Question 1

A nurse is assessing a postoperative client who suddenly develops restlessness, tachycardia, and sharp chest pain that worsens with inspiration. Breath sounds are decreased on the right side. Which finding is most concerning for this client’s condition?

Accepted Answer

Answer reason: Sudden dyspnea, unilateral decreased breath sounds, and tracheal deviation strongly indicate a tension pneumothorax—a life-threatening emergency. Tracheal shift is the most critical assessment finding because it signals increasing intrathoracic pressure and impending cardiovascular collapse.

Question 2

A client reports new onset shortness of breath and fatigue. On assessment, the nurse notes a displaced point of maximal impulse (PMI) located laterally in the 6th intercostal space. What does this finding most likely indicate?

Accepted Answer

Answer reason: A laterally displaced PMI in the 6th intercostal space is a hallmark assessment finding of left ventricular hypertrophy, caused by increased workload or chronic hypertension. This physical assessment cue is highly specific to changes in cardiac structure.

Question 3

Normal pulse on scale is _______?

Accepted Answer

Answer reason: A pulse graded as +2 indicates a normal, expected amplitude—easily palpable, not weak, and not bounding. The pulse grading scale ranges from 0 (absent) to +4 (bounding), and +2 is widely accepted as the standard normal finding during cardiovascular assessment.

Question 4

Which term best describes a strong and full pulse volume during physical assessment?

Accepted Answer

Answer reason: A strong, full pulse is described as bounding. Thready indicates a weak pulse, while regular and irregular describe rhythm rather than strength or amplitude.

Question 5

The nurse is assessing the lungs of a patient with asthma. What should the nurse most likely hear?

Accepted Answer

Answer reason: Asthma causes airway narrowing and bronchospasm, producing high-pitched expiratory wheezes. Crackles suggest fluid; a pleural rub indicates pleural inflammation; vascular/vesicular sounds are normal.

Question 6

Nandani is diagnosed with 'strep throat.' Which clinical manifestation would the nurse expect in the client?

Accepted Answer

Answer reason: Streptococcal pharyngitis typically presents with erythematous (fiery red) pharyngeal and tonsillar membranes and fever; other options describe sinusitis or airway issues unrelated to strep throat.

Question 7

Which of the following is NOT a physical assessment finding in Parkinson's disease?

Accepted Answer

Answer reason: Parkinson's disease commonly presents with mask-like facies, dysarthria, and a pill-rolling tremor. Cognitive changes may occur; the absence of cognitive impairment is not a typical physical finding.

Question 8

Tympanic temperature was taken from John, a client who was recently brought into the ER due to a frequent barking cough. The temperature reads 37.9 degrees Celsius. As a nurse, you conclude that this temperature is?

Accepted Answer

Answer reason: The normal tympanic temperature is roughly 36.4–38.0°C. A reading of 37.9°C is within the normal range but near the upper limit, so it is at the high end of the normal range.

Question 9

The clinic nurse assesses a toddler with a tentative diagnosis of neuroblastoma. Symptoms the nurse observes that suggest this problem include?

Accepted Answer

Answer reason: Neuroblastoma in toddlers commonly presents with an irregular abdominal mass that may cross the midline and systemic signs such as weakness, pallor, and weight loss. Other options reflect findings of different conditions (e.g., symptoms of an intracranial tumor or auditory or neurologic deficits) rather than neuroblastoma.

Question 10

An elderly client is admitted to the emergency room. Which symptom is the client with a fractured hip most likely to exhibit?

Accepted Answer

Answer reason: Hip fractures typically present with malalignment of the affected limb—classically, shortening with external rotation. Pain is common but less specific; a cool extremity or absent pulses suggest an uncommon vascular compromise.

Question 11

What is the first action the nurse should take when a client with a myocardial infarction on 2 L/min of oxygen via a nasal cannula develops a sudden onset of a new cardiac rhythm?

Accepted Answer

Answer reason: With a sudden dysrhythmia in an MI patient, first, assess oxygenation. Hypoxemia can precipitate arrhythmias. Check SpO2 before intervening; then increase oxygen, obtain a 12‑lead ECG, and notify the provider as indicated.

Question 12

Brain death is said to occur if there is?

