Multiple choice

Question 1

Nursing diagnoses, based on an assessment of a number of factors, give a nurses a common language with which to communicate nursing findings. the best description of a nursing diagnosis is that it is:
A) used to evaluate the aetiology of a disease
B) a pattern of coping
C) a concise description of actual or potential health problems or of wellness strengths
D) the patient’s perceptions of and satisfaction with their own health status

Answer 1

A) used to evaluate the aetiology of a disease
B) a pattern of coping
C) a concise description of actual or potential health problems or of wellness strengths*
D) the patient’s perceptions of and satisfaction with their own health status

Question 2

During an interview a good rule to follow is to:
A) stop the patient each time something is said that is not understood
B) spend more time listening to the patient than talking
C) consistently think of your next response so the patient will know that you understand them
D) use “why” questions to seek clarification of unusual symptoms or behaviour

Answer 2

A) stop the patient each time something is said that is not understood
B) spend more time listening to the patient than talking*
C) consistently think of your next response so the patient will know that you understand them
D) use “why” questions to seek clarification of unusual symptoms or behaviour

Question 3

The organs that aid the lymphatic system are:
A) liver, lymph nodes and stomach
B) pancreas, small intestine and thymus
C) spleen, tonsils and thymus
D) pancreas, spleen and tonsils

Answer 3

A) liver, lymph nodes and stomach
B) pancreas, small intestine and thymus
C) spleen, tonsils and thymus*
D) pancreas, spleen and tonsils

Question 4

The second heart sound (S2) is the result of:
A) opening of the mitral and tricuspid valves
B) closing of the mitral and tricuspid valves
C) opening of the aortic and pulmonic valves
D) closing of the aortic and pulmonic valves

Answer 4

A) opening of the mitral and tricuspid valves
B) closing of the mitral and tricuspid valves
C) opening of the aortic and pulmonic valves
D) closing of the aortic and pulmonic valves*

Question 5

In order to differentiate between an acute infection and chronic inflammation, you palpate the lymph nodes. Your findings would reveal which of the following to confirm an acute infection:
A) nodes are hard, unilateral, non tender and fixed
B) nodes are bilateral, enlarged, warm, tenders and firm but they move freely
C) nodes are enlarged, firm, non tender and mobile
D) nodes are clumped in strings

Answer 5

A) nodes are hard, unilateral, non tender and fixed
B) nodes are bilateral, enlarged, warm, tenders and firm but they move freely*
C) nodes are enlarged, firm, non tender and mobile
D) nodes are clumped in strings

Question 6

During an assessment of the spine, the patient would be asked to:
A) adduct and extend
B) suprinate, evert and retract
C) extend, adduct, invert and rotate
D) flex, extend, abduct and rotate

Answer 6

A) adduct and extend
B) suprinate, evert and retract
C) extend, adduct, invert and rotate
D) flex, extend, abduct and rotate*

Question 7

A risk factor of melanoma is:
A) brown eyes
B) darkly pigmented skin
C) skin that freckles or burns before tanning
D) use of sunscreen products

Answer 7

A) brown eyes
B) darkly pigmented skin
C) skin that freckles or burns before tanning*
D) use of sunscreen products

Question 8

Select the sequence of techniques used during an examination of the abdomen:
A) percussion, inspection, palpation, auscultation
B) inspection, palpation, percussion, auscultation
C) inspection, auscultation, percussion, palpation
D) auscultation, inspection, palpation, percussion

Answer 8

A) percussion, inspection, palpation, auscultation
B) inspection, palpation, percussion, auscultation
C) inspection, auscultation, percussion, palpation*
D) auscultation, inspection, palpation, percussion

Question 9

Although a full mental status examination may not be required, the nurse must be aware of the four main headings of the assessment while performing the interview and physical examination. These headings are:
A) mood, affect, consciousness and orientation
B) memory, attention, thought content and perceptions
C) language, orientation, attention and abstract reasoning
D) appearances, behaviour, cognition and thought process

Answer 9

A) mood, affect, consciousness and orientation
B) memory, attention, thought content and perceptions
C) language, orientation, attention and abstract reasoning
D) appearances, behaviour, cognition and thought process*

Question 10

Several changes occur in the eye with the ageing process. the thickening and yellowing of the lens is referred to as:
A) presbyopia
B) floaters
C) macular degeneration
D) senile cataract

