Therapeutic Communication
1. Which cultural group wants hot, hot, cold, cold; yin to their yang?
a. The nurse is caring for a client who insists on having very hot and very cold at each meal. The nurse correctly recognizes this is a health belief in
which cultural group?
1) Chinese Americans
2. If somebody is stressed out during exam – relax them
a. The nurse is providing care to a client in the emergency department who received a breathing treatment earlier. The nurse is now preparing th
client for a procedure and notes that the client is breathing in a shallow manner and the client's hands are trembling. Which action will help
decrease the client's level of anxiety?
1) The nurse should explain all procedures in a calm, reassuring voice.
Skin, Hair & Nails – 2
1. Why would a woman have a full beard?
a. Hirsutism – excess body hair in females on face, chest, abdomen, arms and legs
i. d/t endocrine or metabolic dysfunction
b. The nurse is assessing a female client and notes facial hirsutism. The client asks the nurse, “Why did this happen to me?” Which of the followin
statements is the best nursing response?
i. “You may have some hormone imbalances.”
2. Hypothyroidism question from 1st week quiz – it’s on final
a. If pt has hypothyroidism – they’re movements and cognition are slowed down
b. The nurse is planning care for a client w/ hypothyroidism. Which of the following would be the priority nursing diagnosis for this client?
i. Activity intolerance r/t fatigue
Head, Neck, Related Lymphatics – 11
1. Know if you’re palpating lymph nodes. What’s normal and abnormal?
a. The nurse is performing an assessment of the client’s head and neck. The client requests information about the assessment of her lymph node
Which of the following is the best response?
i. “Sometimes, enlarged lymph nodes indicate an infection”
b. The nurse is palpating an adult client’s neck and does not note any palpable lymph nodes. The nurse understands that this is:
i. A normal finding in adults
2. What will make me worried for nosebleed? what will not make me worried for nosebleed?
a. A client arrives in the emergency room w/ complaints of intermittent nosebleeds for the past two days. Which of the following assessments
would be a priority for the nurse in this situation? HYPERTENSION
i. Request information from the client regarding increased propensity for bruising or bleeding. Obtain a blood pressure. Request info
from client to determine if there was any recent thin, watery drainage from nose
3. What is the leading cause of blindness in US?
a. Diabetic retinopathy
4. Know the differences between nystagmus and ptosis, strabismus, and myopia
a. During the assessment of a client’s eyes, the nurse suspects that the client has ptosis. Which of the following did the nurse most likely find?
i. The eyelid is drooping
b. During an eye examination, the nurse requests that the client read letters located on the Snellen E chart. The client’s vision is determined to be
20/200. Which of the following is true regarding these findings? Select all
i. Client is legally blind. Client is myopic.
c. The nurse is assessing the client’s eye w/ an opthalmoscope. The nurse is preparing to focus on the fundus and rotates the lens diopter wheel
into the negative numbers. Based on this information, which condition does the client most likely have?
i. Myopia
d. After a comprehensive eye exam, it is determined that the client requires corrective lenses for myopia. Which explanation by the nurse to the
client is the most appropriate?
i. Your glasses will help you to see objects in the distance
e. Nystagmus – rapid fluttering of the eyeball caused by CN III damage
f. Ptosis – one eyelid drooping caused by CN III damage
g. Strabismus – axes of the eyes cannot be directed at same object, light is reflected at different axes
i. Esotropia – convergent in which eyes deviate inward
ii. Exotropia – divergent in which the deviation is outward
h. Myopia – nearsightedness, light rays focus in front of retina
Eye –
1. Presbyopia vs hyperopia vs myopia vs astigmatism – know differences
a. During an eye assessment, a young adult client reports difficulty-seeing items within close range. This assessment data is consistent with which
item?
1) Hyperopia
b. Presbyopia – decreased ability of the lens to change shape to accommodate for near vision
c. Hyperopia – farsightedness, light rays focus behind the retina
, d. Astigmatism – familial condition in which the refraction of light is spread over wide area of retina instead of distinct point.
