T=2, P=1, A=0, L=5
9. While assessing an adult client’s head and neck, the nurse
observes a large swelling at the base of the neck and the 20. A 29-year-old female is currently 9 weeks pregnant. She
client manifest cough, hoarseness of voice and tight feeling has no living children. Two years ago she had 2 miscarriages
in the throat? at 10 and 12 weeks gestation. What is her GTPAL?
A. Goiter A. G=3, T=0, P=0, A=2, L=0

10. The nurse is preparing to assess the neck of an adult 21. A 30-year-old female is 20 weeks pregnant with twins.
client. To inspect movement of the client’s thyroid gland, She has a 6 year old who was born at 40 weeks gestation.
the nurse should ask the client to? She has no history of miscarriage or abortion. What is her
B. Swallow a small sip of water GTPAL?
B. G=2, T=1, P=0, A=0, L=1

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22. During the physical examination of a 60-year-old client, 33. During a prenatal visit a patient tells you her last
the nurse finds that the pulsation of the temporal artery is menstrual period was January 30, 2016. Based on Naegele’s
weak. What is an appropriate action by the nurse for this Rule, when is the estimated due date of her baby?
client? A. November 6, 2016
B. recognize the weakened pulsation as an age-
related change 34. During a prenatal visit a patient tells you her last
menstrual period was November 25, 2016. Based on
23. A client report severe pain in the posterior region of the Naegele’s Rule, when is the estimated due date of her baby?
neck and difficulty turning the head to the right. What D. September 1, 2017
additional information should the nurse collect?
D. Previous injuries to the head and neck 35. While assessing the eyes of an adult client, the nurse
uses a wisp of cotton to stimulate the client’s?
24. A nurse is assessing a client with hyperthyroidism for the D. corneal reflexes
presence of a bruit. Which assessment technique should the
nurse use? 36. An adult client visits the clinic and tells the nurse that
D. Auscultation she has had a sudden change in her visions. The nurse
should explain to the client that the sudden changes in
25. While performing an examination of the head and neck, vision are often associated with:
a nurse notices left-sided facial drooping and paralysis. The D. head trauma
nurse recognizes this as what condition?
C. Bell’s palsy 37. An adult client tells the nurse that he has been
experiencing gradual vision loss. The nurse should:
26. A nurse palpates an enlarged, hard, and non-tender left- C. check the client’s blood pressure
sided supraclavicular lymph node in a client. Where should
the nurse focus the physical assessment to obtain more data 38. The client is diagnosed with glaucoma. Which symptom
about this finding? should the nurse expect the client to report?
B. Abdomen and thoracic area for changes A. Loss of peripheral vision
associated with malignancy
39. A client tells the nurse that she has difficulty seeing
27. While the nurse is assessing a client for an unrelated while driving at night. The nurse should explain to the client
health concern, the client experiences a sudden, severe that night blindness is often associated with?
headache with no known cause. He also complains of D. vitamin A deficiency
dizziness and trouble seeing out of one eye. What
associated condition should the nurse suspect in this client? 40. An adult client visits the clinic and tells the nurse that he
D. Impending stroke has been experiencing Diplopia for the past few days. The
nurse refers the client to a physical for evaluation of
28. While examining a client, the nurse observes that he possible?
appears to be nodding his head involuntarily. Which of the B. Increased intracranial pressure
following conditions should the nurse additionally assess for
based on this finding? 41. The nurse performing an eye examination, will
C. aortic insufficiency document normal findings for accommodation when?
D. the pupils constrict while fixating on an object
29. You’re assessing the one minute APGAR score of being moved closer to the patient’s eyes
newborn baby. On assessment you note the following about
your newborn patient: weak cry, some flexion of the arm 42. Which assessment finding alerts the nurse to provide
and legs, active movement and cries to stimulation, heart patient teaching about cataract development?
rate 145, and pallor all over the body and extremities. What C. Blurred vision and light sensitivity
is your patient’s APGAR score?
D. APGAR 6 43. When assessing a patient’s consensual pupil response,
the nurse should?
30. You’re assessing the five minute APGAR score of a D. Shine a light into one pupil and observe the
newborn baby. On assessment, you note the following response of both pupils
about your newborn patient: pink body and hands with
cyanotic feet, heart rate 109, grimace to stimulation, flaccid, 44. When obtaining a health history from a 49-year-old
and irregular cry. What is your patient’s APGAR score? patient, which patient statement is most important to
B. APGAR 5 communicate to the primary health care provider?
D. “I can’t see as far over to the side”
31. You’re assessing the five minute APGAR score of a
newborn baby. On assessment, you note the following 45. The nurse is testing the visual acuity of a patient in the
about your newborn patient: heart rate 97, no response to outpatient clinic. The nurse’s instruction for this test include
stimulation, flaccid, absent respiration, cyanotic throughout. asking the patient to?
What is your patient’s APGAR score? A. Stand 20 feet from the wall chart
D. APGAR 1
46. A patient who underwent eye surgery is required to
32. During a prenatal visit a patient tells you her last wear an eye patch until the scheduled postop clinic visit.
menstrual period was January 20, 2016. Based on Naegele’s Which nursing dx will the nurse include in the plan of care?
Rule, when is the estimated due date of her baby? B. Risk for falls related to temporary decrease in
A. October 27, 2016 stereoscopic vision

