Nurse Moose
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    Exam Review

    1. The nurse inspects the client's fingernails. Which differentiating characteristics are observed in this assessment finding?
      A)Longitudinal pigmented bands and red brown linear streaks of recent onset.
      B)Thinned depressed nails with lateral edges tilting up to form a concave profile and proximal subungual fungal infection.
      C)Transverse furrows and nail plate white spots that move forward with nail growth.
      D)A nail base angle greater than 180 degrees and nail plate loosened at the distal-lateral edge, progressing proximally.
    2. The nurse is calculating the one-minute Apgar score for a newborn infant and determines that the heart rate is 150 beats/minute, a vigorous cry is present, muscle tone is good with total flexion, quick reflex irritability noted, and skin color is dusky and cyanotic. Which Apgar score should the nurse assign to this infant? (Enter numeric value only.)
    3. The nurse notes an enlarged, visible lymph node on the client's neck. Which action should the nurse take next?
      A)Auscultate the lymph node for the presence of a bruit.
      B)Ask the client about any localized tenderness at the site.
      C)Cover the inflamed area and notify the healthcare provider.
      D)Record this normal finding in the assessment record.
    4. A woman comes to the clinic for her first prenatal visit. The nurse is conducting a health history and the woman begins to cry when asked about previous pregnancies. Which response is best for the nurse to provide?
      A)Allow the client to compose herself then change the subject.
      B)"Why don't I come back in a few minutes after you are more composed."
      C)"I'm so sorry that I made you cry. I didn't mean to upset you."
      D)Offer a tissue and sit quietly until the crying subsides.
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    Exam Review

    1. The school nurse is interviewing an adolescent who wants to go home from school because of "back pain." Which question should the nurse ask first?
      A)"What were you doing when you first noticed the problem?"
      B)"Have you taken any medications to relieve the pain?"
      C)"Do you remember ever having this type of pain in the past?"
      D)"Does changing your position make the pain worse?
    2. While the nurse is obtaining a health history, the client reports experiencing shortness of breath at times. The nurse determines that the client's respirations are regular and deep and respiratory rate is 14 breaths/minute. Which is the best nursing action?
      A)Explain to the client the possible causes of dyspnea or "shortness of breath."
      B)Ask the client to describe the episodes of dyspnea in more detail.
      C)Document "dyspnea on exertion" in the client's medical record.
      D)Ask the client to perform light exercise and observe the respiratory effort.
    3. While the nurse is taking a health history, the client announces, "I don't have time for this. This is a waste of time. I need treatment." Which response is best for the nurse to provide?
      A)"I am sorry you feel that way. Perhaps you'd like to return when you have more time."
      B)"You sound angry. Would you like to tell me about it?"
      C)Ignore the angry outburst and continue with the history questions.
      D)Move closer and place a hand on the client's shoulder to demonstrate concern.
    4. A clinic nurse is assessing infants and toddlers for fine and gross motor development. Which child should the nurse refer to a healthcare provider for further evaluation?
      A)3-year-old preferring to walk on the tip toes.
      B)1.5-year-old attempting to scribble on paper.
      C)5-month-old with use of whole hand grasp.
      D)3.5-month-old with diminished Moro reflex.
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    Exam Review

