Question 1

Schamroth window test is done for?

Accepted Answer

Answer reason: The Schamroth window test assesses for digital clubbing; loss of the diamond-shaped window between opposing nails indicates clubbing.

Question 2

_____ is a diagnostic test for carpal tunnel syndrome?

Accepted Answer

Answer reason: Phalen's maneuver provokes paresthesia in the median nerve distribution and is a standard bedside test for carpal tunnel syndrome.

Question 3

Glasgow Coma Scale (GCS) is a measure of?

Accepted Answer

Answer reason: The Glasgow Coma Scale evaluates eye opening, verbal, and motor responses to determine a patient’s level of consciousness (LOC), not memory, fluid volume, or direct ICP.

Question 4

An 18-year-old woman comes to the physician’s office for a routine prenatal checkup at 34 weeks gestation. Abdominal palpation reveals the fetal position as right occipital anterior (ROA). At which of the following sites would the nurse expect to find the fetal heart tone?

Accepted Answer

Answer reason: In ROA the fetus is in a cephalic (vertex) presentation with its back on the mother’s right anterior side. Fetal heart tones are best heard over the fetal back and, in vertex, below the umbilicus—thus below the umbilicus on the mother’s right.

Question 5

Which obstetric grip permits determination of the fetal presentation?

Accepted Answer

Answer reason: Pawlik’s grip (the third Leopold maneuver) identifies the presenting part over the pelvic inlet and thus determines fetal presentation.

Question 6

GCS introduced in which year?

Accepted Answer

Answer reason: The Glasgow Coma Scale was introduced by Teasdale and Jennett in 1974.

Question 7

Severe head injury GCS score?

Accepted Answer

Answer reason: Severe traumatic brain injury is defined as Glasgow Coma Scale score of 8 or less; moderate is 9–12 and mild is 13–15.

Question 8

Earliest sign of increased ICP?

Accepted Answer

Answer reason: The most sensitive and earliest indicator of rising intracranial pressure is a change in level of consciousness (e.g., confusion, restlessness). Papilledema and hypertension are late signs.

Question 9

The nurse is going to assess a pressure ulcer for healing progress. Which tool would be appropriate?

Accepted Answer

Answer reason: The PUSH (Pressure Ulcer Scale for Healing) is specifically designed to monitor and quantify healing progress of pressure ulcers. Braden and Norton assess risk of development; staging tools classify stage, not healing.

Question 10

In order to assess a femoral pulse, you would palpate the patient?

Accepted Answer

Answer reason: The femoral artery is palpated in the femoral triangle of the groin, just below the inguinal ligament.

Question 11

During each patient contact in a motorcycle accident what action should the nurse perform most frequently-?

Accepted Answer

Answer reason: In trauma care the priority during every contact is ongoing reassessment—checking ABCs and patient status—to detect changes early. This is done more frequently than planning, positioning checks, or ambulation.

Question 12

The nurse would assess the progress of ascites on a daily basis by?

Accepted Answer

Answer reason: Ascites reflects fluid accumulation; the best daily indicators of change are weight and abdominal girth measurements. I&O, electrolytes, vital signs, and oxygen levels do not directly quantify ascitic fluid.

Question 13

During the change of shift report, the nurse states that the client's last pulse strength was a 1+. The oncoming nurse recognizes that the client's pulse was?

Accepted Answer

Answer reason: Peripheral pulse grading: 0 absent, 1+ weak/thready, 2+ normal, 3+ full, 4+ bounding. Therefore a 1+ pulse is weak.

Question 14

The nurse is observing the respirations of a client when she notes that the respiratory cycle is marked by periods of apnea lasting from 10 seconds to 1 minute. The apnea is followed by respirations that gradually increase in depth and frequency. The nurse should document that the client is experiencing?

Accepted Answer

Answer reason: Cheyne-Stokes is characterized by cyclical periods of apnea followed by respirations that gradually increase and then decrease in depth and frequency. Kussmaul is deep, rapid breathing; Biot is irregular clusters with abrupt apnea; diaphragmatic refers to breathing pattern using the diaphragm.