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47. The nurse is assessing a 65-year-old patient for 61. While assessing the eye of an adult client the nurse
presbyopia. Which situation will the nurse give the patient observes an inward turning of the client’s eye. The nurse
before the test? should document the client’s?
A. “hold this card and read the print out loud” A. Estropia

48. When the patient turns his head quickly during the 62. The nurse is examining an adult client’s eye. The nurse
admission assessment, the nurse observes nystagmus. What has explained the positions test to the client. The nurse
is the indicated nursing action? determined that the client needs a further instruction when
B. Place a fall-risk bracelet on the patient the client says that the position test.
C. requires the covering of each eye separately
49. The charge nurse must intervene immediately if
observing a nurse who is caring for a patient with vestibular 63. Transmission of sound waves in the inner ear is known
disease? as?
C. Encourage the patient to ambulate C. sensorineural hearing
independently
64. An adult client visits the clinic and complains of tinnitus.
50. Pause for a while. Inhale Exhale. Shade letter D. it’s a The nurse should ask the client if she has been:
bonus point C. taking antibiotics

51. The nurse should report which assessment finding 65. The nurse is preparing to examine the ears of an adult
immediately to the health care provider? client with an otoscope. The nurse should plan to:
A. The tympanum is blue-tinged D. firmly pull the auricle out, up and back

52. Which equipment will the nurse obtain to perform a 66. The nurse is planning to conduct the Weber test on an
Rinne test? adult male client. To perform this test, the nurse should plan
B. Tuning fork to?
D. strike a tuning fork and place it on the center of
53. Which action should the nurse take when providing the client’s head or forehead
patient teaching to a 76-year-old with mild presbycusis?
C. Ask for permission to turn off the television 67. The nurse has performed the Rinne test on an older
before teaching client. After the test the client reports that her bone
conduction sound was heard together longer than air
54. Which action can the nurse be working in the Emergency conduction sound. The nurses determines that the client is
Department delegate to experienced unlicensed assistive most likely experiencing?
personnel (UAP)? C. conductive hearing loss
B. perform Snellen testing of visual acuity for a
patient with a history of cataracts 68. A nurse is working with a client who has an impaired
ability to smell. He explains that he was in an automobile
55. The nurse working in the vision & hearing clinic receives accident many years ago and suffered nerve damage that
telephone calls from several pts who wants appointment in resulted in this condition. Which nerve should the nurse
the clinic ASAP. Which patient should be seen first? suspect that the damaged CN in this client is the?
A. 71-year-old who has noticed increasing loss of A. Cranial nerve 1 (olfactory)
peripheral vision
69. The nurse is preparing to examine the sinuses of an adult
56. The nurse evaluates that wearing bifocals improved the client. After examining the frontal sinuses, the nurse should
patient’s myopia and presbyopia by assessing for proceed to examine the:
B. Both near and distant vision C. maxilliary sinuses