Accepted Answer

Answer reason: Brain death is defined clinically by irreversible coma, the absence of brainstem reflexes, and apnea. Spinal reflexes may persist; hypothermia confounds assessment, and cortical death alone does not meet criteria.

Question 13

The nurse should anticipate that the client with a gastric ulcer will have pain?

Accepted Answer

Answer reason: Gastric ulcer pain typically occurs shortly after eating (30–60 minutes) and is not relieved by food, whereas duodenal ulcer pain occurs 2–3 hours after meals and at night, and is relieved by food.

Question 14

Which of the following statements is true regarding temperature?

Accepted Answer

Answer reason: Rectal thermometers have a blunt, pear-shaped or round bulb to reduce trauma and provide accurate core readings. Oral temperature is less accurate than rectal. BMR decreases with age and increases with activities like swimming.

Question 15

The nurse is reviewing the record of a client with a diagnosis of cirrhosis and notes documentation of asterixis. How should the nurse assess for its presence?

Accepted Answer

Answer reason: Asterixis (flapping tremor), seen in hepatic encephalopathy, is elicited by asking the client to extend the arms with the wrists dorsiflexed and the fingers spread; brief, nonrhythmic lapses cause a flapping motion. Foot dorsiflexion assesses for Homan's sign; abdominal girth measures ascites; leaning forward is for cardiac assessment.

Question 16

While performing a physical examination, the nurse is performing transillumination. Transillumination is basically performed to assess which of the following parts of the body?

Accepted Answer

Answer reason: Transillumination uses a light to assess air-filled versus fluid-filled cavities; it is commonly used to evaluate the frontal and maxillary sinuses for sinusitis.

Question 17

The nurse is caring for a client with status epilepticus. The most important nursing assessment of this client is?

Accepted Answer

Answer reason: Status epilepticus greatly increases cerebral metabolic demand and the risk of hypoxia/anoxia. Continuous monitoring of neurological status—especially the level of consciousness—detects worsening brain injury and guides urgent interventions. Other assessments are secondary.

Question 18

A client has sustained a severe head injury that damaged the occipital lobe. The nurse should remain particularly alert for which of the following problems?

Accepted Answer

Answer reason: The occipital lobe is responsible for visual processing; injury to this area commonly causes visual field deficits or cortical blindness. Swallowing relates to the brainstem and cranial nerves, judgment to the frontal lobe, and hearing to the temporal lobe.

Question 19

Which of the following clients is experiencing an abnormal change in vital signs: a client whose?

Accepted Answer

Answer reason: A drop in blood pressure upon standing indicates orthostatic hypotension, an abnormal vital sign change.

Question 20

A home care nurse visits a client with COPD on 2 L/min of home oxygen who has a respiratory rate of 22 and increased dyspnea. What is the nurse's initial action?

Accepted Answer

Answer reason: The initial nursing action is assessment. For a COPD client with increased dyspnea and an RR of 22, the nurse should first collect data (SpO2, lung sounds, work of breathing, color, mental status) to determine severity before deciding to increase oxygen or call EMS. Reassurance without assessment is inappropriate.

Question 21

The nurse is caring for a client with a Brown-Séquard spinal cord injury. The nurse should expect the client to have?

Accepted Answer

Answer reason: Brown-Sequard (hemisection) causes ipsilateral motor and proprioception loss and contralateral loss of pain and temperature sensation. Thus, the expected finding is sensory loss on the side opposite the injury.

Question 22

In children, what is the most appropriate route for measuring temperature?

Accepted Answer

Answer reason: Rectal temperature provides the most accurate core measurement in infants and young children; oral measurement is unreliable in young children, axillary measurement is less accurate, and the elbow is not a valid route.

Question 23

While assessing vibration sense, the nurse should place the stem of the tuning fork on which of the following parts of the patient's body?

Accepted Answer

Answer reason: Vibration sense is tested by placing the stem of a vibrating tuning fork on bony prominences (e.g., the distal phalanx or the malleolus) to best transmit vibration through bone.

Question 24

Hindrances to auscultation may include all of the following except?

Accepted Answer

Answer reason: Noise, hair rubbing, and patient movement interfere with accurate auscultation. Lightly placing the bell on the skin is the correct technique for hearing low-pitched sounds and is not a hindrance.

