Exam Two Study Questions and answers
2024 update A+ graded
A 33-year-old male client returns to the medical-surgical unit following a thyroidectomy.
Which assessment finding requires an immediate intervention by the nurse?
-The client makes noises when he breathes.
-The client is sleepy from the anesthesia.
-The client reports thirst.
-The client reports pain at the surgical site. - answer the client makes noises when he
breathes.
A 54-year-old man is found to be anemic. Which of the following nursing diagnoses is
most likely to be recorded in his plan of care?
Fatigue
Decreased activity level
Altered nutrition
Depression - answer Fatigue
A 56-year-old client with Mexican heritage has a diagnosis of heart failure. The nurse's
morning lung assessment of the client reveals crackles in the mid to lower lungs and
respiratory rate of 32. The nurse notices that the client is restless, and his skin has an
ashen appearance. Which nursing action is the priority intervention? - answer
Measure the pulse oximetry.
A 63-year-old nurse comes to the office upset because she has found an enlarged
lymph node under her right arm. She states she found it last week while taking a
shower. She isn't sure if she has any breast lumps because she doesn't know how to do
self-breast examinations. She states her last mammogram was 5 years ago and it was
normal. Her past medical history is significant for high blood pressure and chronic
obstructive pulmonary disease. She quit smoking 2 years ago after a 55-pack a year
history. She denies any illegal drugs and drinks alcohol rarely. Her mother died of a
heart attack and her father died of a stroke. She has no children. Examination shows an
older woman appearing her stated age. Visual inspection of her right axilla reveals
nothing unusual. Palpation reveals a 2-cm hard fixed lymph node. She denies any
,tenderness. Visualization of both breasts is normal. Palpation of her left axilla and
breast is - answer Breast Cancer
A 66-year-old female client is reporting abdominal pain. The nurse assesses the client's
abdomen by first inspecting the abdomen. What should the nurse do next?
Palpate the abdomen.
Auscultate the abdomen.
Percuss the abdomen.
Measure abdominal girth. - answer Auscultate the abdomen.
A 66-year-old woman has come to the clinic with complaints of increasing fatigue over
the last several months. She claims to frequently feel lethargic and listless and states
that, "I can never seem to get warm, no matter what the thermostat is set at." How
should the nurse proceed with assessment?
Assess for other signs and symptoms of Cushing's syndrome.
Assess the woman for hypothyroidism.
Order tests to rule out an overactive thyroid gland.
Palpate the woman's parotid gland for enlargement. - answer Assess the woman for
hypothyroidism.
A 73-year-old woman comes to the office for evaluation of new onset of tremors. She is
not taking any medications, herbs, or supplements. She has no chronic medical
conditions. She does not smoke or drink alcohol. She walks into the examination room
with slow, shuffling steps. She has decreased facial mobility with a blunt expression
without any changes in hair distribution on her face. Based on this description, what is
the most likely reason for the client's symptoms?
Cushing's syndrome
Myxedema
Parkinson's disease
Nephrotic syndrome - answer Parkinson's disease
A client comes to the clinic and reports pain when he touches his ear. With what is this
finding most consistent?
Otitis externa
Otitis media
Acoustic neuroma
Meniere disease - answer Otitis externa
A client comes to the emergency department reporting a sudden onset of dyspnea.
What finding is a manifestation of dyspnea?
Painful breathing
Inability to breathe
,Shortness of breath
Rapid breathing - answer Shortness of breath
A client complains of abdominal pain with cramping diarrhea, nausea, vomiting, weight
loss, and loss of energy. The nurse should suspect which of the following as the
underlying cause?
Pancreatitis
Gastroesophageal reflux
Crohn's disease
Gastric ulcer - answer Crohn's disease
A client complains of difficulty sleeping, stating he has to sit up with the help of several
pillows and cannot breathe when lying flat. This client has a condition known as what?
Tachypnea
Pneumonia
Orthopnea
Sleep apnea - answer Orthopnea
A client complains of recurring headaches that are worse when first waking in the
morning and with coughing or sneezing. What would be the nurse's most appropriate
action?
