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A mother brings her newborn in for an assessment and asks, "Is there something wrong
with my baby? His head seems so big." Which statement is true regarding the relative
proportions of the head and trunk of the newborn?
a. At birth, the head is one fifth the total length.
b. Head circumference should be greater than chest circumference at birth.
c. The head size reaches 90% of its final size when the child is 3 years old.
d. When the anterior fontanel closes at 2 months, the head will be more proportioned to
the body.
A patient has been admitted after an accident at work. During the assessment, the
patient is having trouble hearing and states, "I don"t know what the matter is. All of a
sudden, I can"t hear you out of my left ear!" What should the nurse do next?
a. Make note of this finding for the report to the next shift.
b. Prepare to remove cerumen from the patient's ear.
c. Notify the patient's health care provider.
d. Irrigate the ear with rubbing alcohol.
In recording the childhood illnesses of a patient who denies having had any, which note
by the nurse would be most accurate?
a. Patient denies usual childhood illnesses.
b. Patient states he was a "very healthy" child.
c. Patient states his sister had measles, but he didn't.
d. Patient denies measles, mumps, rubella, chickenpox, pertussis, and strep throat.
The nurse is unable to palpate the right radial pulse on a patient. The best action would
be to:
a. Auscultate over the area with a fetoscope.
b. Use a goniometer to measure the pulsations.
c. Use a Doppler device to check for pulsations over the area.
d. Check for the presence of pulsations with a stethoscope.
The nurse is assessing voice sounds during a respiratory assessment. Which of these
findings indicates a normal assessment? Select all that apply.
a. Voice sounds are faint, muffled, and almost inaudible when the patient whispers "one,
two, three" in a very soft voice.
b. As the patient repeatedly says "ninety-nine," the examiner clearly hears the words
"ninety-nine."
c. When the patient speaks in a normal voice, the examiner can hear a sound but cannot
exactly distinguish what is being said.
d. As the patient says a long "ee-ee-ee" sound, the examiner also hears a long "ee-ee-ee"
sound.
e. As the patient says a long "ee-ee-ee" sound, the examiner hears a long "aaaaaa"
sound.
The nurse is preparing to teach a woman about BSE. Which statement by the nurse is
correct?
a. "BSE is more important than ever for you because you have never had any children."
b. "BSE is so important because one out of nine women will develop breast cancer in
her lifetime."
c. "BSE on a monthly basis will help you become familiar with your own breasts and
feel their normal variations."
d. "BSE will save your life because you are likely to find a cancerous lump between
mammograms."
A man arrives at the clinic for his annual wellness physical. He is experiencing no acute
health problems. Which question or statement by the nurse is most appropriate when
beginning the interview?
a. "How is your family?"
b. "How is your job?"
c. "Tell me about your hypertension."
d. "How has your health been since your last visit?"
When auscultating the anterior thorax of a pregnant woman, the nurse notices the
presence of a murmur over the second, third, and fourth intercostal spaces. The murmur
is continuous but can be obliterated by pressure with the stethoscope or finger on the
thorax just lateral to the murmur. The nurse interprets this finding to be:
a. Murmur of aortic stenosis.
b. Most likely a mammary souffle.
c. Associated with aortic insufficiency.
d. Indication of a patent ductus arteriosus.
A patient tells the nurse, "Sometimes I wake up at night and I have real trouble
breathing. I have to sit up in bed to get a good breath." When documenting this
information, the nurse would note:
a. Orthopnea.
b. Acute emphysema.
c. Paroxysmal nocturnal dyspnea.
d. Acute shortness of breath episode.
In performing an examination of a 3-year-old child with a suspected ear infection, the
nurse would:
a. Omit the otoscopic examination if the child has a fever.
b. Pull the ear up and back before inserting the speculum.
c. Ask the mother to leave the room while examining the child.
d. Perform the otoscopic examination at the end of the assessment.