Question 25

The nurse is performing an assessment of a client with pneumococcal pneumonia. Which of the following assessments would the nurse anticipate finding?

Accepted Answer

Answer reason: Lobar consolidation in pneumococcal pneumonia transmits bronchial breath sounds to the periphery. Fremitus is typically increased (not decreased), cough is usually productive, and percussion over the consolidation is dull (not hyperresonant).

Question 26

The nurse is assessing a young child during a clinic visit for a mild respiratory infection. Koplik spots are noted on the oral mucous membranes. The nurse recognizes that the presence of these spots suggests?

Accepted Answer

Answer reason: Koplik spots on the buccal mucosa are pathognomonic for measles (rubeola) and appear around one to two days before the rash.

Question 27

The nurse is assessing the heart sounds of a client with mitral stenosis following a history of rheumatic fever. To hear a mitral murmur, the nurse should place the stethoscope at?

Accepted Answer

Answer reason: Mitral valve sounds and murmurs are best heard at the cardiac apex along the left midclavicular line. Among the options, the midclavicular location identifies the mitral area.

Question 28

The body part most likely to display jaundice in the dark-skinned individual is?

Accepted Answer

Answer reason: In dark-skinned clients, jaundice is most reliably observed in areas with minimal pigmentation, such as the hard palate and sclera. Among the options, the roof (hard palate) of the mouth is the best site.

Question 29

While performing a neurological assessment on a client with a closed-head injury, the nurse notes a positive Babinski reflex. The nurse should?

Accepted Answer

Answer reason: In adults, a positive Babinski indicates corticospinal or upper motor neuron dysfunction and is abnormal after a head injury; it may signal worsening neurologic status and should be reported promptly.

Question 30

The nurse is assessing a client with multiple trauma who is at risk for developing acute respiratory distress syndrome. Which is the earliest sign of acute respiratory distress syndrome that the nurse should assess for?

Accepted Answer

Answer reason: Early ARDS presents with hypoxemia and tachypnea before adventitious sounds or increased work of breathing appear. Crackles and retractions typically appear later, and wheezing is not characteristic.

Question 31

Which of the following is a late sign of increased intracranial pressure (ICP) in a child?

Accepted Answer

Answer reason: Bradycardia is part of Cushing’s triad and represents a late sign of increased ICP. Nausea, irritability, and headache are early manifestations.

Question 32

When a Babinski is positive, the great toe ____?

Accepted Answer

Answer reason: A positive Babinski sign is extension (dorsiflexion) of the great toe with or without fanning of the other toes, indicating an upper motor neuron lesion.

Question 33

The nurse is performing the admission assessment of a client with an acute episode of asthma. Which of the following assessments would the nurse anticipate finding?

Accepted Answer

Answer reason: Asthma causes narrowing of the airways, leading to high-pitched expiratory wheezes and prolonged expiration. Purulent sputum suggests infection; prolonged inspiration is not typical, and lethargy is not an expected acute finding.

Question 34

Which of the following statements is true about pulse?

Accepted Answer

Answer reason: Heart rate naturally decreases with aging as vagal tone increases; children and young adults have higher baseline pulse rates.

Question 35

XYZ patient is admitted with abdominal discomfort. As a nurse, you are going to examine the patient's abdomen. What is the best statement you will say to your patient before the examination?

Accepted Answer

Answer reason: Before an abdominal examination, the patient should void to reduce discomfort and to avoid a distended bladder, which can interfere with palpation and percussion. The other options are incorrect for abdominal assessment preparation.

Question 36

A nurse is assessing jugular venous pressure, and she knows the head of the bed should be elevated to ... degrees for the procedure?

Accepted Answer

Answer reason: Jugular venous pressure is best assessed with the patient's head of the bed elevated about 30–45 degrees to visualize venous pulsations; 30 degrees is the standard starting position.

Question 37

An elderly woman is admitted with a fractured right femoral neck. Which clinical manifestation would the nurse expect to find?

Accepted Answer

Answer reason: Femoral neck fractures typically present with pain, limited mobility, external rotation, and apparent shortening of the affected limb due to muscle pull and displacement. Of the options, shortening is the expected finding.