Answer 10

A) presbyopia
B) floaters
C) macular degeneration
D) senile cataract*

Question 11

The medical record indicates that a person has an injury to Broca's area. When meeting this person you would expect:
A) difficulty speaking
B) receptive aphasia
C) visual disturbances
D) emotional liability

Answer 11

A) difficulty speaking*
B) receptive aphasia
C) visual disturbances
D) emotional liability

Question 12

The sensation of vertigo is the result of:
A) otitis media
B) pathology in the semicircular canals
C) pathology in the cochlea
D) 4th cranial nerve damage

Answer 12

A) otitis media
B) pathology in the semicircular canals*
C) pathology in the cochlea
D) 4th cranial nerve damage

Question 13

A main characteristic of dementia is:
A) impairment of short and long term memory
B) hallucinations
C) sudden onset of symptoms
D) substance-induced

Answer 13

A) impairment of short and long term memory
B) hallucinations
C) sudden onset of symptoms
D) substance-induced

Question 14

Depending on the clinical situation, the nurse may establish one of four kinds of database. An episodic database is described as:
A) including a complete health history
B) concerning one main problem
C) evaluation of a previously identified problem
D) rapid collection of data in conjunction with lifesaving measures

Answer 14

A) including a complete health history
B) concerning one main problem*
C) evaluation of a previously identified problem
D) rapid collection of data in conjunction with lifesaving measures

Question 15

During an assessment of a 20-year -old patient with a 3 day history of nausea and vomiting, the nurse notes dry mucosa and deep fissures in the tongue. this finding is reflective of:
A) dehydration
B) irritation by gastric juices
C) a normal oral assessment
D) side effects from nausea medication

Answer 15

A) dehydration*
B) irritation by gastric juices
C) a normal oral assessment
D) side effects from nausea medication

Question 16

Which technique of assessment is used to determine the presence of crepitus, swelling and pulsations?
A) Palpation
B) Inspection
C) Percussion
D) Auscultation

Answer 16

A) Palpation*
B) Inspection
C) Percussion
D) Auscultation

Question 17

The patient's record, laboratory studies, objective data and subjective data combine to form the:
A) database
B) admitting data
C) financial statement
D) discharge summary

Answer 17

A) database*
B) admitting data
C) financial statement
D) discharge summary

Question 18

The nurse is assessing a patient’s pain. the nurse knows that which of the following is considered the most reliable indicator of pain?
A) vital signs
B) the physical assessment
C) computerised axial tomography scan findings
D) the subjective report

Answer 18

A) vital signs
B) the physical assessment
C) computerised axial tomography scan findings
D) the subjective report*

Question 19

When examining the ear with an otoscope, the nurse remembers that the tympanic membrane should appear:
A) light pink with a slight bulge
B) pearly grey and slightly concave
C) pulled in at the base of the cone of light
D) whitish with a small fleck of light in the superior portion

Answer 19

A) light pink with a slight bulge
B) pearly grey and slightly concave*
C) pulled in at the base of the cone of light
D) whitish with a small fleck of light in the superior portion

Question 20

In using the ophthalmoscope to assess a patient’s eyes, the nurse notes a red glow in the patient’s pupils. On the basis of this finding, the nurse would:
A) suspect the there is an opacity in the lens or cornea.
B) check the light source of the ophthalmoscope to verify that it is functioning
C) consider this a normal reflection of the ophthalmoscope light off the inner retina
D) continue with the ophthalmoscopic examination and refer the patient for further evaluation

Answer 20

A) suspect the there is an opacity in the lens or cornea.
B) check the light source of the ophthalmoscope to verify that it is functioning
C) consider this a normal reflection of the ophthalmoscope light off the inner retina*
D) continue with the ophthalmoscopic examination and refer the patient for further evaluation

Question 21

A thorough skin assessment is very important because the skin holds information about:
A) support systems
B) circulatory status
C) socioeconomic status
D) psychological wellness

Answer 21

A) support systems
B) circulatory status*
C) socioeconomic status
D) psychological wellness

Question 22

If urine colour is cloudy on inspection, what can this indicate?
A) presence of bladder cancer
B) dehydration of the client
C) presence of infection or kidney stones
D) use of food supplements

