Question 1

Abnormal facial expressions include all of the following except?

Accepted Answer

Answer reason: Tremors, flat affect, and unilateral facial drooping are abnormal findings; an alert and appropriate facial expression is normal, so it is the exception.

Question 2

The following cannot be assessed in the comatose patient?

Accepted Answer

Answer reason: Neurologic reflexes, cardiovascular status, and musculoskeletal tone can be assessed objectively in coma, but psychological status requires consciousness and communication, so it cannot be assessed.

Question 3

Using sense of touch with different parts of hands and with different degree of pressure is called?

Accepted Answer

Answer reason: Palpation is the assessment technique that uses the sense of touch with different hand parts and varying pressure to evaluate structures and tenderness.

Question 4

Color, size, shape, position and symmetry can be assessed using?

Accepted Answer

Answer reason: These characteristics are visual findings best assessed by inspection; palpation, percussion, and auscultation evaluate different qualities.

Question 5

Objective data gathered during patient assessment includes all but which one of the following?

Accepted Answer

Answer reason: Objective data are observable and measurable (exam findings, records, labs/diagnostics). Patient interviews elicit subjective data, so that pair is not purely objective.

Question 6

When assessing physical presence, abnormal findings include?

Accepted Answer

Answer reason: Asymmetry in general appearance is abnormal. Stated age matching apparent age, even fat distribution, and erect posture are normal findings.

Question 7

Which of the following is reflective of the tympanic body temperature route?

Accepted Answer

Answer reason: Tympanic temperatures reflect core blood supply from the carotid artery and typically read about 0.3–0.6°C (0.5–1.0°F) higher than oral values.

Question 8

If a peripheral pulse is not palpable, attempt to ascertain its presence with a?

Accepted Answer

Answer reason: A Doppler ultrasonic device detects blood flow when a peripheral pulse cannot be palpated; stethoscope bell/diaphragm are for auscultation and a goniometer measures joint angles.

Question 9

This sign is positive in inflammatory processes of the gallbladder, such as cholecystitis?

Accepted Answer

Answer reason: Murphy's sign—arrest of inspiration during deep palpation of the right upper quadrant—is classic for cholecystitis. Rovsing's sign is for appendicitis, Homan's for DVT, and Hook's sign is not the recognized gallbladder test.

Question 10

The nurse suspect tumor, infection around the liver or splenic infarction in the emergency department. The nurse auscultate over the liver and spleen for?

Accepted Answer

Answer reason: Inflammation or infarction involving the liver or spleen produces a peritoneal friction rub heard over those organs. Bruits are vascular, venous hum suggests portal hypertension, and borborygmus are bowel sounds.

Question 11

For Brachioradialis reflexes assessment reflex hammer should strike?

Accepted Answer

Answer reason: The brachioradialis tendon is tapped about 1–2 inches proximal to the wrist on the radial side to elicit the brachioradialis reflex; other locations are unrelated.

Question 12

The frontal sutures, large anterior fontanel, orbital ridges, eyes, and root of the nose are felt on vaginal examination, but neither the mouth nor the chin is palpable. This presentation is?

Accepted Answer

Answer reason: Palpation of anterior fontanel with orbital ridges/eyes and the root of the nose but absence of mouth and chin is classic for brow presentation. Face presentation would include mouth and chin; breech and compound do not match these findings.

Question 13

Ask the client to stand with feet together and arms at sides and eyes open then with eyes closed for 20 second. This test is performed for?

Accepted Answer

Answer reason: The described maneuver is the Romberg test, which evaluates balance/equilibrium (vestibular and proprioceptive function). Air and bone conduction are assessed by Rinne/Weber tests.

Question 14

The appropriate position for abdominal assessment is?

Accepted Answer

Answer reason: Abdominal assessment is best done with the client lying supine and the abdominal muscles relaxed; arms should be at the sides or folded across the chest. High Fowler or prone positions tense or misposition the abdomen.

Question 15

Stereognosis is the test always done with the patient eyes close to assess the?