Question 15

A client is diagnosed with bleeding from the upper gastrointestinal system. The nurse would expect the client's stools to be?

Accepted Answer

Answer reason: Upper GI bleeding produces melena—digested blood in the stool—resulting in black, tarry stools.

Question 16

The nurse is assessing elderly clients at a community center. Which of the following findings would be the most cause for concern?

Accepted Answer

Answer reason: Bilateral rales (crackles) suggest pulmonary edema or heart failure and require prompt evaluation, making this more urgent than common age-related changes like dry mouth, mild height loss, or stiff joints.

Question 17

A client with a head injury has an intracranial pressure (ICP) monitor in place. Cerebral perfusion pressure calculations are ordered. If the client's ICP is 22 and the mean pressure reading is 70, what is the client's cerebral perfusion pressure?

Accepted Answer

Answer reason: Cerebral perfusion pressure = MAP − ICP. 70 − 22 = 48 mm Hg.

Question 18

A client is admitted with a diagnosis of pernicious anemia. Which of the following signs or symptoms would indicate that the client has been noncompliant with ordered B12 injections?

Accepted Answer

Answer reason: Pernicious anemia (vitamin B12 deficiency) causes neurologic manifestations such as numbness and tingling in the hands and feet; their presence suggests inadequate B12 replacement. The other options are not characteristic of B12 deficiency.

Question 19

A client is being evaluated for carpel tunnel syndrome. The nurse is observed tapping over the median nerve in the wrist and asking the client if there is pain or tingling. Which assessment is the nurse performing?

Accepted Answer

Answer reason: Tapping over the median nerve eliciting pain or tingling indicates Tinel’s sign, used to assess carpal tunnel syndrome. Phalen’s is wrist flexion; Kernig’s and Brudzinski’s are meningeal signs.

Question 20

The nurse is performing a breast exam on a client when she discovers a mass. Which characteristic of the mass would most indicate a reason for concern?

Accepted Answer

Answer reason: Malignant breast masses are typically hard/firm, irregular, and fixed and usually non-tender. Of the options, firmness is the most concerning feature; tenderness, regular shape, and mobility suggest benign etiologies.

Question 21

A client has developed diabetes insipidus after removal of a pituitary tumor. Which finding would the nurse expect?

Accepted Answer

Answer reason: Postoperative pituitary damage can decrease ADH secretion, causing diabetes insipidus characterized by large volumes of dilute urine (polyuria). Hypertension, polyphagia, and hyperkalemia are not typical findings.

Question 22

The nurse is caring for a client with possible cervical cancer. What clinical data would the nurse most likely find in the client's history?

Accepted Answer

Answer reason: Postcoital bleeding is a classic early symptom of cervical cancer due to friable cervical lesions. Nausea/vomiting and fever are nonspecific; foul-smelling discharge may occur later but is less specific than contact bleeding.

Question 23

The nurse caring for a client with a head injury would recognize which assessment finding as the most indicative of increased ICP?

Accepted Answer

Answer reason: Papilledema (optic disc swelling) is a classic, more specific sign of increased intracranial pressure compared with nonspecific symptoms like headache, nausea/vomiting, or dizziness.

Question 24

The nurse is assessing a client upon arrival to the emergency department. Partial airway obstruction is suspected. Which clinical manifestation is a late sign of airway obstruction?

Accepted Answer

Answer reason: Cyanosis is a late sign of hypoxia from airway obstruction. Restlessness is an early sign, stridor indicates obstruction but is not a late manifestation, and rales are more associated with fluid in the lungs rather than airway blockage.

Question 25

A client is experiencing acute abdominal pain. Which abdominal assessment sequence is appropriate for the nurse to use for examination of the abdomen?

Accepted Answer

Answer reason: For abdominal assessment, inspection is followed by auscultation before other maneuvers to avoid stimulating or altering bowel sounds; this sequence best fits option B among the choices.

Question 26

The nurse is caring for a client following a crushing injury to the chest. Which finding would be most indicative of a tension pneumothorax?

Accepted Answer

Answer reason: Tension pneumothorax increases intrapleural pressure causing mediastinal shift with tracheal deviation away from the affected side. Other findings are less specific or indicate different problems.