1) Cornea curves more in one direction than another Light is refracted and focused on two focal points on or near retina
2) Blurred or double vision
Ears, Nose, Mouth, Throat –
1. Know what term anosmia is
a. The nurse is performing a neurological assessment on a client experiencing anosmia. Which cranial nerve does the nurse assess to further
investigate this issue?
1) Olfactory (CN 1)
2. #24 is B = rine test (know what rine test is!!)
a. The nurse is discussing the Rinne test to a group of student nurses. Which statement by the nurse is most appropriate?
1) This test compares air and bone conduction of sound using a tuning fork
3. Where is balance in brain? (cerebellum) 747
a. Coordinates stimuli from the cerebral cortex to provide precise timing for skeletal muscle coordination and smooth movements
b. Assists w/ maintaining equilibrium and muscle tone
c. Receives info about body position from inner ear and then sends impulses to muscles, whose contraction maintains or restores balance
Respiratory System – 5
1. If I go in and tell somebody that I’m taking their vitals – do I tell them everything that I’m doing?
a. The nurse is assessing the client's respiratory system. Which method will result in the most accurate assessment of the client's respiratory rate
1) The nurse should count the respirations in an unobtrusive manner w/o informing the client.
2. You got a big hairy man – you’re listening to cardiac and you hear crackles what do you do?
a. During auscultation of the breath sounds of an adult male client, the nurse hears crackling sounds over most of the chest. Which of the
following would be the best action for the nurse to take next?
1) Wet the chest hair before auscultating the chest.
3. How does nicotine act on BP? What does it do?
a. The client is visiting the HCP’s office for a head-to-toe assessment. During the nurse’s assessment of the client’s skin, the nurse notes that the
client is pale. Which of the following findings may be related to the client’s color? Select all
1) Client’s BP is 96/62,
2) The client states, “I just smoked a cigarette before I came in the office”
3) The client’s O2 sats is 86% on room air
4) The client states, “It is snowing again outside w/ a wind chill factor of -11 degrees F”.
b. Nicotine is vasoconstrictor (constricts BV BP), aggravates peripheral vascular disease
Breasts & Axillae – 3
1. Why would you have pt sitting and lean forward vs laying down arm over head?
a. The nurse is teaching self-breast examination to a client and demonstrates inspecting the breasts with arms over the head. The client asks the
nurse why this is necessary. Which response by the nurse is the most appropriate?
1) “This is the best position to look for skin dimpling."
2. Breast Health and Screenings – different cultures
a. The nurse is conducting a breast health workshop for a group of women. Which would the nurse include in this workshop when outlining risk
factors for breast cancer? Select all that apply.
1) Caucasians, Family hx, low socioeconomic status, HRT therapy
CV System – 8
1. Know what a normal heart sound is in elderly pts
a. In the cardiac assessment of a 78 y/o client w/ no history of CV disease, the nurse hears a soft sound directly before S1, at the apex of the hear
with the bell of the stethoscope. There is no change in this sound w/ position or respirations. The nurse would implement which of the
following actions for this client?
1) Document the finding as normal in older adults
b. The nurse is performing a cardiac assessment on a healthy elderly adult client. Which of the following findings may be expected when
compared to when the client was middle-aged? (Select all that apply)
1) Systolic murmur, increased systolic BP, increased stroke volume, slight decrease in HR
2. Know the auscultation differences of, sounds of, and definitions of stenosis, murmur, bruit (489)
a. The nurse is assessing a client and notes a loud, blowing sound over the right carotid artery. Based on this data, which diagnosis does the nurse
anticipate?
1) Stricture of the carotid
b. The nurse is auscultating the temporal artery and hears a soft blowing sound. Which term will the nurse use when documenting this finding?
1) Bruit
c. The nurse is auscultating the thyroid gland and notes a bruit. Which conclusion by the nurse is appropriate based on this assessment finding?