Answer 22

A) presence of bladder cancer
B) dehydration of the client
C) presence of infection or kidney stones*
D) use of food supplements

Question 23

When examining a patient, the nurse observes abdominal pulsations between the xiphoid and umbilicus. The nurse would suspect the these are:
A) pulsations of the renal arteries
B) pulsations of the vena cava
C) normal abdominal aortic pulsations
D) increased peristalsis from a bowel obstruction

Answer 23

A) pulsations of the renal arteries
B) pulsations of the vena cava
C) normal abdominal aortic pulsations*
D) increased peristalsis from a bowel obstruction

Question 24

When assessing a patient’s lungs, the nurse recalls that the left lung:
A) consists of two lobes
B) is divided by the horizontal fissure
C) consists primarily of an upper lobe on the posterior chest
D) is shorter than the right lung because of the underlying stomach

Answer 24

A) consists of two lobes*
B) is divided by the horizontal fissure
C) consists primarily of an upper lobe on the posterior chest
D) is shorter than the right lung because of the underlying stomach

Question 25

A 67 year old patient states that he recently began to have pain in his left calf when climbing the 10 stairs to his apartment. the pain is relieved by sitting for about 2 minutes; then he is able to resume his activities. This patient is most likely experiencing:
A) claudication
B) sore muscles
C) muscle cramps
D) venous insufficiency

Answer 25

A) claudication*
B) sore muscles
C) muscle cramps
D) venous insufficiency

Question 26

When measuring a patient's body temperature, the nurse keeps in mind that body temperature is influenced by:
A) constipation
B) the patient's emotional state
C) the diurnal cycle
D) the nocturnal cycle

Answer 26

A) constipation
B) the patient’s emotional state
C) the diurnal cycle*
D) the nocturnal cycle

Question 27

The physician comments that a patient has abdominal ‘borborygmi’. The nurse knows that this term refers to:

a. a loud continuous hum.
b. a peritoneal friction rub.
c. hypoactive bowel sounds.
d. hyperactive bowel sounds.

Answer 27

The physician comments that a patient has abdominal ‘borborygmi’. The nurse knows that this term refers to:

a. a loud continuous hum.
b. a peritoneal friction rub.
c. hypoactive bowel sounds.
d. hyperactive bowel sounds. *

Question 28

What is one of the main functions of the urinary system?
Select one:
a. Responsible for release of adrenaline
b. Responsible for regulation of blood volume and composition
c. Responsible for insulin release
d. Responsible for drainage of lymphatic system

Answer 28

What is one of the main functions of the urinary system?
Select one:
a. Responsible for release of adrenaline
b. Responsible for regulation of blood volume and composition*
c. Responsible for insulin release
d. Responsible for drainage of lymphatic system

Question 29

What is the role of the ureter in the prevention of reflux of urine?
Select one:
a. Acts as a valve-like mechanism to prevent reflux due to muscle contraction and angle of entry
b. Blocks off upwards-heading urine by use of sphincter control
c. The kidney connection to the ureter has a one-way valve
d. The ureter spasms and contracts, blocking off entry to the kidney

Answer 29

What is the role of the ureter in the prevention of reflux of urine?
Select one:
a. Acts as a valve-like mechanism to prevent reflux due to muscle contraction and angle of entry *
b. Blocks off upwards-heading urine by use of sphincter control
c. The kidney connection to the ureter has a one-way valve
d. The ureter spasms and contracts, blocking off entry to the kidney

Question 30

When is the bladder NOT palpable on abdominal examination?
Select one:
a. The bladder is never palpable.
b. Before the patient has voided
c. After the patient has voided 
d. The bladder is always palpable.

Answer 30

When is the bladder NOT palpable on abdominal examination?
Select one:
a. The bladder is never palpable.
b. Before the patient has voided
c. After the patient has voided*
d. The bladder is always palpable.

