Head, Face, Neck
Which outcome would be appropriate for a client being treated with Levothyroxine for Hypothyroidism who has been discharged to home?
A) The client states they will call the MD for daily checkups, B) The client states that the Levothyroxine dosage may have to be adjusted, C) The client will demonstrate how to check their neck for masses, D) The client will increase their daily intake of table salt
What is: B) The client states that the Levothyroxine dosage may have to be adjusted
Rationale: Levothyroxine dosage may have to be adjusted (up or down) based on blood tests (T4 and TSH), keeping these within normal range
Which of the following statements regarding the results obtained from use of the Snellen chart is true?
A)The smaller the numerator, the poorer the vision, B) The larger the denominator, the poorer the vision, C) The larger the numerator, the better the vision, D) The smaller the denominator, the poorer the vision
What is: B) The larger the denominator, the poorer the vision (Ex: 20/30) *numerator (top #) represents distance that patient standing away from chart in feet/denominator (bottom #) represents distance from which patient with perfect eyesight is still able to read smallest line that the patient can clearly visualize.
Which of the following is a risk factor related to oral cancer?
A) Tobacco use, B) Frequent upper respiratory infections, C) Being under the age of 50, D) Having gingivitis
What is: A) Tobacco use
Rationale: Tobacco plays a significant role in the development of oral cancer
Which assessment finding would the RN expect for a client with Chronic Respiratory disease?
A) Cutaneous angiomas, B) Restlessness and anxiousness, C) Clubbing of the distal phalanges, D) Significant drowsiness
What is: C) Clubbing of the distal phalanges
Which physiologic mechanism causes the first heart sound?
A) Closing of the mitral valve, B) Filling of the ventricle, C) Closing of the aortic valve, D) Filling of the atria.
What is? A) Closing of the mitral valve
A client with Hypothyroidism asks the RN why the provider ordered Levothyroxine for them. Which response by the RN is correct?
A) Levothyroxine dissolves the goiter, B) Levothyroxine replaces the missing hormones, C) Levothyroxine increases thyroid stimulating hormone (TSH), D) Levothyroxine decreases inflammation
What is: B) Levothyroxine replaces the missing hormones
Rationale: Levothyroxine replaces missing hormone Thyroxine (T4)
Decreased vision in older adults may be due to which of the following conditions?
A) Fixation, B) Retinoblastoma, C) Presbyopia, D) Macular degeneration
What is: D) Macular degeneration
Rationale: Decreased vision in older adults most commonly caused by cataracts, glaucoma or macular degeneration
The nasal mucosa of a client with rhinitis would be:
A) Pale with bright red bleeding, B) Moist and pink, C) Bright red and swollen, D) Swollen, boggy and gray
What is: C) Bright red and swollen
Which technique would the RN use to assess for tactile fremitus?
A) By placing the fingertips on the sides of the neck, B) By placing the thumb on the spinous process of the client, C) By placing warmed hands sideways on the posterolateral chest wall, D) By placing the palmar base of one hand to touch the client's chest
What is: D) By placing the palmar base of one hand to touch the client's chest
Which heart sound occurs because of the closure of the semilunar valves?
A) S1, B) S2, C) S3, D) S4
What is: B) S2
A client with hypothyroidism reports difficulty with ADLS and being "too tired to do anything." Which nursing diagnosis would be most appropriate when planning interventions for the client?
A) Depression related to fatigue, B) Altered nutrition: More than body requirements related to excessive intake, C) Activity intolerance related to fatigue, D) Fatigue related to role demands
What is: C) Activity intolerance related to fatigue
Rationale: activity intolerance is when individual lacks energy to complete ADLS. The data provided by the client supports the diagnosis.
Which pupil diameters are considered normal? Select-all-that-apply:
A) 6mm, B) 2mm, C) 8mm, D) 3mm, E) 9mm, F)7 mm, G) 5mm, H) 4mm
What is: D) 3mm, 5mm, H) 4mm
In addition to initiating digestion of food, saliva:
A) Protects the mucosa from caustic substances, B) Augments taste sensation, C) Cleans and protects the mucosa, D) Inhibits overgrowth of bacteria in the mouth
What is: C) Cleans and protects the mucosa
Rationale: Saliva moistens and lubricates food, starts digestion and cleans/protects the mucosa.
Which assessment findings would the RN identify with a barrel chest? Select-all-that-apply:
A) Thorax is symmetrical in the elliptical shape, B) Chest appears as if held in continuous inspiration, C) Ribs appear to be horizontal in relation to the spine, D) Scapulae are placed symmetrically in each hemithorax, E) Anteroposterior diameter is equal to transverse diameter
What is: B) Chest appears as if held in continuous inspiration, C) Ribs appear to be horizontal in relation to the spine, E) Anteroposterior diameter is equal to transverse diameter
Which assessment finding indicates abnormally elevated pressures in the right side of the heart?