1) Indicates increased blood flow
3. If you have hx of syncope, what are nursing interventions to keep patient safe?
1. Which cultural group wants hot, hot, cold, cold; yin to their yang?
a. The nurse is caring for a client who insists on having very hot and very cold at each meal. The nurse correctly recognizes this is a health belief in
which cultural group?
1) Chinese Americans
2. If somebody is stressed out during exam – relax them
a. The nurse is providing care to a client in the emergency department who received a breathing treatment earlier. The nurse is now preparing th
client for a procedure and notes that the client is breathing in a shallow manner and the client's hands are trembling. Which action will help
decrease the client's level of anxiety?
1) The nurse should explain all procedures in a calm, reassuring voice.
Skin, Hair & Nails – 2
1. Why would a woman have a full beard?
a. Hirsutism – excess body hair in females on face, chest, abdomen, arms and legs
i. d/t endocrine or metabolic dysfunction
b. The nurse is assessing a female client and notes facial hirsutism. The client asks the nurse, “Why did this happen to me?” Which of the followin
statements is the best nursing response?
i. “You may have some hormone imbalances.”
2. Hypothyroidism question from 1st week quiz – it’s on final
a. If pt has hypothyroidism – they’re movements and cognition are slowed down
b. The nurse is planning care for a client w/ hypothyroidism. Which of the following would be the priority nursing diagnosis for this client?
i. Activity intolerance r/t fatigue
Head, Neck, Related Lymphatics – 11
1. Know if you’re palpating lymph nodes. What’s normal and abnormal?
a. The nurse is performing an assessment of the client’s head and neck. The client requests information about the assessment of her lymph node
Which of the following is the best response?
i. “Sometimes, enlarged lymph nodes indicate an infection”
b. The nurse is palpating an adult client’s neck and does not note any palpable lymph nodes. The nurse understands that this is:
i. A normal finding in adults
2. What will make me worried for nosebleed? what will not make me worried for nosebleed?
a. A client arrives in the emergency room w/ complaints of intermittent nosebleeds for the past two days. Which of the following assessments
would be a priority for the nurse in this situation? HYPERTENSION
i. Request information from the client regarding increased propensity for bruising or bleeding. Obtain a blood pressure. Request info
from client to determine if there was any recent thin, watery drainage from nose
3. What is the leading cause of blindness in US?
a. Diabetic retinopathy
4. Know the differences between nystagmus and ptosis, strabismus, and myopia
a. During the assessment of a client’s eyes, the nurse suspects that the client has ptosis. Which of the following did the nurse most likely find?
i. The eyelid is drooping
b. During an eye examination, the nurse requests that the client read letters located on the Snellen E chart. The client’s vision is determined to be
20/200. Which of the following is true regarding these findings? Select all
i. Client is legally blind. Client is myopic.
c. The nurse is assessing the client’s eye w/ an opthalmoscope. The nurse is preparing to focus on the fundus and rotates the lens diopter wheel
into the negative numbers. Based on this information, which condition does the client most likely have?
i. Myopia
d. After a comprehensive eye exam, it is determined that the client requires corrective lenses for myopia. Which explanation by the nurse to the
client is the most appropriate?
i. Your glasses will help you to see objects in the distance
e. Nystagmus – rapid fluttering of the eyeball caused by CN III damage
f. Ptosis – one eyelid drooping caused by CN III damage
g. Strabismus – axes of the eyes cannot be directed at same object, light is reflected at different axes
i. Esotropia – convergent in which eyes deviate inward
ii. Exotropia – divergent in which the deviation is outward
h. Myopia – nearsightedness, light rays focus in front of retina
Eye –
1. Presbyopia vs hyperopia vs myopia vs astigmatism – know differences
a. During an eye assessment, a young adult client reports difficulty-seeing items within close range. This assessment data is consistent with which
item?
1) Hyperopia
b. Presbyopia – decreased ability of the lens to change shape to accommodate for near vision
c. Hyperopia – farsightedness, light rays focus behind the retina
, d. Astigmatism – familial condition in which the refraction of light is spread over wide area of retina instead of distinct point.
