The nurse will use which technique of assessment to determine the presence of crepitus,
swelling, and pulsations?
a. Palpation
b. Inspection
c. Percussion
d. Auscultation
Which of these would be formulated by a nurse using diagnostic reasoning?
a. Nursing diagnosis
b. Medical diagnosis
c. Diagnostic hypothesis
d. Diagnostic assessment
The nurse knows that auscultation of fine crackles would most likely be noticed in:
a. A healthy 5-year-old child.
b. A pregnant woman.
c. The immediate newborn period.
d. Association with a pneumothorax.
When measuring a patient’s weight, the nurse is aware of which of these guidelines?
a. The patient is always weighed wearing only his or her undergarments.
b. The type of scale does not matter, as long as the weights are similar from day to day.
c. The patient may leave on his or her jacket and shoes as long as these are documented
next to the weight.
d. Attempts should be made to weigh the patient at approximately the same time of day,
if a sequence of weights is necessary.
While assessing a 7-month-old infant, the nurse makes a loud noise and notices the
following response: abduction and flexion of the arms and legs; fanning of the fingers,
and curling of the index finger and thumb in a C position, followed by the infant
bringing in the arms and legs to the body. What does the nurse know about this
response?
a. This response could indicate brachial nerve palsy.
b. This reaction is an expected startle response at this age.
c. This reflex should have disappeared between 1 and 4 months of age.
d. This response is normal as long as the movements are bilaterally symmetric.
A 70-year-old man has a blood pressure of 150/90 mm Hg in a lying position, 130/80
mm Hg in a sitting position, and 100/60 mm Hg in a standing position. How should the
nurse evaluate these findings?
a. These readings are a normal response and attributable to changes in the patient’s
position.
b. The change in blood pressure readings is called orthostatic hypotension.
c. The blood pressure reading in the lying position is within normal limits.
d. The change in blood pressure readings is considered within normal limits for the
patient’s age.
During an inspection of a patient’s face, the nurse notices that the facial features are
symmetric. This finding indicates which cranial nerve is intact?
a. VII
b. IX
c. XI
d. XII
When taking a history from a newly admitted patient, the nurse notices that he often
pauses and expectantly looks at the nurse. What would be the nurse’s best response to
this behavior?
a. Be silent, and allow him to continue when he is ready.
b. Smile at him and say, “Don”t worry about all of this. I”m sure we can find out why
you”re having these pains.”
c. Lean back in the chair and ask, “You are looking at me kind of funny; there isn”t
anything wrong, is there?”
d. Stand up and say, “I can see that this interview is uncomfortable for you. We can
continue it another time.”
The nurse is reviewing the development of culture. Which statement is correct
regarding the development of one’s culture? Culture is:
a. Genetically determined on the basis of racial background.
b. Learned through language acquisition and socialization.
c. A nonspecific phenomenon and is adaptive but unnecessary.
d. Biologically determined on the basis of physical characteristics.
The nurse is assessing the lungs of an older adult. Which of these changes are normal in
the respiratory system of the older adult?
a. Severe dyspnea is experienced on exertion, resulting from changes in the lungs.
b. Respiratory muscle strength increases to compensate for a decreased vital capacity.
c. Decrease in small airway closure occurs, leading to problems with atelectasis.
d. Lungs are less elastic and distensible, which decreases their ability to collapse and
recoil.
The nurse is assessing a 30-year-old unemployed immigrant from an underdeveloped
country who has been in the United States for 1 month. Which of these problems related
to his nutritional status might the nurse expect to find?
a. Obesity
b. Hypotension
c. Osteomalacia (softening of the bones)
d. Coronary artery disease
A woman who is 8 weeks pregnant is in the clinic for a checkup. The nurse reads on her
chart that her cervix is softened and looks cyanotic. The nurse knows that the woman is
exhibiting __________ sign and __________ sign.
a. Tanner; Hegar
b. Hegar; Goodell
c. Chadwick; Hegar
d. Goodell; Chadwick
The nurse is auscultating the chest in an adult. Which technique is correct?
a. Instructing the patient to take deep, rapid breaths
b. Instructing the patient to breathe in and out through his or her nose
c. Firmly holding the diaphragm of the stethoscope against the chest
d. Lightly holding the bell of the stethoscope against the chest to avoid friction
The nurse is examining the hip area of a patient and palpates a flat depression on the
upper, lateral side of the thigh when the patient is standing. The nurse interprets this
finding as the:
a. Ischial tuberosity.
b. Greater trochanter.
c. Iliac crest.
d. Gluteus maximus muscle.
The nurse notices that a patient has ulcerations on the tips of the toes and on the lateral
aspect of the ankles. This finding indicates:
a. Lymphedema.
b. Raynaud disease.
c. Arterial insufficiency.
d. Venous insufficiency.
When examining an infant, the nurse should examine which area first?
a. Ear
b. Nose
c. Throat
d. Abdomen
An imaginary line connecting the highest point on each iliac crest would cross the
__________ vertebra.
a. First sacral
b. Fourth lumbar
c. Seventh cervical
d. Twelfth thoracic
During an examination of the anterior thorax, the nurse is aware that the trachea
bifurcates anteriorly at the:
a. Costal angle.
b. Sternal angle.
c. Xiphoid process.
d. Suprasternal notch.
The nurse auscultates a functional systolic murmur, grade II/IV, on a woman in week 30
of her pregnancy. The remainder of her physical assessment is within normal limits. The
nurse would:
a. Consider this finding abnormal, and refer her for additional consultation.
b. Ask the woman to run briefly in place and then assess for an increase in intensity of
the murmur.
c. Know that this finding is normal and is a result of the increase in blood volume
during pregnancy.
d. Ask the woman to restrict her activities and return to the clinic in 1 week for
re-evaluation.