Question 27

Which assessment finding in a client with COPD indicates to the nurse that the respiratory problem is chronic?

Accepted Answer

Answer reason: Digital clubbing reflects long-standing hypoxemia from chronic cardiopulmonary disease such as COPD. Wheezing, productive cough, and cyanosis can occur in acute or chronic episodes and do not specifically indicate chronicity.

Question 28

The nurse is performing a neurological assessment on a client admitted with TIAs. Assessment findings reveal an absence of the gag reflex. The nurse suspects injury to?

Accepted Answer

Answer reason: The gag reflex is primarily mediated by cranial nerve IX (afferent limb) with motor output via X; loss of the reflex most directly indicates glossopharyngeal nerve injury.

Question 29

A student in a cardiac unit is performing auscultation of a client's heart. The nurse recognizes that the student is performing pulmonic auscultation correctly when the stethoscope is placed?

Accepted Answer

Answer reason: The pulmonic valve area is auscultated at the left second intercostal space along the sternal border. The 5th ICS MCL is the mitral area; the other sites are not the pulmonic area.

Question 30

A client with appendicitis reports increased pain when releasing pressure after deep palpation over the right lower quadrant. This assessment finding is known as?

Accepted Answer

Answer reason: Pain that worsens on sudden release after deep palpation indicates peritoneal irritation—rebound tenderness (Blumberg sign)—commonly seen in appendicitis. Murphy's sign is for cholecystitis, Rovsing's sign is RLQ pain with LLQ palpation, and Cullen's sign is periumbilical ecchymosis.

Question 31

Which of the following are priority assessment data to gather from a client diagnosed with pneumonia?

Accepted Answer

Answer reason: Pneumonia primarily compromises gas exchange in the lungs, so the top priority is assessing respiratory status—listening to breath sounds for crackles, wheezes, or diminished sounds.

Question 32

Which step should the nurse perform first during a well-baby checkup for an 8-month-old infant sitting on the mother's lap?

Accepted Answer

Answer reason: For infants, perform the least invasive and most quiet assessments first while the child is calm. Auscultating heart and lungs should be done before measurements or shining light in the eyes, which may upset the infant.

Question 33

When should the nurse notify the physician regarding a patient in Buck's traction?

Accepted Answer

Answer reason: Neurovascular compromise (e.g., decreased pulses, paresthesia, pallor, paralysis) indicates potential limb ischemia/compartment syndrome and requires immediate provider notification in a patient in traction.

Question 34

Which is the best method to use for determining the degree of early ascites in a client with chronic hepatitis?

Accepted Answer

Answer reason: Serial abdominal girth is the most reliable bedside method to quantify and monitor early ascites. Inspection is insensitive early, hepatomegaly does not gauge ascites, and a fluid wave usually appears only with large-volume ascites.

Question 35

Which of the following describes decerebrate posturing?

Accepted Answer

Answer reason: Decerebrate posturing is an extensor pattern with arching of the back and rigid extension of the arms and legs. Flexor posturing (decorticate) is described in option A.

Question 36

Which question should the nurse ask to determine a long-term effect of cleft palate repair in a preschooler during a routine well-child checkup?

Accepted Answer

Answer reason: Children with cleft palate are at risk for chronic otitis media and conductive hearing loss even after repair; asking about the child’s response when called screens for hearing impairment, a common long-term issue.

Question 37

When taking the health history of a client admitted for repair of cystocele and rectocele, what symptoms should the nurse expect the client to report?

Accepted Answer

Answer reason: Cystocele and rectocele (pelvic organ prolapse) commonly cause urinary incontinence and a sensation of pelvic/low abdominal pressure; other options reflect infections or unrelated GI symptoms.

Question 38

Which nursing assessment is the highest priority to assure client safety for a client who had an orthopedic leg injury requiring surgery and application of a cast?

Accepted Answer

Answer reason: After leg surgery with a cast, the priority is neurovascular checks distal to the cast to prevent ischemia/compartment syndrome. Assessing capillary refill by blanching toenail beds best ensures circulation and client safety; the other options are lower priority.

