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A man has come in to the clinic for a skin assessment because he is worried he might
have skin cancer. During the skin assessment the nurse notices several areas of
pigmentation that look greasy, dark, and 'stuck on" his skin. Which is the best
prediction?
a. Senile lentigines, which do not become cancerous
b. Actinic keratoses, which are precursors to basal cell carcinoma
c. Acrochordons, which are precursors to squamous cell carcinoma
d. Seborrheic keratoses, which do not become cancerous
The nurse has just completed an examination of a patient's extraocular muscles. When
documenting the findings, the nurse should document the assessment of which cranial
nerves?
a. II, III, and VI
b. II, IV, and V
c. III, IV, and V
d. III, IV, and VI
When performing an otoscopic examination of a 5-year-old child with a history of
chronic ear infections, the nurse sees that his right tympanic membrane is amber-yellow
in color and that air bubbles are visible behind the tympanic membrane. The child
reports occasional hearing loss and a popping sound with swallowing. The preliminary
analysis based on this information is that the child:
a. Most likely has serous otitis media.
b. Has an acute purulent otitis media.
c. Has evidence of a resolving cholesteatoma.
d. Is experiencing the early stages of perforation.
The nurse is explaining the mechanism of the growth of long bones to a mother of a
toddler. Where does lengthening of the bones occur?
a. Bursa
b. Calcaneus
c. Epiphyses
d. Tuberosities
While performing a well-child assessment on a 5 year old, the nurse notes the presence
of palpable, bilateral, cervical, and inguinal lymph nodes. They are approximately 0.5
cm in size, round, mobile, and nontender. The nurse suspects that this child:
a. Has chronic allergies.
b. May have an infection.
c. Is exhibiting a normal finding for a well child of this age.
d. Should be referred for additional evaluation.
The nurse is examining a patient who is complaining of "feeling cold." Which is a
mechanism of heat loss in the body?
a. Exercise
b. Radiation
c. Metabolism
d. Food digestion
During an assessment of a 68-year-old man with a recent onset of right-sided weakness,
the nurse hears a blowing, swishing sound with the bell of the stethoscope over the left
carotid artery. This finding would indicate:
a. Valvular disorder.
b. Blood flow turbulence.
c. Fluid volume overload.
d. Ventricular hypertrophy.
When performing the corneal light reflex assessment, the nurse notes that the light is
reflected at 2 o"clock in each eye. The nurse should:
a. Consider this a normal finding.
b. Refer the individual for further evaluation.
c. Document this finding as an asymmetric light reflex.
d. Perform the confrontation test to validate the findings.
The nurse would use bimanual palpation technique in which situation?
a. Palpating the thorax of an infant
b. Palpating the kidneys and uterus
c. Assessing pulsations and vibrations
d. Assessing the presence of tenderness and pain
The nurse notices the presence of periorbital edema when performing an eye
assessment on a 70-year-old patient. The nurse should:
a. Check for the presence of exophthalmos.
b. Suspect that the patient has hyperthyroidism.
c. Ask the patient if he or she has a history of heart failure.
d. Assess for blepharitis, which is often associated with periorbital edema.
The nurse is performing a genital examination on a male patient and notices urethral
drainage. When collecting urethral discharge for microscopic examination and culture,
the nurse should:
a. Ask the patient to urinate into a sterile cup.
b. Ask the patient to obtain a specimen of semen.
c. Insert a cotton-tipped applicator into the urethra.
d. Compress the glans between the examiner's thumb and forefinger, and collect any
discharge.
The nurse keeps in mind that the most important reason to share information and to
offer brief teaching while performing the physical examination is to help the:
a. Examiner feel more comfortable and to gain control of the situation.
b. Examiner to build rapport and to increase the patient's confidence in him or her.
c. Patient understand his or her disease process and treatment modalities.
d. Patient identify questions about his or her disease and the potential areas of patient
education.
The nurse recognizes which of these persons is at greatest risk for undernutrition?
a. 5-month-old infant
b. 50-year-old woman
c. 20-year-old college student
d. 30-year-old hospital administrator
During an examination, the nurse notices severe nystagmus in both eyes of a patient.
Which conclusion by the nurse is correct? Severe nystagmus in both eyes:
a. Is a normal occurrence.
b. May indicate disease of the cerebellum or brainstem.
c. Is a sign that the patient is nervous about the examination.
d. Indicates a visual problem, and a referral to an ophthalmologist is indicated.
When the nurse is performing a genital examination on a male patient, the patient has
an erection. The nurse's most appropriate action or response is to:
a. Ask the patient if he would like someone else to examine him.
b. Continue with the examination as though nothing has happened.
c. Stop the examination, leave the room while stating that the examination will resume
at a later time.
d. Reassure the patient that this is a normal response and continue with the examination.
The nurse is taking the history of a patient who may have a perforated eardrum. What
would be an important question in this situation?
a. "Do you ever notice ringing or crackling in your ears?"
b. "When was the last time you had your hearing checked?"
c. "Have you ever been told that you have any type of hearing loss?"
d. "Is there any relationship between the ear pain and the discharge you mentioned?"
During the examination of a woman in her second trimester of pregnancy, the nurse
notices the presence of a small amount of yellow drainage from the nipples. The nurse
knows that this is:
a. An indication that the woman's milk is coming in.
b. A sign of possible breast cancer in a pregnant woman.
c. Most likely colostrum and considered a normal finding at this stage of the pregnancy.
d. Too early in the pregnancy for lactation to begin and refers the woman to a specialist.