The nurse is preparing to assess a hospitalized patient who is experiencing significant
shortness of breath. How should the nurse proceed with the assessment?
a. The patient should lie down to obtain an accurate cardiac, respiratory, and abdominal
assessment.
b. A thorough history and physical assessment information should be obtained from the
patient’s family member.
c. A complete history and physical assessment should be immediately performed to
obtain baseline information.
d. Body areas appropriate to the problem should be examined and then the assessment
completed after the problem has resolved.
During an examination of a child, the nurse considers that physical growth is the best
index of a child’s:
a. General health.
b. Genetic makeup.
c. Nutritional status.
d. Activity and exercise patterns.
During a group prenatal teaching session, the nurse teaches Kegel exercises. Which
statements would be appropriate for this teaching session? Select all that apply.
a. “Kegel exercises help keep your uterus strong during the pregnancy.”
b. “Kegel exercises should be performed twice a day.”
c. “Kegel exercises should be performed 50 to 100 times a day.”
d. “To perform Kegel exercises, slowly squeeze to a peak at the count of eight, and then
slowly release to a count of eight.”
e. “To perform Kegel exercises, rapidly perform alternating squeeze-release exercises
up to the count of eight.”
The nurse is preparing to palpate the rectum and should use which of these techniques?
The nurse should:
a. Flex the finger, and slowly insert it toward the umbilicus.
b. First instruct the patient that this procedure will be painful.
c. Insert an extended index finger at a right angle to the anus.
d. Place the finger directly into the anus to overcome the tight sphincter.
During percussion, the nurse knows that a dull percussion note elicited over a lung lobe
most likely results from:
a. Shallow breathing.
b. Normal lung tissue.
c. Decreased adipose tissue.
d. Increased density of lung tissue.
When examining a patient’s CN function, the nurse remembers that the muscles in the
neck that are innervated by CN XI are the:
a. Sternomastoid and trapezius.
b. Spinal accessory and omohyoid.
c. Trapezius and sternomandibular.
d. Sternomandibular and spinal accessory.
Which of these clinical situations would the nurse consider to be outside normal limits?
a. A patient has had one pregnancy and states that she believes she may be entering
menopause. Her breast examination reveals breasts that are soft and slightly sagging.
b. A patient has never been pregnant. Her breast examination reveals large pendulous
breasts that have a firm, transverse ridge along the lower quadrant in both breasts.
c. A patient has never been pregnant and reports that she should begin her period
tomorrow. Her breast examination reveals breast tissue that is nodular and somewhat
engorged. She states that the examination was slightly painful.
d. A patient has had two pregnancies, and she breastfed both of her children. Her
youngest child is now 10 years old. Her breast examination reveals breast tissue that is
somewhat soft, and she has a small amount of thick yellow discharge from both nipples.
A 42-year-old woman complains that she has noticed several small, slightly raised,
bright red dots on her chest. On examination, the nurse expects that the spots are
probably:
a. Anasarca.
b. Scleroderma.
c. Senile angiomas.
d. Latent myeloma.
During an examination, a patient states that she was diagnosed with open-angle
glaucoma 2 years ago. The nurse assesses for characteristics of open-angle glaucoma.
Which of these are characteristics of open-angle glaucoma? Select all that apply.
a. Patient may experience sensitivity to light, nausea, and halos around lights.
b. Patient experiences tunnel vision in the late stages.
c. Immediate treatment is needed.
d. Vision loss begins with peripheral vision.
e. Open-angle glaucoma causes sudden attacks of increased pressure that cause blurred
vision.
f. Virtually no symptoms are exhibited.
While discussing the history of a 6-month-old infant, the mother tells the nurse that she
took a significant amount of aspirin while she was pregnant. What question would the
nurse want to include in the history?
a. “Does your baby seem to startle with loud noises?”
b. “Has your baby had any surgeries on her ears?”
c. “Have you noticed any drainage from her ears?”
d. “How many ear infections has your baby had since birth?”
A 62-year-old man is experiencing fever, chills, malaise, urinary frequency, and
urgency. He also reports urethral discharge and a dull aching pain in the perineal and
rectal area. These symptoms are most consistent with which condition?
a. Prostatitis
b. Polyps
c. Carcinoma of the prostate
d. BPH
During reporting, the nurse hears that a patient is experiencing hallucinations. Which is
an example of a hallucination?
a. Man believes that his dead wife is talking to him.
b. Woman hears the doorbell ring and goes to answer it, but no one is there.
c. Child sees a man standing in his closet. When the lights are turned on, it is only a dry
cleaning bag.
d. Man believes that the dog has curled up on the bed, but when he gets closer he sees
that it is a blanket.
Which vein(s) is(are) responsible for most of the venous return in the arm?
a. Deep
b. Ulnar
c. Subclavian
d. Superficial
The nurse notices that the mother of a 2-year-old boy brings him into the clinic quite
frequently for various injuries and suspects there may be some child abuse involved.
During an inspection of his mouth, the nurse should look for:
a. Swollen, red tonsils.
b. Ulcerations on the hard palate.
c. Bruising on the buccal mucosa or gums.
d. Small yellow papules along the hard palate.
Which statement concerning the sphincters is correct?
a. The internal sphincter is under voluntary control.
b. The external sphincter is under voluntary control.
c. Both sphincters remain slightly relaxed at all times.
d. The internal sphincter surrounds the external sphincter.
In the hot/cold theory, illnesses are believed to be caused by hot or cold entering the
body. Which of these patient conditions is most consistent with a cold condition?
a. Patient with diabetes and renal failure
b. Teenager with an abscessed tooth
c. Child with symptoms of itching and a rash
d. Older man with gastrointestinal discomfort