Accepted Answer

Answer reason: Stereognosis assesses cortical sensory function by having the patient, with eyes closed, identify familiar objects by touch. It does not assess gait/posture or vision.

Question 16

The point of maximal impulse/apical pulse should assess on midclavicular line?

Accepted Answer

Answer reason: The PMI/apical impulse is normally located at the left 5th intercostal space at the midclavicular line, also called the mitral area; it is not at the heart base.

Question 17

The nurse would expect to develop crepitus in a patient with osteoarthritis of the knee during which physical assessment technique?

Accepted Answer

Answer reason: Joint crepitus in osteoarthritis is best detected by feeling a grating sensation while palpating the joint during movement.

Question 18

Which of the following is the most basic function and therefore should be tested first in an assessment of mental status?

Accepted Answer

Answer reason: Level of consciousness is the foundational element of the mental status exam and must be assessed first because it affects the validity of other assessments such as behavior, judgment, and language.

Question 19

Pt stands for 2-30 seconds with both arms straight forward, palms up, tap arms downward; this test is called?

Accepted Answer

Answer reason: Extending both arms forward with palms up for ~20–30 seconds and observing for downward drift/pronation assesses for pronator drift, a sign of corticospinal tract dysfunction.

Question 20

Which pulse is measured on the left side of the chest directly over the heart?

Accepted Answer

Answer reason: The apical pulse is measured at the apex of the heart on the left 5th intercostal space at the midclavicular line, directly over the heart. Brachial (upper arm), carotid (neck), and radial (wrist) are not over the heart.

Question 21

When palpating the client's neck for lymphadenopathy, where should the nurse position himself?

Accepted Answer

Answer reason: Cervical lymph node palpation is performed with the client seated and the examiner facing the client to systematically compare both sides.

Question 22

Considered as Safest and most non invasive method of temperature taking?

Accepted Answer

Answer reason: Axillary temperature measurement is the least invasive and safest site; oral and rectal are more invasive and tympanic can be contraindicated or risk ear trauma, especially in children.

Question 23

Which of the following is a OBJECTIVE data?

Accepted Answer

Answer reason: Objective data are observable and measurable signs noted by the nurse; blue nails (cyanosis) are visible. Dizziness, chest pain, and anxiety are subjective symptoms reported by the patient.

Question 24

Client has undergone Upper GI and Lower GI series. Which type of health assessment framework is used in this situation?

Accepted Answer

Answer reason: Upper and lower GI studies organize assessment findings by the gastrointestinal system, which corresponds to a body system framework.

Question 25

A nurse finds that a patient cannot identify different scents when eyes are closed. Which cranial nerve is affected?

Accepted Answer

Answer reason: Inability to identify scents indicates loss of smell, which is mediated by the olfactory nerve (cranial nerve I).

Question 26

A client is admitted with acute glomerulonephritis. What is the priority nursing intervention?

Accepted Answer

Answer reason: Acute glomerulonephritis often causes fluid retention and hypertension, risking hypertensive crisis and encephalopathy. Continuous blood pressure monitoring is the immediate priority to detect and manage this complication. Antibiotics may be needed if infection persists and fluids/diuretics are secondary to provider orders, but first priority is BP monitoring.

Question 27

What is the first sign of infection in an elderly patient?

Accepted Answer

Answer reason: Older adults often lack classic febrile responses; acute confusion/delirium is a common early sign of infection such as UTI or pneumonia.

Question 28

The sphygmomanometer is used to measure what?

Accepted Answer

Answer reason: A sphygmomanometer is the blood pressure cuff used to measure arterial blood pressure; it does not measure glucose, pulse, or blood group.

Question 29

Which assessment test is used to evaluate median nerve compression by wrist flexion?

Accepted Answer

Answer reason: Phalen’s test flexes the wrists to provoke symptoms of carpal tunnel syndrome due to median nerve compression. Allen’s tests arterial patency, Ortolani detects hip dysplasia, and Russell’s sign refers to knuckle abrasions from induced vomiting.