Question 39

A patient's record shows a respiratory rate of 22 breaths per minute while resting; what is the most appropriate nursing action?

Accepted Answer

Answer reason: Normal adult respiratory rate is 12-20/min. A rate of 22/min at rest is mildly elevated but not emergent; the priority is to verify and reassess after a short interval before escalating.

Question 40

Which manifestations does a nurse expect to find in a 4-year-old child with celiac disease during assessment and health history?

Accepted Answer

Answer reason: Celiac disease causes malabsorption leading to steatorrhea (foul-smelling stools), malnutrition, and muscle wasting; option A describes these classic findings.

Question 41

Which observation most concerns the nurse assessing a client diagnosed with burns in the emergency department?

Accepted Answer

Answer reason: A charred, waxy white appearance indicates a full-thickness (third-degree) burn with severe tissue destruction and poor perfusion, making it the most critical finding compared with partial-thickness or superficial burns.

Question 42

Which question should the nurse ask to help determine if a client who has fallen and sustained a leg injury has a fracture?

Accepted Answer

Answer reason: Fracture pain is typically sharp, localized, and continuous, worsening with movement. Dull ache, cramping, or a stretched feeling suggest strain, spasm, or sprain rather than fracture.

Question 43

While measuring a patient's apical pulse, where should the nurse place the stethoscope?

Accepted Answer

Answer reason: The apical impulse/mitral area is auscultated at the left 5th intercostal space along the midclavicular line, which is where the apical pulse is best heard.

Question 44

Which nursing intervention is appropriate for a client with liver cirrhosis who develops ascites?

Accepted Answer

Answer reason: Ascites is monitored by measuring abdominal girth daily to track fluid accumulation. High sodium worsens fluid retention, routine fluid restriction to 3 L/day is not appropriate (restriction is usually stricter and based on hyponatremia), and Trendelenburg is not indicated.

Question 45

Which stage of pressure ulcer is characterized by skin breaks, abrasion, blister, or shallow crater with edema and infection?

Accepted Answer

Answer reason: Stage II pressure ulcers involve partial-thickness skin loss and present as an abrasion, blister, or shallow crater; Stage I is intact skin, while Stages III–IV are full-thickness.

Question 46

What is the best method for determining the degree of early ascites in a client with chronic hepatitis?

Accepted Answer

Answer reason: Serial abdominal girth measurement provides an objective, sensitive way to track changes in ascitic fluid volume early; inspection/palpation are less sensitive and a fluid wave is often absent with small volumes.

Question 47

What does a Glasgow Coma Scale (GCS) score of 3-5-4 indicate about the client's level of consciousness?

Accepted Answer

Answer reason: GCS is scored E-V-M. A score of 3-5-4 corresponds to E3 (opens eyes to speech), V5 (oriented verbal response), and M4 (withdraws to pain). Therefore, the accurate statement is that the client can open eyes when spoken to.

Question 48

Which respiratory finding indicates that a client's asthma status is worsening?

Accepted Answer

Answer reason: Markedly diminished or absent breath sounds indicate critically reduced airflow from severe bronchoconstriction and impending respiratory failure—an ominous sign of worsening asthma. Loud wheezing can occur with obstruction but is less concerning than near-silent lungs; emotional apprehension is not a respiratory finding.

Question 49

What clinical signs should the nurse expect in a prenatal client diagnosed with a vaginal infection caused by Candida albicans?

Accepted Answer

Answer reason: Candida vaginitis typically presents with vulvovaginal pruritus, irritation/pain, and a characteristic discharge. Costovertebral angle pain suggests pyelonephritis, absence of signs is incorrect, and proteinuria/hematuria/hypertension indicate other conditions such as preeclampsia or renal disease.

Question 50

Which assessment would be most important for a nurse to perform on a 65-year-old patient presenting with persistent diplopia?

Accepted Answer

Answer reason: Persistent diplopia suggests cranial nerve dysfunction or intracranial pathology; the priority is a comprehensive neurologic evaluation, including cranial nerves III, IV, and VI, rather than isolated ocular tests.

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