NURS 104 Questions (PDF)

NURS 104 QUESTIONS WEEK 1-6 Week 1 5 Questions Interviewing Health history Communication Documentation Week 2 10 Questions General Survey Vital Signs Symptom and Pain Assessment Assessment techniques Week 3 7 Questions Thorax and Lungs Week 4 8 Questions Heart and Neck Vessels PV Week 5 5 Questions Head Face and neck Regional Lymphatic System Eyes Ears Nose Mouth Throat Week 6 2 Questions MSK 1. Which information is an example of objective data? A. Clients history of allergies B. Client's use of medications at home C. Last menstrual period 1month ago D. 2.5 cm scar on the right lower forearm 2. Which of the following is the most reliable indicator for pain? A. Magnetic resonance imaging results (MRI) B. The client's description of pain C. Tissue enzyme levels D. Blood drug levels 3. Which information does the review of systems section provide in the complete health history? A. Objective findings related to each system B. Subjective data related to each system C. An opportunity to teach the client medical terms D. Information necessary for the nurse to diagnose the medical concern 4. Which statement represents subjective data obtained from the client regarding their skin? A. Skin appears dry B. No lesions are noted on the skin C. Client denies any colour change D. Lesion is noted on the lateral aspect of the right arm 5. Which assessment findings would require immediate attention by the nurse for an adult client? (Select all that apply.) A. Temperature: 38.9°C B. Systolic blood pressure (BP): 130 mm Hg C. Respiratory rate: 18 breaths per minute D. Heart rate: 130 beats per minute 6. The nurse is assessing the apical pulse of a 3-month-old infant and finds that the heart rate is 12 beats per minute. The nurse interprets this result as: A. Higher than expected, probably as a result of crying B. Normal for this age C. Higher than expected, reflecting persistent tachycardia D. Lower than expected 7. The nurse is preparing to perform a physical assessment on a hospitalized patient. What sequence should the nurse use? A. The nurse should introduce himself or herself and then put on gloves. B. The nurse should introduce himself or herself and perform the inspection first, followed by auscultation. C. The nurse should introduce himself or herself and wash his or her hands. D. The nurse should introduce himself or herself, explain the procedure, and then put on gloves. 8. The nurse is preparing to verbally communicate a change in patient status to another health care provider. Which of the following frameworks should the nurse use to organize her communication? A. SOAP B. SBAR C. Narrative charting D. Discharge reporting Chapter 4 & 5 Review MCQ 1. When reading a medical record, you see the following notation: Patient states, “I have had a cold for about a week, and now I am having difficulty breathing.” This is an example of: a. past history. b. a review of systems. c. a functional assessment. d. a reason for seeking care. 2. You have reason to question the reliability of the information being provided by a patient. One way to verify the reliability within the context of the interview is to: a. rephrase the same questions later in the interview. b. review the patient's previous medical records. c. call the person identified as emergency contact to verify data provided. d. provide the patient with a printed history to complete and then compare the data provided. 3. The statement “Reason for seeking care” has replaced the “chief complaint.” This change is significant because: a.“chief complaint” is really a diagnostic statement. b. the newer term allows another individual to supply the necessary information. c. the newer term incorporates wellness needs. d. “Reason for seeking care” can incorporate the history of present illness. 4. During an initial interview, the examiner says, “Mrs. J., tell me what you do when your headaches occur.” With this question, the examiner is seeking information about: a. the patient's perception of the problem. b. aggravating or relieving factors. c. the frequency of the problem. d. the severity of the problem. 5. A genogram is useful in showing information concisely. It is used specifically for: a. past history. b. past health history, specifically hospitalizations. c. family history. d. the eight characteristics of presenting symptoms. 6. Select the best description of “review of systems” as part of the health history. a. the evaluation of the past and present health state of each body system b. a documentation of the problem as described by the patient c. the recording of the objective findings of the practitioner d. a statement that describes the overall health state of the patient 14. The nurse is assessing an 87-year-old client's vital signs. The nurse riotio 126 bpm. What should the nurse do next? A. Take a full set of vital signs B. Ask another nurse to retake her pulse C. Take the apical pulse for a full minute D. Ask a RN to take charge of the client 15. What aspects of the pulse rate are assessed? A. Rate, rhythm, force, strength B. Rate, regularity, fullness, elasticity C. Rate, rhythm, force, size D. Rate, regularity, fullness, strength 16. After taking a nap in a supine position, a 