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For which of the following patients would a comprehensive health history be appropriate?
- A. A new patient with the chief complaint of 'I sprained my ankle'
- B. An established patient with the chief complaint of 'I have an upper respiratory infection'
- C. A new patient with the chief complaint of 'I am here to establish care'
- D. A new patient with the chief complaint of 'I cut my hand'
Correct Answer: C
Rationale: A comprehensive health history is suitable for a new patient establishing care to ensure all aspects of health are reviewed.
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Which is true of women who have had a unilateral mastectomy?
- A. They no longer require breast examination.
- B. They should be examined carefully along the surgical scar for masses.
- C. Lymphedema of the ipsilateral arm usually suggests recurrence of breast cancer.
- D. Women with breast reconstruction over their mastectomy site no longer require examination.
Correct Answer: B
Rationale: A woman who has had breast cancer remains at high risk for recurrence, especially in the contralateral breast. The mastectomy site should be carefully examined for local recurrence as well. Lymphedema or swelling of the ipsilateral arm following mastectomy is common and does not usually indicate recurrence. Women with breast reconstruction must also undergo careful examination.
A blood pressure reading consists of a top number, or , and bottom number, or
- A. Oxygen Saturation & Pulse
- B. Diastolic & Systolic
- C. Systolic & Diastolic
- D. Millimeters & Mercury
Correct Answer: C
Rationale: BP readings show systolic (top, ventricular contraction) and diastolic (bottom, relaxation) pressures , in mmHg. Oxygen saturation and pulse are separate. Diastolic over systolic reverses order. Millimeters and mercury is the unit, not the terms. Choice C is correct, per standard BP notation (e.g., 120/80 mmHg), a foundational nursing concept for documenting cardiac workload.
The nurse is reviewing the anatomy and physiologic functioning of the heart. Which statement best describes what is meant by atrial kick?
- A. The atria contract during systole and attempt to push against closed valves.
- B. Contraction of the atria at the beginning of diastole can be felt as a palpitation.
- C. Atrial kick is the pressure exerted against the atria as the ventricles contract during systole.
- D. The atria contract toward the end of diastole and push the remaining blood into the ventricles.
Correct Answer: D
Rationale: Toward the end of diastole, the atria contract and push the last amount of blood (approximately 25% of stroke volume) into the ventricles. This active filling phase is called presystole, or atrial systole, or sometimes the atrial kick.
The nurse is reviewing statistics regarding breast cancer. Which woman, aged 40 years in the United States, has the highest risk for developing breast cancer?
- A. Black
- B. White
- C. Asian
- D. American Indian
Correct Answer: A
Rationale: The incidence of breast cancer varies within different cultural groups. White women have a higher incidence of breast cancer than black women starting at age 45 years; but black women have a higher incidence before age 45 years. Asian, Hispanic, and American Indian women have a lower risk for development of breast cancer.
Which step of the nursing process includes data collection by health history, physical examination, and interview?
- A. Planning.
- B. Diagnosis.
- C. Evaluation.
- D. Assessment.
Correct Answer: D
Rationale: Data collection is part of the assessment phase of the nursing process.