After the examination of an infant, the nurse documents opisthotonos. The nurse
recognizes that this finding often occurs with:
a. Cerebral palsy.
b. Meningeal irritation.
c. Lower motor neuron lesion.
d. Upper motor neuron lesion.
A patient has a normal pupillary light reflex. The nurse recognizes that this reflex
indicates that:
a. The eyes converge to focus on the light.
b. Light is reflected at the same spot in both eyes.
c. The eye focuses the image in the center of the pupil.
d. Constriction of both pupils occurs in response to bright light.
A nurse is assessing a patient’s risk of contracting a sexually transmitted infection (STI).
An appropriate question to ask would be:
a. “You know that it’s important to use condoms for protection, right?”
b. “Do you use a condom with each episode of sexual intercourse?”
c. “Do you have a sexually transmitted infection?”
d. “You are aware of the dangers of unprotected sex, aren”t you?”
A patient has been admitted with chronic arterial symptoms. During the assessment, the
nurse should expect which findings? Select all that apply.
a. Patient has a history of diabetes and cigarette smoking.
b. Skin of the patient is pale and cool.
c. His ankles have two small, weeping ulcers.
d. Patient works long hours sitting at a computer desk.
e. He states that the pain gets worse when walking.
f. Patient states that the pain is worse at the end of the day.
A 62-year-old man states that his physician told him that he has an “inguinal hernia.”
He asks the nurse to explain what a hernia is. The nurse should:
a. Tell him not to worry and that most men his age develop hernias.
b. Explain that a hernia is often the result of prenatal growth abnormalities.
c. Refer him to his physician for additional consultation because the physician made the
initial diagnosis.
d. Explain that a hernia is a loop of bowel protruding through a weak spot in the
abdominal muscles.
The nurse is conducting a visual examination. Which of these statements regarding
visual pathways and visual fields is true?
a. The right side of the brain interprets the vision for the right eye.
b. The image formed on the retina is upside down and reversed from its actual
appearance in the outside world.
c. Light rays are refracted through the transparent media of the eye before striking the
pupil.
d. Light impulses are conducted through the optic nerve to the temporal lobes of the
brain.
Which of these specific measurements is the best index of a child’s general health?
a. Vital signs
b. Height and weight
c. Head circumference
d. Chest circumference
A 40-year-old patient who has just finished chemotherapy for breast cancer tells the
nurse that she is concerned about her mouth. During the assessment the nurse finds
areas of buccal mucosa that are raw and red with some bleeding, as well as other areas
that have a white, cheesy coating. The nurse recognizes that this abnormality is:
a. Aphthous ulcers.
b. Candidiasis.
c. Leukoplakia.
d. Koplik spots.
A 70-year-old man is visiting the clinic for difficulty in passing urine. In the health
history, he indicates that he has to urinate frequently, especially at night. He has burning
when he urinates and has noticed pain in his back. Considering this history, what might
the nurse expect to find during the physical assessment?
a. Asymmetric, hard, and fixed prostate gland
b. Occult blood and perianal pain to palpation
c. Symmetrically enlarged, soft prostate gland
d. Soft nodule protruding from the rectal mucosa
The nurse is comparing the concepts of religion and spirituality. Which of the following
is an appropriate component of one’s spirituality?
a. Belief in and the worship of God or gods
b. Attendance at a specific church or place of worship
c. Personal effort made to find purpose and meaning in life
d. Being closely tied to one’s ethnic background
During an assessment of the sclera of a black patient, the nurse would consider which
of these an expected finding?
a. Yellow fatty deposits over the cornea
b. Pallor near the outer canthus of the lower lid
c. Yellow color of the sclera that extends up to the iris
d. Presence of small brown macules on the sclera
The nurse is describing a weak, thready pulse on the documentation flow sheet. Which
statement is correct?
a. “Is easily palpable; pounds under the fingertips.”
b. “Has greater than normal force, then suddenly collapses.”
c. “Is hard to palpate, may fade in and out, and is easily obliterated by pressure.”
d. “Rhythm is regular, but force varies with alternating beats of large and small
amplitude.”
To assess the head control of a 4-month-old infant, the nurse lifts up the infant in a
prone position while supporting his chest. The nurse looks for what normal response?
The infant:
a. Raises the head, and arches the back.
b. Extends the arms, and drops down the head.
c. Flexes the knees and elbows with the back straight.
d. Holds the head at 45 degrees, and keeps the back straight.
