SOLUTIONS
A 23-year-old nulliparous woman is concerned that her breasts
seem to change in size all month long and they are very tender
around the time she has her period. The nurse should explain to
her that
a. nonpregnant women usually do not have these breast changes
and this is cause for concern.
b. breasts often change in response to stress so it is important to
assess her life stressors.
c. cyclical breast changes are normal.
d. breast changes normally occur during pregnancy and she
should have a pregnancy test. Correct Answers c
A 3-year-old boy is brought to the emergency department with
stridor, nasal flaring, intercostal and supraclavicular retractions,
and respiratory rate of 40 breaths/min. What type of situation is
this?
a. Stable
b. Acute
c. Urgent
d. Emergency Correct Answers d
A 45-year-old man has been admitted to the hospital with
suspicion of pulmonary embolism. Which of the following
symptoms should the nurse report to the primary health
practitioner immediately?
a. Chest pain
b. Shortness of breath
c. Respirations 20 breaths/min
,d. Productive cough Correct Answers a
A 62-year-old woman comes to the clinic with an exacerbation
of asthma. Which of the following findings indicate worsening
status of her asthma?
a. Increased wheezing
b. Sustained rhonchi
c. Decreased respirations
d. Pulse oximetry 94% Correct Answers a
A 92-year-old woman with a history of COPD presents with
increasing shortness of breath, decreased lung sounds in the
bases, increased ankle edema, and 5-lb weight gain in 1 week.
What is the most likely problem?
a. Impaired gas exchange
b. Ineffective airway clearance
c. Activity intolerance
d. fluid volume excess Correct Answers d
A dorsalis pedis of +1/4 may indicate
a. DVT.
b. PAD.
c. Raynaud disease.
d. lymphadenopathy Correct Answers b
A high-pitched crowing sound from the upper airway (stridor)
results from:
a. Aspiration of foreign object
b. Tracheal / laryngeal spasm
c. All of the above
d. Tracheal / laryngeal inflammation Correct Answers c
, A history of smoking has an extremely significant role in the
development of which of the following?
a. Venous insufficiency
b. DVT
c. PAD
d. Raynaud disease Correct Answers c
A male patient presents to the clinic with a complaint of a hard,
irregular, nontender mass on his chest under the areola. Upon
examination, the nurse notes that the mass is immobile and
suspects
a. gynecomastia.
b. benign lesion.
c. Paget disease.
d. carcinoma. Correct Answers d
A patient has a sternum that is displaced anteriorly, depressing
the adjacent costal cartilages. (Chest seems narrow, and pushed
forward) this is:
a. Pectus excavatum (funnel chest)
b. Pectuc carinatum (pigeon chest)
c. Flail chest
d. Barrel chest Correct Answers b
A patient has dyspnea, edema, weight gain, and liquid intake
greater than output. These symptoms are consistent with which
nursing diagnosis?
a. Ineffective cardiac tissue perfusion
b. Decreased cardiac output
c. Impaired gas exchange