Ask the doctor for an order for an MRI
Perform a focused assessment
Prepare the client for a spinal tap
Perform a generalized assessment - answer Perform a focused assessment
A client has been diagnosed with candidiasis and prescribed fluconazole 20 mg PO
now, following by 10 mg PO daily. What is the nurse's best action
Assess the client's baseline renal function
Assess the client's skin integrity and administer the medication as prescribed
Question the provider about the prescribed dose
Confirm the client's allergy status - answer Question the provider about the
prescribed dose
A client has been placed on amphotericin B. The nurse caring for this client should
administer this medication:
intramuscularly.
intravenously.
subcutaneously.
orally. - answer intravenously
, A client has been reporting persistent headaches. Which is an example of subjective
data? - answer Pain is 4 out of 10 on a pain scale.
A client in the ED tells the nurse that she is having difficulty breathing at rest. What term
would the nurse use in documenting this finding?
Tachypnea
Anxiety
Dyspnea
Shortness of breath - answer Dyspnea
A client is explaining to the nurse how vaginal dryness has decreased her enjoyment of
sexual intercourse. The nurse is aware that which of the following are the glands that
produce mucus that lubricates the vagina during intercourse?
Sebaceous glands
Bartholin's glands
Cowper's glands
Eccrine glands - answer Bartholin's glands
A client presents at the clinic complaining of a loss of balance. What test should the
nurse expect the physician to carry out on a client with a loss of balance?
Romberg test
Audiometric test
Weber test
Rinne test - answer Romberg test
A client presents to the health care clinic and reports pain in the eyes when working on
the computer for long periods of time. The client states that he almost ran into a parked
car yesterday because he misjudged the distance from the bumper of his own car. He
works for a computer software company and has noticed he is experiencing difficulty
reading the manuals that accompany the software he installs for companies. What
nursing diagnosis can the nurse confirm based on this data?
Disturbed Self Concept
Risk for Injury
Self-Care Deficit
Ineffective Individual Coping - answer Risk for Injury
A client presents to the health care clinic with a 3-week history of pain and swelling of
the right foot. A nurse inspects the foot and observes swelling and a large ulcer on the
heel. The client reports the right heel is very painful and he has trouble walking. Which
nursing diagnosis should the nurse confirm from these data?
Risk for Skin Breakdown
Fear of Loss of Extremity
2024 update A+ graded
A 33-year-old male client returns to the medical-surgical unit following a thyroidectomy.
Which assessment finding requires an immediate intervention by the nurse?
-The client makes noises when he breathes.
-The client is sleepy from the anesthesia.
-The client reports thirst.
-The client reports pain at the surgical site. - answer the client makes noises when he
breathes.
A 54-year-old man is found to be anemic. Which of the following nursing diagnoses is
most likely to be recorded in his plan of care?
Fatigue
Decreased activity level
Altered nutrition
Depression - answer Fatigue
A 56-year-old client with Mexican heritage has a diagnosis of heart failure. The nurse's
morning lung assessment of the client reveals crackles in the mid to lower lungs and
respiratory rate of 32. The nurse notices that the client is restless, and his skin has an
ashen appearance. Which nursing action is the priority intervention? - answer
Measure the pulse oximetry.
A 63-year-old nurse comes to the office upset because she has found an enlarged
lymph node under her right arm. She states she found it last week while taking a
shower. She isn't sure if she has any breast lumps because she doesn't know how to do
self-breast examinations. She states her last mammogram was 5 years ago and it was
normal. Her past medical history is significant for high blood pressure and chronic
obstructive pulmonary disease. She quit smoking 2 years ago after a 55-pack a year
history. She denies any illegal drugs and drinks alcohol rarely. Her mother died of a
heart attack and her father died of a stroke. She has no children. Examination shows an
older woman appearing her stated age. Visual inspection of her right axilla reveals
nothing unusual. Palpation reveals a 2-cm hard fixed lymph node. She denies any
,tenderness. Visualization of both breasts is normal. Palpation of her left axilla and
breast is - answer Breast Cancer
A 66-year-old female client is reporting abdominal pain. The nurse assesses the client's
abdomen by first inspecting the abdomen. What should the nurse do next?
Palpate the abdomen.
Auscultate the abdomen.
Percuss the abdomen.
Measure abdominal girth. - answer Auscultate the abdomen.