70-year-old client immediately stands up to turn on the television. Based on her developmental stage, which of the following conditions could this client be experiencing with this sudden postural change? A. Orthostatic hypotension B. Extra-cardiac signs C. Pre-hypertension D. Hypertension 17. The client has been experiencing pain for the past two days and has come in for an assessment. The client suddenly experiences another acute pain episode. The nurse notes that the client is tachycardic and has an increased blood pressure. The client becomes concerned and asks the nurse what is happening. What would be the nurse's best response? A. "This is your body's reaction to acute pain" B. "This seems to be the beginning stages of a heart attack. I'll call the doctor' C. "This may be an indication of the initial stages of hypertension" D. "This may indicate some cardiac issues that need to be further investigated" 18. Which of the following is true regarding pain in children? A. Infants have the same capacity for pain as do adults B. Preverbal infants do not remember pain C. Children older than 2 years of age can accurately rate pain intensity D. Children will exaggerate their descriptions of pain in the presence of a health care provider 19. Which of the following should the nurse anticipate when caring for a 50-year-old client complaining of pain. A. A normal pulse rate range B. A decrease in body temperature C. An elevated blood pressure D. A decrease in oxygen saturation rate 20. When performing a physical assessment, which techinique would the nurse use first? A. Palpation B. Inspection C. Percussion D. Auscultation 21. A 42 yr old client, in the clinic for monitoring of his BP readings over the past 2 months. They range from 124/84 to 130/82 mmHg, with an average reading of 128/80 mm Hg. In which BP category does this fall in? A. Normal Blood Pressure B. Requires monthly monitoring C. Potential for hypotension D. Diagnosis of hypertension 22. Which position would indicate to the nurse that a client with COPD is having difficulty breathing? A. Fowlers B. Trendelenburg C. Tripod D. Prone 23. Which of the following techniques involves using the sense of hearing when assessing a client? A. Palpation B. Inspection C. Percussion D. Auscultation 24. When inspecting the anterior chest of an adult for a respiratory assessment, the nurse should include which assessment? A. Diaphragmatic excursion B. Symmetrical chest expansion C. Presence of breath sounds D. Shape and configuration of the chest wall 25. When using the mnemonic OPQRSTUV to help remember all the points of a client's perception of his or her problem, what does the "S" signify? A. Swelling B. Subjectivity C. Severity D. Symptoms 26.A client complains of difficulty breathing. On auscultation, the nurse finde that there is a high pitched, inspiratory crowing sound. What would best describe this type of adventitious sound? A. a. Dyspnea B. b.Stridor C. Wheeze D. Atelectasis 27. What is important to remember when auscultating a client's breath sounds? A. Ensure total silence in exam room B. Auscultate for bilateral comparison C. Ensure the room is at body temperature D. Auscultate the posterior chest first 28. The nurse notes a high-pitched musical note in a client's breath sounds. How should the nurse document this finding? A. Crackles B. Stridor C. Wheezes D. Normal breath sound 29. Which two breath sounds are only found when auscultating the posterior chest? A. Bronchovesicular and vesicular B. Tracheal and bronchial C. Bronchial and vesicular D. Bronchial and bronchovesicular 30. Which of the following is important for the nurse to remember when conducting a thoracic assessment on an elderly client? A. The client may fatigue easily during auscultation when asked to take deep breaths B. The client may have more respiratory problems and requires a more extensive exam C. The client may not tolerate the length of exam; thus, the exam should be left for the doctor D. The client may feel pain during palpation on the chest due to the loss of muscle 31. The primary respiratory muscles engaged in normal inspiration include which structure? A. Diaphragm and intercostal B. Sternomastoid and scalene C. Trapezius and rectus abdominis D. External obliques and pectoralis major Rapid breathing is known as which of the following A. Tachypnea B. Hypoxemia C. Fremitus D. Tachycardia 34. The predominant sound heard when percussing over healthy lung tissue. A. Orthopnea B. Resonance C. Hyperresonance D. Tachycardia 35. The nurse begins to assess a 66-year-old client's heart sounds. Which action is used to assess her apical pulse? A. Auscultate for 30 seconds B. Palpate using fingertips C. Landmark at the aortic site D. Auscultate for 60 seconds 36. Which of the following precautions is necessary when palpating the carotid pulses? A. Palpate one pulse at a time B. Bilateral palpation over the neck region C. Position the client on there right side D. Observe for dysrhythmias 37. Which statements demonstrate understanding of auscultating the cardiac region of the precordium (select all that apply). A. High-pitched sounds are best heard with the diaphragm of the stethoscope. B. S2 heart sound represents the start