A) Pulmonary congestion, B) Pulmonary hypertension, C) Distended neck veins, D) Systolic BP higher than Diastolic BP
What is: C) Distended neck veins
Which of the following statements related to aggravating symptoms or triggers of headaches is true?
A) Poor posture may trigger a migraine headache, B) Certain foods (Ex: chocolate or cheese) may precipitate onset of tension headaches, C) Premenstrual hormone fluctuations may precipitate onset of cluster headaches, D) Alcohol consumption may precipitate onset of cluster or migraine headaches
What is: D) Alcohol consumption may precipitate onset of cluster or migraine headaches
Rationale: Aggravating symptoms/triggers for cluster headaches include alcohol consumption, stress, wind and heat exposure. Migraines can be triggered by hormonal fluctuations, foods, sleep patterns, changes in weather. Tension headaches can be triggered by stress, anxiety and poor posture.
A client with allergies reports their eyes hurt and itch. Upon assessment the RN sees that the client's eyes are reddened and puffy. Which nursing diagnosis would be most appropriate when planning interventions for the client?
A) Impaired self-concept related to inflammation, B) Chronic pain related to changes of the eyes, C) Fatigue related to acute pain D) Acute pain related to inflammation
What is: D) Acute pain related to inflammation
An enlarged tongue (macroglossia) may accompany which other condition?
A) Indurated ulcer, B) Down Syndrome, C) Hairy tongue, D) Cleft Palate
What is: B) Down Syndrome
Rationale: *Hair tongue can occur from antibiotic use or heavy smoking
Which observations would the RN expect in a client with COPD? Select-all-that-apply:
A) The neck muscles appear to be hypertrophied from overwork, B) The spinous processes appear as if they are in a straight line, C) There are no major changes in the color of the client's skin, D) The client leans forward with the arms against the knees, E) The anteroposterior and transverse diameter are equal
What is: A) The neck muscles appear to be hypertrophied from overwork, D) The client leans forward with the arms against the knees, E) The anteroposterior and transverse diameter are equal
Which risk factors for cardiovascular disease are modifiable and which are non-modifiable?
A) Age, B) Stress, C) BP, D) Obesity, E) Smoking, F) Cholesterol, G) Diabetes, H) Genetics, I) Gender, J) Race, K) Inactivity
What is: (Modifiable) Cholesterol, Diabetes, BP, Inactivity, Smoking, Stress & Obesity
(Non-modifiable) Age, Gender, Race, Genetics
The client has a headache. Which questions would the RN ask? Select-all-that-apply:
A) Have you ever had this kind of headache before? B) Where do you feel the pain?, C) When did the headache begin? D) Is the pain on one side or throbbing all over? E) What did you do to cause the headache?
What is: A) Have you ever had this kind of headache before? B) Where do you feel the pain?, C) When did the headache begin? D) Is the pain on one side or throbbing all over?
Rationale: Asking what the client did to cause headache infers it is their fault
A client with allergies asks the RN what they can do to prevent seasonal allergies at home. Which response provided by the RN are correct? Select-all-that-apply:
A) Bathe after being outside, B) Wash your clothes everyday, C) Always blow your nose three times a day, D) Keep doors and windows closed, E) Use a HEPA air filtration system
What is: A) Bathe after being outside, D) Keep doors and windows closed, E) Use a HEPA air filtration system
Rationale: all three help minimize exposing mucous membranes to pollen
Upon examination of an American Indian, the RN notices the presence of a bifid uvula. How should this finding be interpreted?
A) This may indicate the presence of oral cancer, B) This is rate and indicates other congenital anomalies may be present, C) This condition is frequently associated with cleft palate, D) This is an expected variation associated with this individual
What is: D) This is an expected variation associated with this individual
Rationale: Bifid uvula is a condition in which the uvula is split completely or partially and seen more commonly in Native Americans.
The middle-aged client reports, "I can't get my breath when I walk." Upon assessment the RN notes that the client has a barrel chest and is using accessory muscles to breathe. Respiratory rate is 28. Upon palpation there is limited expansion and decreased tactile fremitus. On ausculatation, prolonged expiration, scattered wheezes and rhonchi are present. Which disorder should the RN suspect?
A) Atelectasis, B) Pneumonia, C) Emphysema, D) Pleural Effusion
What is: C) Emphysema
Which items asked during the health history assessment provide information about the cardiovascular system? Select-all-that-apply:
A) Childhood rheumatic illness, B) Swelling in legs, C) Family history of stroke, D) Color of urine, E) Number of children, F) Food allergies
What is: A) Childhood rheumatic illness, B) Swelling in legs, C) Family history of stroke