Question 31

When palpating the abdomen of a 20-year-old patient, the nurse notes the presence of tenderness in the left upper quadrant with deep palpation. Which of the following structures is most likely to be involved?
Select one:
a. Spleen 
b. Sigmoid
c. Appendix
d. Gallbladder

Answer 31

When palpating the abdomen of a 20-year-old patient, the nurse notes the presence of tenderness in the left upper quadrant with deep palpation. Which of the following structures is most likely to be involved?
Select one:
a. Spleen *
b. Sigmoid
c. Appendix
d. Gallbladder

Question 32

Which of the following is a normal finding in the abdominal assessment?
Select one:
a. The presence of a bruit in the femoral area
b. A tympanic percussion note in the umbilical region
c. A palpable spleen between the ninth and eleventh ribs in the left midaxillary line
d. A dull percussion note in the left upper quadrant at the midclavicular line

Answer 32

Which of the following is a normal finding in the abdominal assessment?
Select one:
a. The presence of a bruit in the femoral area
b. A tympanic percussion note in the umbilical region *
c. A palpable spleen between the ninth and eleventh ribs in the left midaxillary line
d. A dull percussion note in the left upper quadrant at the midclavicular line

Question 33

While assessing a hospitalised, bedridden patient, the nurse notes that the patient has been incontinent of stool. The stool is loose and grey-tan in colour. The nurse recognises that this finding indicates which of the following?
Select one:
a. Occult blood
b. Inflammation
c. Absent bile pigment 
d. Ingestion of iron preparations

Answer 33

While assessing a hospitalised, bedridden patient, the nurse notes that the patient has been incontinent of stool. The stool is loose and grey-tan in colour. The nurse recognises that this finding indicates which of the following?
Select one:
a. Occult blood
b. Inflammation
c. Absent bile pigment *
d. Ingestion of iron preparations

Question 34

A 60-year-old male patient has been treated for pneumonia for the past 6 weeks. He is seen today in the clinic for an ‘unexplained’ weight loss of 4 kilograms over the last 6 weeks. The nurse knows that:
Select one:
a. his weight loss is probably from unhealthy eating habits.
b. chronic diseases such as hypertension cause weight loss.
c. unexplained weight loss often accompanies short-term illnesses.
d. his weight loss is probably the result of a mental health dysfunction.

Answer 34

A 60-year-old male patient has been treated for pneumonia for the past 6 weeks. He is seen today in the clinic for an ‘unexplained’ weight loss of 4 kilograms over the last 6 weeks. The nurse knows that:
Select one:
a. his weight loss is probably from unhealthy eating habits.
b. chronic diseases such as hypertension cause weight loss.
c. unexplained weight loss often accompanies short-term illnesses.*
d. his weight loss is probably the result of a mental health dysfunction.

Question 35

A 70-year-old man has a blood pressure of 150/90 in a lying position, 130/80 in a sitting position, and 100/60 in a standing position. How should the nurse evaluate these findings?
Select one:
a. This is a normal response due to changes in the patient’s position.
b. The change in blood pressure readings is called orthostatic hypotension.
c. The blood pressure reading in the lying position is within normal limits.
d. The change in blood pressure reading is considered within normal limits for the patient’s age.

Answer 35

A 70-year-old man has a blood pressure of 150/90 in a lying position, 130/80 in a sitting position, and 100/60 in a standing position. How should the nurse evaluate these findings?
Select one:
a. This is a normal response due to changes in the patient’s position.
b. The change in blood pressure readings is called orthostatic hypotension. *
c. The blood pressure reading in the lying position is within normal limits.
d. The change in blood pressure reading is considered within normal limits for the patient’s age.

Question 36

During an examination, the nurse notes that a female patient has a round ‘moon' face, central trunk obesity and a cervical hump. Her skin is fragile with bruises. The nurse notes that the patient has which condition?
Select one:
a. Marfan's syndrome
b. Gigantism
c. Cushing's syndrome 
d. Acromegaly

Answer 36

During an examination, the nurse notes that a female patient has a round ‘moon' face, central trunk obesity and a cervical hump. Her skin is fragile with bruises. The nurse notes that the patient has which condition?
Select one:
a. Marfan's syndrome
b. Gigantism
c. Cushing's syndrome *
d. Acromegaly

Question 37

During a nutritional assessment, why is it important for the nurse to ask a patient what medications they are taking?
Select one:
a. Certain drugs can affect the metabolism of nutrients.
b. The nurse needs to assess the patient for allergic reactions.
c. Medications need to be documented on the record for the physician’s review.
d. Medications can affect memory and ability to identify food eaten in the last 24 hours.