of diastole and closure of the semilunar heart valves C. Bruits are abnormal sounds heard at the apex of the heart during atrial contraction D. There are 3 sites for cardiac auscultation centered around the heart valves 38. When listening to heart sounds, which valve closures can be best heard at the base of the heart? A. Mitral and tricuspid B. Tricuspid and aortic C. Aortic and pulmonic D. Mitral and pulmonic 40. Prior to administering specific cardiovasoular medications, the nurse must check the rate of the apical pulse in which location? A. Third left intercostal space at the Midclavicular line B. Fourth left intercostal space at the sternal border C. Fourth left intercostal space at the anterior axillary line D. Fifth left intercostal space at the Midclavicular 41. Which knowledge will the nurse have when listening to the S1 heart sound? A. It is louder than S2 at the base of the heart. B. Indicates the beginning of diastole. C. Coincides with the carotid artery pulse. D. Is caused by the closure of the semilunar valves 42. A client is concerned about her enlarged lymph nodes after experiencing a severe case of the flu a few days ago. The nurse palpates her lymph nodes. Which data would be most concerning and would warrant immediate follow-up? A. Enlarged nodes 0.5 cm in size B. Lymph nodes that are non-tender to touch C. Lymph nodes that are non-moveable D. Soft lymph nodes, non-tender to touch 43. While inspecting a client's tympanic membrane. Which color would be considered normal? A. Bright pink membrane B. Pearly grey membrane C. Bluish tinged membrane D. Yellow waxy membrane 44. The nurse is preparing to test the visual acuity of a client using the Snellen Chart. Which of the following identifies the accurate procedure for this test? A. Both eyes are assessed together, followed by the right eye B. The right eye is tested followed by the left eye, and then both eyes tested together C. The client is asked to stand 40 feet from the chart D. The client is asked to stand 30 feet from the chart 45. Which of the following instruments would be used to assess the client's external auditory canal tympanic membrane? A. Ophthalmoscope B. Tuning fork C. Otoscope D. Percussion hammer 46. Select the statement that best describes a normal lymph node? A. Movable, soft, and non-tender B. Movable, firm, and tender C. Immovable, soft, and tender D. Immovable, firm, and non-tender 47. A 5-year-old child's throat is being inspected and the nurse notes that the tonsils are rough surfaced, pink in color, with indentations and graded as 2+. What would the nurse document this as? A. Requirement for a follow up assessment B. Abnormal finding for a 5-year-old child C. Normal finding for a 5-year-old child D. Indication of an acute infection 48. Which one of the following is a normal finding when inspecting the mouth of an adult client? A. Tonsils touch each other and are covered with exudate B. Pink slightly rough tongue with a midline depression C. Pink moist gingivae with localize edema D. The soft palate and uvula are enlarged as the client says "ah" 49. During ocular examinations, the nurse assesses the movement of the extracular muscles by stimulating which of the following? A. Cranial nerves VII and VIII B. The ciliary body C. The corneal reflex D. Cranial nerves III, IV, and VI 50. Which statement represents a normal finding when testing for visual accommodation? A. Pupillary constriction when looking at a near object B. Pupillary dilation when looking at a far object C. Changes in peripheral vision in response to light D. Involuntary blinking in the presence of bright light 51. Which statement reflects a normal pupillary light reflex during assessment? A. The eyes converge to focus on the light. B. Light is reflected at the same spot in both eyes. C. The eye focuses the image on the centre of the pupil. D. Constriction of both pupils occurs in response to bright light 52. The nurse is assessing a client with potential hearing loss. Which statement reflects air conduction? A. Air conduction is the normal pathway for hearing B. Vibrations of the bones in the skull cause air conduction C. Amplitude of sound determines the pitch that is heard D. Loss of air conduction is called a conductive hearing loss 53. How will the nurse position a client to inspect the vertebral column? A. Supine B. Prone C. Standing D. Kneeling 54. When performing a MSK assessment what does the nurse need to keep in mind? A. Perform tests on painful areas first B. Perform the entire MSK exam in full C. Perform muscle testing after ROM testing D. Compare findings bilaterally 55.A client has an S-shaped curvature on her thoracic and lumbar spine. What would the nurse document this as? A. Kyphosis B. Scoliosis C. Lordosis D. Barrel Chest 56. The nurse wants to check the ROM of a client's knee. Which movements are the knees able to make? A. Supination and pronation B. Inversion and extension C. Supination and flexion D. Flexion and extension 57. What assessment technique would the nurse use to assess for the presence of crepitus during an MSK exam? A. Percussion B. Auscultation C. Inspection D. Palpation

NURS 104 Questions (PDF)

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