57. A nurse should include which instructions when teaching 70. An adult client visits the clinic complaining of recurrent
a patient with repeated Hordeolum how to prevent further ulcers in the mouth. The nurse assess the clients mouth and
infection? observe a painful ulcer. The nurse should document the
B. discard all open or used cosmetics applied near presence of:
the eyes D. apthous stomatitis

58. In reviewing a 55-year-old patient’s medical record, the 71. An adult client visits the clinic and tells the nurse that
nurse notes that the last eye examination revealed an she has been experiencing frequent nosebleed for the past
intraocular pressure of 28mmHg. The nurse will plan to month. The nurse should:
assess: D. refer the client for further evaluation
D. peripheral vision
72. The nurse is assessing the mouth of an older client and
59. A patient diagnosed with external otitis is being observes that the client appears to have a poorly fitting
discharged from the emergency department with an ear dentures. The nurse should instruct the client that she may
wick in place. Which statement by the patient indicated a be at greater risk for?
need for further teaching? A. Aspiration
C. “I will clean the ear canal daily with a cotton-
tipped applicator” 73. An adolescent tells the nurse that her mother says she
grinds her teeth when she sleeps. The nurse should explain
60. A client has tested 20/40 on the distant visual acuity to the client that grinding her teeth maybe a sign of?
using Snellen chart. The nurse should: D. stress and anxiety
D. Refer the client to an optometrist

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74. A nurse inspects the gums and teeth of a middle aged 86. The nurse is preparing to auscultate the posterior thorax
adult and notices the presence of small brown spots on the of an adult female client. The nurse should?
chewing surfaces of several of the molar teeth. What A. Place the bell of the stethoscope firmly on the
question should the nurse ask the client to determine the posterior chest wall
cause of this finding?
A. “are you experiencing any tooth pain?” 87. While assessing the thoracic area of an adult client, the
nurse explains the auscultate for voice sounds. To assess
75. A nurse examines a client with complaints of a sore bronchophony, the nurse should ask the client to?
throat and finds that the tonsils are enlarged and seen A. Repeat the phrase “ninety nine”
midway between the pillars and uvula. Using a grading scale
pf 1+ tp 4+, how should the nurse appropriately document 88. The nurse assesses an adult client and observes the
the tonsils? clients breathing pattern is very labored and noisy with
D. 2+ occasional coughing. The nurse should refer the client to the
physician for possible?
76. A client visits the clinic and tells the nurse that she has a A. Chronic bronchitis
painful cracking in the corners of the lips. The nurse should
assess the client’s diet for deficiency of: 89. While assessing an adult client’s lungs during the post-
D. riboflavin operative period, the nurse detects coarse crackles. The
nurse should refer the client to a physician for a possible?
77. The nurse is assessing a client who has been taking B. Pleuritis
antibiotics for an infection for 10 days. The nurse observes
whitish curd like patches in the client’s mouth. The nurse 90. The nurse assesses an adult client’s breath sounds and
should explain to the client that these spots are most likely hears sonorous wheezes primarily during the client’s
known as: expiration. The nurse should refer the client to the physician
A. Candida Albicans infection for possible:
B. asthma
78. The nurse is assessing an adult client’s oral cavity for
possible oral cancer. The nurse should explain to the client 91. The client has been admitted through the emergency
that the most common site for oral cancer is the? department with chronic bronchitis, has elevated C02 levels
B. Area underneath the tongue and has been placed on O2. What priority assessment would
the nurse include?
79. An adult client visits the clinic complaining of a sore D. evaluate changes in respiratory patter and rate
throat. After assessing the throat, the nurse documents the
client’s tonsillitis as 4+. The nurse should explain to the 92. The nurses assesses the respiratory pattern of an adult
client that 4+ tonsils are present when the nurse observes client. The nurse determines that the client is experiencing
tonsils that are? Kussmaul’s respiration with hyperventilation. The nurse
C. Touching each other should contact the client’s physician because this type of
respiratory pattern usually indicates?
80. Which action by the nurse is appropriate to prevent the A. Diabetic ketoacidosis
gag reflex during observation of the uvula?
A. Depress the tongue slightly off center 93. Elevated sebaceous gland, known as Montgomery’s
glands are located in the breast’s
81. While assessing an adult client tells the nurse that she D. aerolas
“has had difficulty catching her breath since yesterday”. The
nurse should assess the client for further for signs and 94. The size and shape of the breast in females are related
symptoms of? to the amount of?
A. Emphysema D. fatty tissue