A 66-year-old woman has come to the clinic with complaints of increasing fatigue over
the last several months. She claims to frequently feel lethargic and listless and states
that, "I can never seem to get warm, no matter what the thermostat is set at." How
should the nurse proceed with assessment?
Assess for other signs and symptoms of Cushing's syndrome.
Assess the woman for hypothyroidism.
Order tests to rule out an overactive thyroid gland.
Palpate the woman's parotid gland for enlargement. - answer Assess the woman for
hypothyroidism.
A 73-year-old woman comes to the office for evaluation of new onset of tremors. She is
not taking any medications, herbs, or supplements. She has no chronic medical
conditions. She does not smoke or drink alcohol. She walks into the examination room
with slow, shuffling steps. She has decreased facial mobility with a blunt expression
without any changes in hair distribution on her face. Based on this description, what is
the most likely reason for the client's symptoms?
Cushing's syndrome
Myxedema
Parkinson's disease
Nephrotic syndrome - answer Parkinson's disease
A client comes to the clinic and reports pain when he touches his ear. With what is this
finding most consistent?
Otitis externa
Otitis media
Acoustic neuroma
Meniere disease - answer Otitis externa
A client comes to the emergency department reporting a sudden onset of dyspnea.
What finding is a manifestation of dyspnea?
Painful breathing
Inability to breathe
,Shortness of breath
Rapid breathing - answer Shortness of breath
A client complains of abdominal pain with cramping diarrhea, nausea, vomiting, weight
loss, and loss of energy. The nurse should suspect which of the following as the
underlying cause?
Pancreatitis
Gastroesophageal reflux
Crohn's disease
Gastric ulcer - answer Crohn's disease
A client complains of difficulty sleeping, stating he has to sit up with the help of several
pillows and cannot breathe when lying flat. This client has a condition known as what?
Tachypnea
Pneumonia
Orthopnea
Sleep apnea - answer Orthopnea
A client complains of recurring headaches that are worse when first waking in the
morning and with coughing or sneezing. What would be the nurse's most appropriate
action?
Ask the doctor for an order for an MRI
Perform a focused assessment
Prepare the client for a spinal tap
Perform a generalized assessment - answer Perform a focused assessment
A client has been diagnosed with candidiasis and prescribed fluconazole 20 mg PO
now, following by 10 mg PO daily. What is the nurse's best action
Assess the client's baseline renal function
Assess the client's skin integrity and administer the medication as prescribed
Question the provider about the prescribed dose
Confirm the client's allergy status - answer Question the provider about the
prescribed dose
A client has been placed on amphotericin B. The nurse caring for this client should
administer this medication:
intramuscularly.
intravenously.
subcutaneously.
orally. - answer intravenously
, A client has been reporting persistent headaches. Which is an example of subjective
data? - answer Pain is 4 out of 10 on a pain scale.
A client in the ED tells the nurse that she is having difficulty breathing at rest. What term
would the nurse use in documenting this finding?
Tachypnea
Anxiety
Dyspnea
Shortness of breath - answer Dyspnea
A client is explaining to the nurse how vaginal dryness has decreased her enjoyment of
sexual intercourse. The nurse is aware that which of the following are the glands that
produce mucus that lubricates the vagina during intercourse?
Sebaceous glands
Bartholin's glands
Cowper's glands
Eccrine glands - answer Bartholin's glands
A client presents at the clinic complaining of a loss of balance. What test should the
nurse expect the physician to carry out on a client with a loss of balance?
Romberg test
Audiometric test
Weber test
Rinne test - answer Romberg test
A client presents to the health care clinic and reports pain in the eyes when working on
the computer for long periods of time. The client states that he almost ran into a parked
car yesterday because he misjudged the distance from the bumper of his own car. He
works for a computer software company and has noticed he is experiencing difficulty
reading the manuals that accompany the software he installs for companies. What
nursing diagnosis can the nurse confirm based on this data?
Disturbed Self Concept
Risk for Injury
Self-Care Deficit
Ineffective Individual Coping - answer Risk for Injury
A client presents to the health care clinic with a 3-week history of pain and swelling of
the right foot. A nurse inspects the foot and observes swelling and a large ulcer on the
heel. The client reports the right heel is very painful and he has trouble walking. Which
nursing diagnosis should the nurse confirm from these data?
Risk for Skin Breakdown
Fear of Loss of Extremity