During an examination of a 3-year-old child, the nurse will need to take her blood
pressure. What might the nurse do to try to gain the child's full cooperation?
a. Tell the child that the blood pressure cuff is going to give her arm a big hug.
b. Tell the child that the blood pressure cuff is asleep and cannot wake up.
c. Give the blood pressure cuff a name and refer to it by this name during the
assessment.
d. Tell the child that by using the blood pressure cuff, we can see how strong her
muscles are.
An 85-year-old man has been hospitalized after a fall at home, and his 86-year-old wife
is at his bedside. She tells the nurse that she is his primary caregiver. The nurse should
assess the caregiver for signs of possible caregiver burnout, such as:
a. Depression.
b. Weight gain.
c. Hypertension.
d. Social phobias.
The nurse notices that an infant has a large, soft lump on the side of his head and that
his mother is very concerned. She tells the nurse that she noticed the lump
approximately 8 hours after her baby's birth and that it seems to be getting bigger. One
possible explanation for this is:
a. Hydrocephalus.
b. Craniosynostosis.
c. Cephalhematoma.
d. Caput succedaneum.
A patient has been diagnosed with venous stasis. Which of these findings would the
nurse most likely observe?
a. Unilateral cool foot
b. Thin, shiny, atrophic skin
c. Pallor of the toes and cyanosis of the nail beds
d. Brownish discoloration to the skin of the lower leg
During an examination, a patient has just successfully completed the finger-to-nose and
the rapid-alternating-movements tests and is able to run each heel down the opposite
shin. The nurse will conclude that the patient's __________ function is intact.
a. Occipital
b. Cerebral
c. Temporal
d. Cerebellar
A 31-year-old patient tells the nurse that he has noticed pain in his left ear when people
speak loudly to him. The nurse knows that this finding:
a. Is normal for people of his age.
b. Is a characteristic of recruitment.
c. May indicate a middle ear infection.
d. Indicates that the patient has a cerumen impaction.
When performing a physical examination, safety must be considered to protect the
examiner and the patient against the spread of infection. Which of these statements
describes the most appropriate action the nurse should take when performing a physical
examination?
a. Washing one's hands after removing gloves is not necessary, as long as the gloves are
still intact.
b. Hands are washed before and after every physical patient encounter.
c. Hands are washed before the examination of each body system to prevent the spread
of bacteria from one part of the body to another.
d. Gloves are worn throughout the entire examination to demonstrate to the patient
concern regarding the spread of infectious diseases.
The nurse is assessing a patient who is obese for signs of metabolic syndrome. This
condition is diagnosed when three or more certain risk factors are present. Which of
these assessment findings are risk factors for metabolic syndrome? Select all that apply.
a. Fasting plasma glucose level less than 100 mg/dL
b. Fasting plasma glucose level greater than or equal to 110 mg/dL
c. Blood pressure reading of 140/90 mm Hg
d. Blood pressure reading of 110/80 mm Hg
e. Triglyceride level of 120 mg/dL
While counting the apical pulse on a 16-year-old patient, the nurse notices an irregular
rhythm. His rate speeds up on inspiration and slows on expiration. What would be the
nurse's response?
a. Talk with the patient about his intake of caffeine.
b. Perform an electrocardiogram after the examination.
c. No further response is needed because sinus arrhythmia can occur normally.
d. Refer the patient to a cardiologist for further testing.
A 50-year-old woman with elevated total cholesterol and triglyceride levels is visiting
the clinic to find out about her laboratory results. What would be important for the
nurse to include in patient teaching in relation to these tests?
a. The risks of undernutrition should be included.
b. Offer methods to reduce the stress in her life.
c. Provide information regarding a diet low in saturated fat.
d. This condition is hereditary; she can do nothing to change the levels.
The nurse is reviewing aspects of substance abuse in preparation for a seminar. Which
of these statements illustrates the concept of tolerance to an illicit substance? The
person:
a. Has a physiologic dependence on a substance.
b. Requires an increased amount of the substance to produce the same effect.
c. Requires daily use of the substance to function and is unable to stop using it.
d. Experiences a syndrome of physiologic symptoms if the substance is not used.