Answer 37

During a nutritional assessment, why is it important for the nurse to ask a patient what medications they are taking?
Select one:
a. Certain drugs can affect the metabolism of nutrients. *
b. The nurse needs to assess the patient for allergic reactions.
c. Medications need to be documented on the record for the physician’s review.
d. Medications can affect memory and ability to identify food eaten in the last 24 hours.

Question 38

The nurse has collected the following information on a patient: palpated blood pressure-180; auscultated blood pressure-170/100; apical pulse-60; radial pulse-70. What is the patient's pulse pressure?
Select one:
a. 10
b. 70
c. 80
d. 100

Answer 38

The nurse has collected the following information on a patient: palpated blood pressure-180; auscultated blood pressure-170/100; apical pulse-60; radial pulse-70. What is the patient's pulse pressure?
Select one:
a. 10
b. 70 *
c. 80
d. 100

Question 39

The nurse is performing a general survey. Which finding is considered normal?
Select one:
a. When standing, the patient’s base is narrow.
b. The patient appears older than his stated age.
c. Arm span (fingertip to fingertip) is greater than the height.
d. Arm span (fingertip to fingertip) equals height.

Answer 39

The nurse is performing a general survey. Which finding is considered normal?
Select one:
a. When standing, the patient’s base is narrow.
b. The patient appears older than his stated age.
c. Arm span (fingertip to fingertip) is greater than the height.
d. Arm span (fingertip to fingertip) equals height. *

Question 40

The nurse is providing care for a 68-year-old woman who is complaining of constipation. What concern exists regarding her nutritional status?
Select one:
a. The absorption of nutrients may be impaired.
b. The constipation may represent a food allergy.
c. She may need emergency surgery for the problem.
d. The gastrointestinal problem will increase her caloric demand.

Answer 40

The nurse is providing care for a 68-year-old woman who is complaining of constipation. What concern exists regarding her nutritional status?
Select one:
a. The absorption of nutrients may be impaired. *
b. The constipation may represent a food allergy.
c. She may need emergency surgery for the problem.
d. The gastrointestinal problem will increase her caloric demand.

Question 41

When considering a nutritional assessment, the nurse is aware that the most common anthropometric measurements include:
Select one:
a. height and weight. 
b. leg circumference.
c. biceps skinfold thickness.
d. hip and waist measurement.

Answer 41

When considering a nutritional assessment, the nurse is aware that the most common anthropometric measurements include:
Select one:
a. height and weight. *
b. leg circumference.
c. biceps skinfold thickness.
d. hip and waist measurement.

Question 42

When measuring a patient's body temperature, the nurse keeps in mind that body temperature is influenced by:
Select one:
a. constipation.
b. the patient's emotional state.
c. the diurnal cycle. 
d. the nocturnal cycle

Answer 42

When measuring a patient's body temperature, the nurse keeps in mind that body temperature is influenced by:
Select one:
a. constipation.
b. the patient's emotional state.
c. the diurnal cycle. *
d. the nocturnal cycle

Question 43

Which of the following best describes the concept of mean arterial pressure (MAP)?
Select one:
a. MAP is the pressure of the arterial pulse.
b. MAP reflects the stroke volume of the heart.
c. It is the pressure forcing blood into the tissues, averaged over the cardiac cycle.
d. It is an average of the systolic and diastolic blood pressures and reflects tissue perfusion.

Answer 43

Which of the following best describes the concept of mean arterial pressure (MAP)?
Select one:
a. MAP is the pressure of the arterial pulse.
b. MAP reflects the stroke volume of the heart.
c. It is the pressure forcing blood into the tissues, averaged over the cardiac cycle. *
d. It is an average of the systolic and diastolic blood pressures and reflects tissue perfusion.

Question 44

Which of the following interventions is most appropriate when the nurse is planning nutritional interventions for a healthy, active 74-year-old woman?
Select one:
a. Decrease the amount of carbohydrates to prevent lean muscle catabolism.
b. Increase the amount of soy and tofu in her diet to promote bone growth and reverse osteoporosis.
c. Decrease the number of kilojoules she is eating because of the decrease in energy requirements from loss of lean body mass.
d. Increase the number of kilojoules she is eating because of the increased energy needs of the elderly.