A patient tells the nurse that, "All my life I"ve been called "knock knees'." The nurse
knows that another term for knock knees is:
a. Genu varum.
b. Genu valgum.
c. Pes planus.
d. Metatarsus adductus.
To palpate the temporomandibular joint, the nurse's fingers should be placed in the
depression __________ of the ear.
a. Distal to the helix
b. Proximal to the helix
c. Anterior to the tragus
d. Posterior to the tragus
The nurse needs to pull the portion of the ear that consists of movable cartilage and skin
down and back when administering eardrops. This portion of the ear is called the:
a. Auricle.
b. Concha.
c. Outer meatus.
d. Mastoid process.
An Asian-American woman is experiencing diarrhea, which is believed to be "cold" or
"yin." The nurse expects that the woman is likely to try to treat it with:
a. Foods that are "hot" or "yang."
b. Readings and Eastern medicine meditations.
c. High doses of medicines believed to be "cold."
d. No treatment is tried because diarrhea is an expected part of life.
During a well-baby checkup, the nurse notices that a 1-week-old infant's face looks
small compared with his cranium, which seems enlarged. On further examination, the
nurse also notices dilated scalp veins and downcast or 'setting sun" eyes. The nurse
suspects which condition?
a. Craniotabes
b. Microcephaly
c. Hydrocephalus
d. Caput succedaneum
A male patient with possible fertility problems asks the nurse where sperm is produced.
The nurse knows that sperm production occurs in the:
a. Testes.
b. Prostate.
c. Epididymis.
d. Vas deferens.
The nurse is caring for a newborn infant. Thirty hours after birth, the infant passes a
dark green meconium stool. The nurse recognizes this is important because the:
a. Stool indicates anal patency.
b. Dark green color indicates occult blood in the stool.
c. Meconium stool can be reflective of distress in the newborn.
d. Newborn should have passed the first stool within 12 hours after birth.
During an assessment, the nurse uses the profile sign to detect:
a. Pitting edema.
b. Early clubbing.
c. Symmetry of the fingers.
d. Insufficient capillary refill.
Which of these correctly describes the average length of pregnancy?
a. 38 weeks
b. 9 lunar months
c. 280 days from the last day of the last menstrual period
d. 280 days from the first day of the last menstrual period
The nurse is preparing to palpate the thorax and abdomen of a patient. Which of these
statements describes the correct technique for this procedure? Select all that apply.
a. Warm the hands first before touching the patient.
b. For deep palpation, use one long continuous palpation when assessing the liver.
c. Start with light palpation to detect surface characteristics.
d. Use the fingertips to examine skin texture, swelling, pulsation, and presence of
lumps.
e. Identify any tender areas, and palpate them last.
f. Use the palms of the hands to assess temperature of the skin.
When assessing the respiratory system of a 4-year-old child, which of these findings
would the nurse expect?
a. Crepitus palpated at the costochondral junctions
b. No diaphragmatic excursion as a result of a child's decreased inspiratory volume
c. Presence of bronchovesicular breath sounds in the peripheral lung fields
d. Irregular respiratory pattern and a respiratory rate of 40 breaths per minute at rest
As a mandatory reporter of elder abuse, which must be present before a nurse should
notify the authorities?
a. Statements from the victim
b. Statements from witnesses
c. Proof of abuse and/or neglect
d. Suspicion of elder abuse and/or neglect
A female patient tells the nurse that she has had six pregnancies, with four live births at
term and two spontaneous abortions. Her four children are still living. How would the
nurse record this information?
a. P-6, B-4, (S)Ab-2
b. Grav 6, Term 4, (S)Ab-2, Living 4
c. Patient has had four living babies.
d. Patient has been pregnant six times.
The nurse is conducting a developmental history on a 5-year-old child. Which questions
are appropriate to ask the parents for this part of the assessment? Select all that apply.
a. "How much junk food does your child eat?"
b. "How many teeth has he lost, and when did he lose them?"
c. "Is he able to tie his shoelaces?"
d. "Does he take a children's vitamin?"
e. "Can he tell time?"
f. "Does he have any food allergies?"
The nurse is assessing a patient who may have hearing loss. Which of these statements
is true concerning air conduction?
a. Air conduction is the normal pathway for hearing.
b. Vibrations of the bones in the skull cause air conduction.
c. Amplitude of sound determines the pitch that is heard.
d. Loss of air conduction is called a conductive hearing loss.
When assessing an older adult, which vital sign changes occur with aging?
a. Increase in pulse rate
b. Widened pulse pressure
c. Increase in body temperature
d. Decrease in diastolic blood pressure
The nurse is assessing a 1-month-old infant at his well-baby checkup. Which
assessment findings are appropriate for this age? Select all that apply.
a. Head circumference equal to chest circumference
b. Head circumference greater than chest circumference
c. Head circumference less than chest circumference
d. Fontanels firm and slightly concave
e. Absent tonic neck reflex
f. Nonpalpable cervical lymph nodes
The salivary gland that is the largest and located in the cheek in front of the ear is the
_________ gland.
a. Parotid
b. Stensen's
c. Sublingual
d. Submandibular