In the majority culture of America, coughing, sweating, and diarrhea are symptoms of
an illness. For some individuals of Mexican-American origin, however, these symptoms
are a normal part of living. The nurse recognizes that this difference is true, probably
because Mexican-Americans:
a. Have less efficient immune systems and are often ill.
b. Consider these symptoms part of normal living, not symptoms of ill health.
c. Come from Mexico, and coughing is normal and healthy there.
d. Are usually in a lower socioeconomic group and are more likely to be sick.
A nurse notices that a patient has ascites, which indicates the presence of:
a. Fluid.
b. Feces.
c. Flatus.
d. Fibroid tumors.
The nurse is palpating the sinus areas. If the findings are normal, then the patient should
report which sensation?
a. No sensation
b. Firm pressure
c. Pain during palpation
d. Pain sensation behind eyes
During a discussion for a men’s health group, the nurse relates that the group with the
highest incidence of prostate cancer is:
a. Asian Americans.
b. Blacks.
c. American Indians.
d. Hispanics.
The nurse is performing a vision examination. Which of these charts is most widely
used for vision examinations?
a. Snellen
b. Shetllen
c. Smoollen
d. Schwellon
During the assessment of an 18-month-old infant, the mother expresses concern to the
nurse about the infant’s inability to toilet train. What would be the nurse’s best
response?
a. “Some children are just more difficult to train, so I wouldn”t 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.”
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
When assessing a woman who is in her third trimester of pregnancy, the nurse looks for
the classic symptoms associated with preeclampsia, which include:
a. Edema, headaches, and seizures.
b. Elevated blood pressure and proteinuria.
c. Elevated liver enzymes and high platelet counts.
d. Decreased blood pressure and edema.
A mother and her 13-year-old daughter express their concern related to the daughter’s
recent weight gain and her increase in appetite. Which of these statements represents
information the nurse should discuss with them?
a. Dieting and exercising are necessary at this age.
b. Snacks should be high in protein, iron, and calcium.
c. Teenagers who have a weight problem should not be allowed to snack.
d. A low-calorie diet is important to prevent the accumulation of fat.
In an individual with otitis externa, which of these signs would the nurse expect to find
on assessment?
a. Rhinorrhea
b. Periorbital edema
c. Pain over the maxillary sinuses
d. Enlarged superficial cervical nodes
A patient is unable to perform rapid alternating movements such as rapidly patting her
knees. The nurse should document this inability as:
a. Ataxia.
b. Astereognosis.
c. Presence of dysdiadochokinesia.
d. Loss of kinesthesia.
Expert nurses learn to attend to a pattern of assessment data and act without consciously
labeling it. These responses are referred to as:
a. Intuition.
b. The nursing process.
c. Clinical knowledge.
d. Diagnostic reasoning.
A patient is complaining of a sharp pain along the costovertebral angles. The nurse is
aware that this symptom is most often indicative of:
a. Ovary infection.
b. Liver enlargement.
c. Kidney inflammation.
d. Spleen enlargement.
A 65-year-old patient is experiencing pain in his left calf when he exercises that
disappears after resting for a few minutes. The nurse recognizes that this description is
most consistent with _______ the left leg.
a. Venous obstruction of
b. Claudication due to venous abnormalities in
c. Ischemia caused by a partial blockage of an artery supplying
d. Ischemia caused by the complete blockage of an artery supplying
A 68-year-old woman has come in for an assessment of her rheumatoid arthritis, and the
nurse notices raised, firm, nontender nodules at the olecranon bursa and along the ulna.
These nodules are most commonly diagnosed as:
a. Epicondylitis.
b. Gouty arthritis.
c. Olecranon bursitis.
d. Subcutaneous nodules.
The nurse is conducting a heritage assessment. Which question is most appropriate for
this assessment?
a. “What is your religion?”
b. “Do you mostly participate in the religious traditions of your family?”
c. “Do you smoke?”
d. “Do you have a history of heart disease?”
During an assessment of an infant, the nurse notes that the fontanels are depressed and
sunken. The nurse suspects which condition?
a. Rickets
b. Dehydration
c. Mental retardation
d. Increased intracranial pressure
A male patient with a history of acquired immunodeficiency syndrome (AIDS) has
come in for an examination and he states, “I think that I have the mumps.” The nurse
would begin by examining the:
a. Thyroid gland.
b. Parotid gland.
c. Cervical lymph nodes.
d. Mouth and skin for lesions.