Health Screening

The nurse is reviewing the patient’s urinalysis and notes the presence of rare epithelial cells. Which interpretation of this finding is correct?

The patient’s thyroid stimulating hormone (TSH) is 9.3 mIU/L and serum free thyroxine (T4) is 0.2 ng/dL. Which findings are consistent with these lab results? Select all that apply.

Which patient is at highest risk for thyroid disease?

The nurse is assisting with the development of a tool in the electronic medical record to prompt providers to screen appropriate individuals for hypothyroidism. The nurse provides which characteristics to the informatics team to include in the tool? Select all that apply.

The urine output of a 40-year-old male patient with a urethral catheter has decreased from 80 mL/h to 15 mL/h. Which action should the nurse take first?

The full-term neonate is born via normal spontaneous vaginal delivery (NSVD). The neonate cries at the perineum and maintained flexion against gravity but is noted to be bluish gray. Which intervention is appropriate?

The neonate of 36 weeks estimated gestational age is born via emergency cesarean section, appears limp, blue, and apneic, and is brought to the warming table. He is warmed, dried, and stimulated, and a pulse oximeter is placed on his right wrist. At 30 seconds of life, his heart rate is 66 bpm and his oxygen saturation is 54%. Positive pressure ventilation is initiated via CPAP bag and mask. At one minute of life, the heart rate is 118 bpm, the extremities are still blue but the trunk is pink, and he begins to move and cry with stimulation. The nurse documents which number for the Apgar score? Enter your answer using a whole number.

The patient is brought to the emergency department following a serious motor vehicular accident (MVA). List the assessments the nurse performs in order from highest to lowest priority.

The emergency department nurse is assessing the unconscious patient following a fall from the ladder while he was doing home improvement work. Which assessment is performed first?

The nurse is involved in a motor vehicular accident in which a minor injury from the seatbelt was sustained. Which action does the nurse take first in helping the other victims?

The nurse delegates a pre-prandial blood sugar check to the unlicensed assistive personnel who fails to perform it before the patient’s food tray arrives and the patient eats breakfast. Who is most at fault?

Which patient is triaged as first to be treated following a hurricane?

The patient is brought to the emergency department following an accident with significant burns. The patient is conscious and alert with 3rd-degree burns over 50% of his body. The nurse helps to get a history and perform a thorough physical examination of this patient. Which type of assessment is the nurse performing?

The nurse is called to the hospital to assist in caring for patients brought to the hospital following a massive gas explosion in the community. Which statement is true regarding the nurse’s involvement with this incident?

Which patient is at the highest risk for ovarian cancer?

Which statement by the patient who has recently undergone a radical mastectomy indicates they understand teaching by the nurse?

The nurse is counseling the parents of a 7-year-old child who are concerned because of a strong family history of type 2 diabetes mellitus. The nurse instructs the parents that the initial screening for type 2 diabetes mellitus will occur at which time? 

The nurse instructs parents on which type of diet to decrease the risk for lead poisoning in their children? 

The nurse uses which technique to counsel a patient with chronic obstructive pulmonary disorder (COPD) about quitting smoking? 

The 5-day-old infant presents to the pediatrician's office for a well-baby visit. The parents report being happy that their child is a "good baby" who sleeps a lot and rarely cries. They also report the baby eats 4 times per day, sleeping for 8 hours at night. The nurse notes the baby is at the 70th percentile for weight. Upon assessment, the baby is minimally responsive. The nurse is most concerned about which condition? 

The 40-year old female patient was recently diagnosed with breast cancer. The nurse understands which factor is most important in determining prognosis? 

Which question does the nurse ask to determine the patient's risk for suicide in the patient with major depressive disorder? 

The nurse is assessing the patient with major depressive disorder. Which characteristic alerts the nurse that the patient may be planning to commit suicide? 

The 9-year-old patient presents to the clinic for a routine well-child visit. Which health screening does the nurse perform?

The nurse is evaluating a 9-month-old male infant who presents for a routine checkup. In obtaining the patient’s history from his mother, the nurse discovers they live in a home built in 1975. The nurse instructs the mother on which health screening schedule?

The 17-year-old pregnant female patient presents for her first prenatal visit. The nurse plans care based on which understanding of recommended screening?