1) Cornea curves more in one direction than another Light is refracted and focused on two focal points on or near retina
2) Blurred or double vision
Ears, Nose, Mouth, Throat –
1. Know what term anosmia is
a. The nurse is performing a neurological assessment on a client experiencing anosmia. Which cranial nerve does the nurse assess to further
investigate this issue?
1) Olfactory (CN 1)
2. #24 is B = rine test (know what rine test is!!)
a. The nurse is discussing the Rinne test to a group of student nurses. Which statement by the nurse is most appropriate?
1) This test compares air and bone conduction of sound using a tuning fork
3. Where is balance in brain? (cerebellum) 747
a. Coordinates stimuli from the cerebral cortex to provide precise timing for skeletal muscle coordination and smooth movements
b. Assists w/ maintaining equilibrium and muscle tone
c. Receives info about body position from inner ear and then sends impulses to muscles, whose contraction maintains or restores balance
Respiratory System – 5
1. If I go in and tell somebody that I’m taking their vitals – do I tell them everything that I’m doing?
a. The nurse is assessing the client's respiratory system. Which method will result in the most accurate assessment of the client's respiratory rate
1) The nurse should count the respirations in an unobtrusive manner w/o informing the client.
2. You got a big hairy man – you’re listening to cardiac and you hear crackles what do you do?
a. During auscultation of the breath sounds of an adult male client, the nurse hears crackling sounds over most of the chest. Which of the
following would be the best action for the nurse to take next?
1) Wet the chest hair before auscultating the chest.
3. How does nicotine act on BP? What does it do?
a. The client is visiting the HCP’s office for a head-to-toe assessment. During the nurse’s assessment of the client’s skin, the nurse notes that the
client is pale. Which of the following findings may be related to the client’s color? Select all
1) Client’s BP is 96/62,
2) The client states, “I just smoked a cigarette before I came in the office”
3) The client’s O2 sats is 86% on room air
4) The client states, “It is snowing again outside w/ a wind chill factor of -11 degrees F”.
b. Nicotine is vasoconstrictor (constricts BV BP), aggravates peripheral vascular disease
Breasts & Axillae – 3
1. Why would you have pt sitting and lean forward vs laying down arm over head?
a. The nurse is teaching self-breast examination to a client and demonstrates inspecting the breasts with arms over the head. The client asks the
nurse why this is necessary. Which response by the nurse is the most appropriate?
1) “This is the best position to look for skin dimpling."
2. Breast Health and Screenings – different cultures
a. The nurse is conducting a breast health workshop for a group of women. Which would the nurse include in this workshop when outlining risk
factors for breast cancer? Select all that apply.
1) Caucasians, Family hx, low socioeconomic status, HRT therapy
CV System – 8
1. Know what a normal heart sound is in elderly pts
a. In the cardiac assessment of a 78 y/o client w/ no history of CV disease, the nurse hears a soft sound directly before S1, at the apex of the hear
with the bell of the stethoscope. There is no change in this sound w/ position or respirations. The nurse would implement which of the
following actions for this client?
1) Document the finding as normal in older adults
b. The nurse is performing a cardiac assessment on a healthy elderly adult client. Which of the following findings may be expected when
compared to when the client was middle-aged? (Select all that apply)
1) Systolic murmur, increased systolic BP, increased stroke volume, slight decrease in HR
2. Know the auscultation differences of, sounds of, and definitions of stenosis, murmur, bruit (489)
a. The nurse is assessing a client and notes a loud, blowing sound over the right carotid artery. Based on this data, which diagnosis does the nurse
anticipate?
1) Stricture of the carotid
b. The nurse is auscultating the temporal artery and hears a soft blowing sound. Which term will the nurse use when documenting this finding?
1) Bruit
c. The nurse is auscultating the thyroid gland and notes a bruit. Which conclusion by the nurse is appropriate based on this assessment finding?
1) Indicates increased blood flow
3. If you have hx of syncope, what are nursing interventions to keep patient safe?