82. An adult client visits the clinic and tells the nurse that he 95. After assessing the breast of a female client, the nurse
has been spitting up rust colored sputum. The nurse should should explain to the client that most breast tumors occur in
refer the client to the physician for possible? the?
D. Tuberculosis C. upper outer quadrant

83. The nurse is planning a presentation of a group of high 96. A female client tells the nurse that her breast become
school students on the topic of lung cancer. Which of the lumpy and sore before menstruation but get better at the
following should the nurse plan to include in the end of menstrual cycle. Then nurse should explain to the
presentation? client that these symptoms are often associated with?
D. studies have indicated that there is a genetic C. fibrocystic breast
component in the development of lung cancer
97. Which of the following statements is true regarding the
84. While assessing an adult client, the nurse observes internal structure of breast? The breast is made up of:
decrease chest expansion at the bases of the client’s lungs. B. Fibrous, glandular, and adipose tissues
The nurse should refer the client to a physician for possible?
D. Chronic Obstructive Pulmonary Disease 98. In performing a breast examination, the nurse knows
that examining the upper outer quadrant of the breast is
85. The nurse is planning to percuss the chest of an adult especially important. The reason for this is that the upper
male client for diaphragmatic excursion. The nurse should outer quadrant is:
begin the assessment by? B. the location of most breast tumors
A. Asking the client to take a deep breath and hold
it

K.M 8
99. While inspecting a patient’s breast, the nurse finds that 110. Which of these clinical situations would the nurse
the left breast is slightly larger than the right with the consider to be outside normal limits?
bilateral presence of Montgomery glands. The nurse should: D. A patient has had two pregnancies, and she
B. consider these findings normal, and proceed breastfed both of her children. Her youngest child is now
with the examination 10 years old. Her breast examination reveals breast tissue
that is somewhat soft, and she has a small amount of thick
100. Good job! It’s a bonus POINT, Shade Letter B. yellow discharge from both nipples.

101. A 14-year-old girl is anxious about not having reached

menarche. When taking the health history, the nurse should
ascertain which of the following? The age that:
A. The girl began to develop breast

102. A woman is in the family planning clinic seeking birth

control information. She states that her breasts change all
month long and that she is worried that this is unusual.
What is the nurse’s best response? The nurse should tell her
that:
C. because of the changing hormones during the
monthly menstrual cycle, cyclic breast changes are
common

103. The nurse is teaching a pregnant woman about breast

milk. Which statement by the nurse is correct?
D. you may notice a thick, yellow fluid expressed
from your breast as early as the fourth month of
pregnancy

104. A 65-year-old patient remarks that she just cannot

believe that her breast sag so much. She states it must be
from a lack of exercise. What explanation should the nurse
offer her? After menopause:
D. the glandular and fat tissue atrophies, causing
breast size and elasticity to diminish, resulting in
breast that sag

105. In examining a 70-year-old male patient, the nurse

notices that he has bilateral gynecomastia. Which of the
following describes the nurses best course of action?
C. explain that his condition may be the result of
hormonal changes, and recommend that he sees
his physician

106. During a health history interview, a female patient

states that she has noticed a few drops of clear discharge
from her right nipple. What should the nurse do next?
C. ask the patient some additional questions about
the medications she is taking

107. During a physical examination, a 45-year-old woman

states that she had has a crusty, itchy rash on her breast for
approximately 2 weeks. In trying to find the cause of the
rash, which question would be important for the nurse to
ask?
C. where did the rash first appear on the nipple,
the areola, or the surrounding skin?

108. A patient is newly diagnosed with benign breast disease.

The nurse recognizes which statement about benign breast
disease to be true? The presence of benign breast disease:
A. Makes it hard to examine the breasts

109. The nurse is palpating a female patient breast during an

examination. Which of these positions is most likely to make
significant lumps more distinct during breast palpation?
A. Supine with the arms raised over her head

K.M 9