NR304/NR 304 FINAL EXAM 75 QUESTIONS
WITH DETAILED CORRECT ANSWERS /A+
GRADE ASSURED
During an assessment of an 80-year-old patient, the nurse notices the following: an
inability to identify vibrations at her ankle and to identify the position of her big toe, a
slower and more deliberate gait, and a slightly impaired tactile sensation. All other
neurologic findings are normal. The nurse should interpret that these findings indicate:
a. CN dysfunction.
b. Lesion in the cerebral cortex.
c. Normal changes attributable to aging.
d. Demyelination of nerves attributable to a lesion. -….ANSWER… .c. Normal changes
attributable to aging.
The nurse is performing a neurologic assessment on a 41-year-old woman with a
history of diabetes. When testing her ability to feel the vibrations of a tuning fork, the
nurse notices that the patient is unable to feel vibrations on the great toe or ankle
bilaterally, but she is able to feel vibrations on both patellae. Given this information,
what would the nurse suspect?
a. Hyperalgesia
b. Hyperesthesia
c. Peripheral neuropathy
d. Lesion of sensory cortex -….ANSWER… .c. Peripheral neuropathy
A 65-year-old patient remarks that she just cannot believe that her breasts sag so
much. She states it must be from a lack of exercise. What explanation should the nurse
offer her? After menopause:
a. Only women with large breasts experience sagging.
b. Sagging is usually due to decreased muscle mass within the breast.
c. A diet that is high in protein will help maintain muscle mass, which keeps the breasts
from sagging.
d. The glandular and fat tissue atrophies, causing breast size and elasticity to diminish,
resulting in breasts that sag. -….ANSWER… .d. The glandular and fat tissue atrophies,
causing breast size and elasticity to diminish, resulting in breasts that sag.
The nurse notices that a patient has had a black, tarry stool and recalls that a possible
cause would be:
a. Gallbladder disease.
b. Overuse of laxatives.
c. Gastrointestinal bleeding.
d. Localized bleeding around the anus. -….ANSWER… .c. Gastrointestinal bleeding.
The nurse is performing an assessment on an adult. The adults vital signs are normal,
and capillary refill time is 5 seconds. What should the nurse do next?
a. Ask the patient about a history of frostbite.
b. Suspect that the patient has venous insufficiency.
c. Consider this a delayed capillary refill time, and investigate further.
d. Consider this a normal capillary refill time that requires no further assessment. –
….ANSWER… .c. Consider this a delayed capillary refill time, and investigate further.
While performing an admission assessment for a client, the nurse notes that the client
has varicose veins with ulcerations and lower extremity edema with a report of a feeling
of heaviness. Which of the following nursing diagnosis should the nurse identify as
being the priority in the client’s care?
A) Impaired tissue perfusion
B) Alteration in body image
C) Alteration in activity intolerance
D) Impaired skin integrity -….ANSWER… .A) Impaired tissue perfusion
During a visit to the clinic, a woman in her seventh month of pregnancy complains that
her legs feel heavy in the calf and that she often has foot cramps at night. The nurse
notices that the patient has dilated, tortuous veins apparent in her lower legs. Which
condition is reflected by these findings?
a. Deep-vein thrombophlebitis
b. Varicose veins
c. Lymphedema
d. Raynaud phenomenon -….ANSWER… .b. Varicose veins
A nurse is caring for a client who has peripheral vascular disease and reports difficulty
sleeping because of cold feet. Which of the following nursing actions should the nurse
take to promote the client’s comfort?
A) Obtain a pair of slipper socks for the client
B) Rub the clients feet briskly for several minutes
C) Increase the client’s oral fluid intake
D) Place a moist heating pad unde the client’s feet -….ANSWER… .A) Obtain a pair of
slipper socks for the client
During the assessment of an 18-month-old infant, the mother expresses concern to the
nurse about the infants inability to toilet train. What would be the nurses best response?
a. Some children are just more difficult to train, so I wouldnt worry about it yet.
b. Have you considered reading any of the books on toilet training? They can be very
helpful.
c. This could mean that there is a problem in your baby’s development. We’ll watch her
closely for the next few months.
d. The nerves that will allow your baby to have control over the passing of stools are not
developed until at least 18 to 24 months of age. -….ANSWER… .d. The nerves that will
allow your baby to have control over the passing of stools are not developed until at
least 18 to 24 months of age.
While performing a rectal examination, the nurse notices a firm, irregularly shaped
mass. What should the nurse do next?
a. Continue with the examination, and document the finding in the chart.
b. Instruct the patient to return for a repeat assessment in 1 month.
c. Tell the patient that a mass was felt, but it is nothing to worry about.
d. Report the finding, and refer the patient to a specialist for further examination. –
….ANSWER… .d. Report the finding, and refer the patient to a specialist for further
examination.
Which of these statements is most appropriate when the nurse is obtaining a
genitourinary history from an older man?
a. Do you need to get up at night to urinate?
b. Do you experience nocturnal emissions, or wet dreams?
c. Do you know how to perform a testicular self-examination?
d. Has anyone ever touched your genitals when you did not want them to? –
….ANSWER… .a. Do you need to get up at night to urinate?
You are assessing an adolescent boy. The first physical sign of puberty is:
a. Height spurt
b. Penis lengthening
c. Sperm production
d. Pubic hair development
e. Testes enlargement -….ANSWER… .e. Testes enlargement
A 22-year-old woman has been considering using oral contraceptives. As a part of her
health history, the nurse should ask:
a. Do you have a history of heart murmurs?
b. Will you be in a monogamous relationship?
c. Have you carefully thought this choice through?