Answer 44

Which of the following interventions is most appropriate when the nurse is planning nutritional interventions for a healthy, active 74-year-old woman?
Select one:
a. Decrease the amount of carbohydrates to prevent lean muscle catabolism.
b. Increase the amount of soy and tofu in her diet to promote bone growth and reverse osteoporosis.
c. Decrease the number of kilojoules she is eating because of the decrease in energy requirements from loss of lean body mass.*
d. Increase the number of kilojoules she is eating because of the increased energy needs of the elderly.

Question 45

A patient has been in the intensive care unit for 10 days. He has just been moved to the medical-surgical unit and the admitting nurse is planning to perform a mental status examination on him. During the tests of cognitive function, the nurse would expect that he:
Select one:
a. may display some disruption in thought content.
b. will state, ‘I am so relieved to be out of intensive care’.
c. will be oriented to place and person but may not be certain of the date.
d. may show evidence of some clouding of his level of consciousness.

Answer 45

A patient has been in the intensive care unit for 10 days. He has just been moved to the medical-surgical unit and the admitting nurse is planning to perform a mental status examination on him. During the tests of cognitive function, the nurse would expect that he:
Select one:
a. may display some disruption in thought content.
b. will state, ‘I am so relieved to be out of intensive care’.
c. will be oriented to place and person but may not be certain of the date. *
d. may show evidence of some clouding of his level of consciousness.

Question 46

During an assessment, the nurse knows that expected assessment findings in the normal adult lung include the presence of:
Select one:
a. adventitious sounds and limited chest expansion.
b. increased tactile fremitus and dull percussion tones.
c. muffled voice sounds and symmetrical tactile fremitus.
d. absent voice sounds and hyperresonant percussion tones.

Answer 46

During an assessment, the nurse knows that expected assessment findings in the normal adult lung include the presence of:
Select one:
a. adventitious sounds and limited chest expansion.
b. increased tactile fremitus and dull percussion tones.
c. muffled voice sounds and symmetrical tactile fremitus *
d. absent voice sounds and hyperresonant percussion tones.

Question 47

During an examination, a patient has just successfully completed the finger-to-nose and the rapid-alternating-movements tests and is able to run each heel down the opposite shin. The nurse will conclude that the patient's \_\_\_\_\_ function is intact.
Select one:
a. occipital
b. cerebral
c. temporal
d. cerebellar

Answer 47

During an examination, a patient has just successfully completed the finger-to-nose and the rapid-alternating-movements tests and is able to run each heel down the opposite shin. The nurse will conclude that the patient's \_\_\_\_\_ function is intact.
Select one:
a. occipital
b. cerebral
c. temporal
d. cerebellar  *

Question 48

The nurse notes that a patient has ulcerations on the tips of the toes and on the lateral ankles. This finding would indicate:
Select one:
a. lymphoedema.
b. Raynaud's disease.
c. arterial insufficiency. 
d. venous insufficiency.

Answer 48

The nurse notes that a patient has ulcerations on the tips of the toes and on the lateral ankles. This finding would indicate:
Select one:
a. lymphoedema.
b. Raynaud's disease.
c. arterial insufficiency. *
d. venous insufficiency.

Question 49

A patient tells the nurse that, ‘Sometimes I wake up at night and I have real trouble breathing. I have to sit up in bed to get a good breath'. When documenting this information, the nurse would note:
Select one:
a. orthopnea.
b. acute emphysema.
c. paroxysmal nocturnal dyspnoea.
d. acute shortness of breath episode.

Answer 49

A patient tells the nurse that, ‘Sometimes I wake up at night and I have real trouble breathing. I have to sit up in bed to get a good breath'. When documenting this information, the nurse would note:
Select one:
a. orthopnea.
b. acute emphysema.
c. paroxysmal nocturnal dyspnoea. *
d. acute shortness of breath episode.

Question 50

Which of the following is included in assessment of general appearance?
Select one:
a. Height
b. Weight
c. Skin colour 
d. Vital signs

Answer 50

Which of the following is included in assessment of general appearance?
Select one:
a. Height
b. Weight
c. Skin colour*
d. Vital signs

Question 51

What would be the first observation you would perform when commencing a general appearance assessment?
Select one:
a. Level of consciousness
b. Nutritional status
c. Personal hygiene
d. Facial expressions

Answer 51

What would be the first observation you would perform when commencing a general appearance assessment?
Select one:
a. Level of consciousness
b. Nutritional status
c. Personal hygiene
d. Facial expressions *