Which developmental milestone is expected of the six-month-old infant who presents for a routine check-up?

At a routine check-up, the nurse expects the healthy 4-month-old to have met which milestone?

At a well-child visit, the mother of a 2-year-old child states, "My child is not keeping up with the other kids." Further evaluation reveals the patient can stack 6 cubes, walk backwards, and copy a line. The child exhibits separation anxiety and has a vocabulary of 10 words but cannot use symbols or use pronouns. Which assessment does the nurse make about the child's development?

The nurse instructs the mother at her child's 9-month well-child visit that patient will be screened for developmental delays and disabilities at which visits?

The nurse informs the parent of an 18-month-old patient at the well-child visit that screening for an autism spectrum disorder at which time(s)?

The patient brought to the emergency department following a motor vehicle accident is found to be brain dead. An organ donor card is found on this person and the organ procurement team is contacted. Which medical history, if found in the patient’s chart, would prompt the nurse to stop the line in the organ procurement process?

The 85-year-old patient fell in the bathroom. Which score will most accurately predict the adverse effects the patient will experience from the fall?

A 30-year-old female presents in the emergency room with symptoms of a lower respiratory infection with a productive cough, but there are no N95 respirators for the staff to utilize. Which action by the nurse is appropriate?

The nurse is participating in a project to reduce infection of multidrug resistant organisms (MDRO). Which type of surveillance will assist in this endeavor?

Which error in the use of a child's car seat occurs most frequently?

A 23-year-old pregnant woman presents to the clinic stating, “I am a teacher and have heard there is a measles outbreak in my community. I want to get the measles vaccine to protect my baby and myself. Which response by the nurse is most appropriate?

The patient presents to the emergency room complaining that his heart is racing and he feels dizzy. His heart rate is 220 bpm, his blood pressure is 80/40 mmHg, and his capillary refill is 5 seconds. He is diaphoretic and is becoming increasingly lethargic. The nurse anticipates which order first?

The 10-year-old patient presents to the emergency room following a fever as high as 105°F for 5 days. The patient’s mother reports the child has had red, watery eyes, poor appetite, and has felt ill during this time. The child was brought to the emergency room upon the appearance of a red rash that started on the child’s face and spread to the neck and chest. Which question will be most helpful in order to determine the cause of this patient’s symptoms?

The school nurse who works in an area with poor vaccination compliance learns a child has developed measles after being in class for the past week. Twenty other children in the class have not received the measles vaccine. The nurse anticipates how many of these children will contract measles?

A patient who was admitted with measles infection spent 4 hours in the busy emergency department. Each hour the patient was in the emergency department, 10 new patients entered the room. This trend continued for six hours after the patient was admitted to a room. How many patients are at risk for contracting the measles virus?

Which neonate must be most closely monitored for signs of Hirschsprung disease?

The nurse is creating a tool to automatically screen for patients who are at an increased risk for aspiration pneumonia. Which patient conditions or medical histories does the nurse include in the screening tool? Select all that apply.

The 82-year-old patient from the long-term care facility is brought to the emergency department with wet-sounding cough and increased work of breathing. Vital signs are normal with the exception of tachypnea and an oxygen saturation of 91% on room air. Upon auscultation, the nurse notes diminished breath sounds over the right upper lobe. Chest radiograph indicates consolidation in the right upper lobe of the lung. The nurse prepares the patient for which test?

A nurse is preparing discharge plans. Which patient is most likely to need home health care services?

The family practice nurse is reviewing telephone messages from patients. Which call is to be returned first?

The nurse is creating a tool to screen patients for depression and includes questions about which symptoms in the tool? Select all that apply.

The 58-year-old patient asks the nurse if he is at risk of heart disease. Which response by the nurse is appropriate?

The elderly patient is brought to the ER by ambulance for confusion, slurred speech, and right-sided weakness. Vital signs, including body temperature and blood pressure, are normal. As the patient is waiting for an urgent head CT, the nurse performs which test first?

The patient with human immunodeficiency virus (HIV) presents to the clinic for a follow-up visit. The nurse provides education to the patient about which cardiovascular complication the patient is most likely to experience related to the disease process?