    1. On the first postpartum day, the nurse examines the breasts of a new mother. Which condition is the nurse most likely to find?
      A)Firm, larger, and very tender to touch.
      B)Soft, with no change from before delivery.
      C)Filling and secreting colostrum.
      D)Slightly firm with immediate let-down response.
    2. A nurse is interacting with a client who is a victim of intimate partner violence (IPV). The client reports feeling unable to leave the relationship because of the children. The nurse responds by saying, "I know this must be very difficult for you." Which type of therapeutic communication is the nurse providing?
      A)Open-ended question.
      B)Clarification.
      C)Empathizing.
      D)Paraphrasing.
    3. The charge nurse observes a practical nurse (PN) measuring the waist circumference of a client who has expressed a concern about health problems related to obesity. Which action should the nurse implement?
      A)Advise the PN that waist circumference measurements are valuable to assess fluid retention but not obesity.
      B)Instruct the PN to measure the client's waist circumference every 8 hours to assess for changes.
      C)Tell the PN that this assessment technique should be performed by the nurse.
      D)Review the measurement obtained by the PN and compare with ideal measurements for this client.
    4. A client has a prescription for vital sign measurement every four hours. The nurse observes that the client's blood pressure has increased from 140/60 mm Hg at noon to 180/90 mm Hg four hours later. Which action should the nurse implement?
      A)Plan to measure the blood pressure in four hours as prescribed.
      B)Repeat the client's blood pressure measurement in fifteen minutes.
      C)Obtain an automatic blood pressure machine for hourly readings.
      D)Reassess the blood pressure if the client reports other symptoms.
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    Exam Review

    1. While-interviewing an elderly client, the nurse observes that the client's hands tremble uncontrollably while reaching for a glass of water. How should the nurse document this finding?
      A)Sensory dysfunction.
      B)Transient ischemic attack.
      C)Muscle flaccidity.
      D)Intention tremor.
    2. An adolescent's mother calls the primary healthcare provider's office to Inquire about the results of her daughter's serum test results that were drawn last week. Since it is the teenager's 18th birthday, how should the nurse respond to this mother's inquiry?
      A)Ask when the adolescent was last seen in the clinic.
      B)Explain that the information cannot be released without the 18-year-old's permission.
      C)Tell the mother to have the teenager call the clinic.
      D)Since the serum samples were drawn last week provide the mother with the findings.
    3. A school-age child presents for a well-child visit with a hemoglobin level of 10 g/dL (100 g/L) and a body mass index of 15 kg/mm2. Which additional assessment should the nurse obtain to help identify a potential cause of these clinical manifestations?
      A)Primary source of water.
      B)Standard household income.
      C)Family history of eating disorders.
      D)Average daily intake of meals.
    4. The nurse is assessing a darkly pigmented child for cyanosis. Which finding indicates cyanosis?
      A)Blue tinge in the nail beds.
      B)Ashen grey tone to lips.
      C)Ashy yellow appearance of skin.
      D)Reddish purple colored palms.
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    Exam Review

    1. Which finding, obtained during a skin assessment of a student, should the school nurse report to the healthcare provider?
      A)Multiple maculopapular pustules over forehead and chin on an adolescent student.
      B)Red, swollen, painful nodule located on the upper back of a school aged student.
      C)Small, white flecks on the hair shafts throughout scalp on a school aged child.
      D)Bilateral patellar abrasions with eschar formation on a preschool aged student.
    2. The nurse is conducting a functional assessment on an older adult client who is reporting decreased activity due to reduced energy and strength. Which action should the nurse perform during the functional assessment?
      A)Question the client about the frequency of falls in recent months.
      B)Request to have the client lie as still as possible for the assessment.
      C)Assist the client with clarifying values about end-of-life care options.
      D)Ask the client how often episodes of sundowning are experienced.
    3. A parent brings a preschool aged client to the clinic because of having diarrhea, vomiting, and high fevers for the past three days. The child begins to cry and cling to the parent when the nurse enters the examination room. Which action should the nurse implement to get the child to cooperate?
      A)Explain to the child the reasons an examination is needed.
      B)Talk to the parent and gradually focus on the child's toy.
      C)Complete the assessment while allowing the child to cry.
      D)Request extra staff to help with the nursing assessments.
    4. While counting the respirations of an adult client who is bedfast, the nurse observes that the client uses the sternocleidomastoid, trapezius, and abdominal muscles during respirations. Which action should the nurse take in response to this finding?
      A)Document the client's asymmetrical thoracic movement during inspiration.
      B)Assist the client to a position that helps the client breathe more easily.
      C)Provide the client an incentive spirometer to increase respiratory effort.
      D)Encourage the client to continue to breathe deeply to expand the lungs.
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