Question 38

A 28-month-old child with severe diarrhea is admitted. Upon assessment, the child is feverish, has dry lips, and is irritable. What is your first nursing priority upon admission?

Accepted Answer

Answer reason: The primary concern in a pediatric client with acute diarrhea is fluid volume deficit. Assessing overall hydration status—including mucous membranes, capillary refill, level of consciousness, and urine output—helps determine the severity of dehydration and guides immediate interventions such as oral or IV fluid replacement. Rapid evaluation prevents progression to hypovolemic shock.

Question 39

During ear examination for a normal Weber test: tuning fork on the top/center of the head?

Accepted Answer

Answer reason: The Weber test evaluates lateralization of sound through bone conduction. In a normal finding, the sound is perceived equally in both ears, indicating balanced auditory function. Lateralization to one side signifies conductive loss in that ear or sensorineural loss in the opposite ear. Proper technique ensures accurate interpretation of auditory health.

Question 40

A rectal glass temperature is taken?

Accepted Answer

Answer reason: For a glass thermometer, a rectal temperature is typically left in place for about 3 minutes to allow an accurate reading; 2 minutes is too short, and 5–10 minutes are unnecessary.

Question 41

Upon admission to the hospital, a client reports having "the worst headache I've ever had." The nurse should give the highest priority to?

Accepted Answer

Answer reason: A sudden, severe 'worst headache' may indicate intracranial hemorrhage. The priority is to obtain a baseline neurological assessment and monitor for deterioration. Analgesics could mask changes; oxygen is not indicated unless the patient is hypoxic; and Foley insertion is not urgent.

Question 42

The most accurate temperature is the?

Accepted Answer

Answer reason: Rectal temperature best reflects core body temperature and is more accurate than oral, axillary, or tympanic routes, which are more affected by environmental and technical factors.

Question 43

In general, the last systems to be assessed are?

Accepted Answer

Answer reason: During a head-to-toe assessment, the most sensitive or invasive areas are examined last to maintain comfort and cooperation; thus, the genitalia, anus, and rectum are assessed last.

Question 44

The nursing assistant reports to the nurse that a client with cirrhosis who had a paracentesis yesterday has become more lethargic and has musty-smelling breath. A critical assessment for increasing encephalopathy is?

Accepted Answer

Answer reason: Musty breath (fetor hepaticus) and lethargy suggest worsening hepatic encephalopathy. Asterixis (a flapping tremor of the hands) is a key assessment finding indicating increasing encephalopathy; the other options do not directly assess this complication.

Question 45

A client is admitted with a possible bowel obstruction. Which question during the nursing history is least helpful in obtaining information about this diagnosis?

Accepted Answer

Answer reason: Key findings of bowel obstruction include colicky pain, vomiting characteristics, and abdominal distention. Asking about the usual diet is less directly informative in diagnosing an acute obstruction than the other focused assessment questions.

Question 46

The nurse is caring for a client after a burn. Which assessment finding best indicates that the client's respiratory efforts are currently adequate?

Accepted Answer

Answer reason: A pulse oximetry reading of 97% provides an objective measure that oxygenation and ventilation are currently adequate. The ability to talk, orientation, or uninhibited chest movement are less specific indicators of effective gas exchange.

Question 47

The following are correct actions when taking a radial pulse, except?

Accepted Answer

Answer reason: The thumb has its own pulse that can be mistaken for the patient's, leading to an inaccurate assessment. Using two or three finger pads at the inner wrist and assessing the rate, rhythm, volume, and bilateral quality are correct actions.

Question 48

When examining a patient with an asthma exacerbation, which lung sound is predominant?

Accepted Answer

Answer reason: An asthma exacerbation causes bronchospasm and airway narrowing, producing high-pitched expiratory wheezes as the predominant lung sounds.

Question 49

What is the temperature difference between oral and axillary measurements?

Accepted Answer

Answer reason: Axillary temperature readings are typically about 0.5°C lower than oral temperatures, so the expected difference is 0.5°C.

Question 50

Nails are normally transparent, smooth, and convex, with a nail bed angle of about degrees?

Accepted Answer

Answer reason: The normal angle between the nail plate and nail bed is about 160 degrees; angles approaching 180 degrees suggest clubbing.

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