A newborn infant has Down syndrome. During the skin assessment, the nurse notices a
transient mottling in the trunk and extremities in response to the cool temperature in the
examination room. The infant's mother also notices the mottling and asks what it is. The
nurse knows that this mottling is called:
a. Caf au lait.
b. Carotenemia.
c. Acrocyanosis.
d. Cutis marmorata.
When the nurse asks for a description of who lives with a child, the method of
discipline, and the support system of the child, what part of the assessment is being
performed?
a. Family history
b. Review of systems
c. Functional assessment
d. Reason for seeking care
The nurse is preparing to perform a functional assessment of an older patient and knows
that a good approach would be to:
a. Observe the patient's ability to perform the tasks.
b. Ask the patient's wife how he does when performing tasks.
c. Review the medical record for information on the patient's abilities.
d. Ask the patient's physician for information on the patient's abilities.
The nurse is performing a genitourinary assessment on a 50-year-old obese male
laborer. On examination, the nurse notices a painless round swelling close to the pubis
in the area of the internal inguinal ring that is easily reduced when the individual is
supine. These findings are most consistent with a(n) ______ hernia.
a. Scrotal
b. Femoral
c. Direct inguinal
d. Indirect inguinal
The nurse is examining a patient's retina with an ophthalmoscope. Which finding is
considered normal?
a. Optic disc that is a yellow-orange color
b. Optic disc margins that are blurred around the edges
c. Presence of pigmented crescents in the macular area
d. Presence of the macula located on the nasal side of the retina
An accessory glandular structure for the male genital organs is the:
a. Testis.
b. Scrotum.
c. Prostate.
d. Vas deferens.
When auscultating over a patient's femoral arteries, the nurse notices the presence of a
bruit on the left side. The nurse knows that bruits:
a. Are often associated with venous disease.
b. Occur in the presence of lymphadenopathy.
c. In the femoral arteries are caused by hypermetabolic states.
d. Occur with turbulent blood flow, indicating partial occlusion.
The nurse is percussing over the lungs of a patient with pneumonia. The nurse knows
that percussion over an area of atelectasis in the lungs will reveal:
a. Dullness.
b. Tympany.
c. Resonance.
d. Hyperresonance.
A 35-year-old woman is at the clinic for a gynecologic examination. During the
examination, she asks the nurse, "How often do I need to have this Pap test done?"
Which reply by the nurse is correct?
a. "It depends. Do you smoke?"
b. "A Pap test needs to be performed annually until you are 65 years of age."
c. "If you have two consecutive normal Pap tests, then you can wait 5 years between
tests."
d. "After age 30 years, if you have three consecutive normal Pap tests, then you may be
screened every 2 to 3 years."
The nurse is performing an assessment on a 29-year-old woman who visits the clinic
complaining of "always dropping things and falling down." While testing rapid
alternating movements, the nurse notices that the woman is unable to pat both of her
knees. Her response is extremely slow and she frequently misses. What should the
nurse suspect?
a. Vestibular disease
b. Lesion of CN IX
c. Dysfunction of the cerebellum
d. Inability to understand directions
A patient has been diagnosed with schizophrenia. During a recent interview, he shows
the nurse a picture of a man holding a decapitated head. He describes this picture as
horrifying but then laughs loudly at the content. This behavior is a display of:
a. Confusion
b. Ambivalence
c. Depersonalization
d. Inappropriate affect
The nurse is performing an assessment. Which of these findings would cause the
greatest concern?
a. Painful vesicle inside the cheek for 2 days
b. Presence of moist, nontender Stensen's ducts
c. Stippled gingival margins that snugly adhere to the teeth
d. Ulceration on the side of the tongue with rolled edges
The nurse is assessing the abilities of an older adult. Which activities are considered
IADLs? Select all that apply.
a. Feeding oneself
b. Preparing a meal
c. Balancing a checkbook
d. Walking
e. Toileting
f. Grocery shopping