Question 30

Crackles are commonly seen in which condition?

Accepted Answer

Answer reason: Crackles (rales) result from fluid in the alveoli and are classically heard in pulmonary edema; asthma and emphysema more often produce wheezes or diminished sounds, and hypoventilation does not typically cause crackles.

Question 31

Which instrument is placed against a patient's chest to hear both lung and heart sounds?

Accepted Answer

Answer reason: A stethoscope is used for auscultation of heart and lung sounds by placing the diaphragm or bell against the chest.

Question 32

A nurse receives a report that a client scores 7 on the Glasgow Coma Scale; which level of consciousness does this indicate?

Accepted Answer

Answer reason: A Glasgow Coma Scale score of 7 is ≤8, which indicates coma (severe impairment of consciousness).

Question 33

Crackles heard on lung auscultation indicate which of the following?

Accepted Answer

Answer reason: Crackles (rales) are discontinuous sounds caused by air moving through fluid in the alveoli, as in pulmonary edema or pneumonia. Bronchospasm/airway narrowing produce wheezes; cyanosis is a visual sign, not an auscultatory finding.

Question 34

The nurse is caring for a client with suspected endometrial cancer. Which symptom is associated with endometrial cancer?

Accepted Answer

Answer reason: Endometrial cancer commonly presents with abnormal uterine bleeding and a thin watery or blood-tinged vaginal discharge. Frothy (trichomoniasis), thick white (candidiasis), and purulent (bacterial infection) discharges indicate infections, not endometrial cancer.

Question 35

The nurse is preparing to administer an injection to a 6-month-old when she notices a white dot in the infant's right pupil. The nurse should?

Accepted Answer

Answer reason: A white pupil can indicate serious pathology such as congenital cataract or retinoblastoma. The nurse should first further assess by checking for a bilateral red reflex; absence or asymmetry warrants urgent referral. Simply documenting or assuming normal is unsafe.

Question 36

An 18-month-old is admitted to the hospital with acute laryngotracheobronchitis. When assessing the respiratory status, the nurse should expect to find?

Accepted Answer

Answer reason: Croup (laryngotracheobronchitis) is an upper-airway illness with classic findings of a harsh barking cough and inspiratory stridor. Drooling suggests epiglottitis, and wheezing is a lower-airway sign seen in asthma/bronchiolitis.

Question 37

When assessing the client with acute arterial occlusion, the nurse would expect to find?

Accepted Answer

Answer reason: Acute arterial occlusion causes distal ischemia (6 Ps). Small black areas on the toes reflect tissue necrosis from emboli/ischemia. Edema and redness/warmth suggest venous problems, and pain occurs distal—not above—the occlusion.

Question 38

A client sustained a severe head injury to the occipital lobe. The nurse should carefully assess the client for?

Accepted Answer

Answer reason: The occipital lobe is the brain’s visual processing center; injury commonly causes visual disturbances. Speech (temporal/frontal), judgment (frontal), and hearing (temporal) are less directly related.

Question 39

The doctor has ordered neurological checks every 30 minutes for a client injured in a biking accident. Which finding indicates that the client's condition is satisfactory?

Accepted Answer

Answer reason: A GCS score of 13 indicates mild impairment and a relatively stable neurologic status. The other findings suggest significant neurologic compromise: doll's eye testing applies to comatose patients, absence of deep tendon reflexes is abnormal, and decerebrate posturing indicates severe brainstem injury.

Question 40

When checking patellar reflexes, the nurse is unable to elicit a knee-jerk response. To facilitate checking the patellar reflex, the nurse should tell the client to?

Accepted Answer

Answer reason: Having the client hook and pull interlocked fingers (Jendrassik maneuver) reinforces and distracts to enhance the patellar deep tendon reflex when it is difficult to elicit.

Question 41

The nurse is performing a physical assessment on a newly admitted client. The last step in the physical assessment is?

Accepted Answer

Answer reason: Standard assessment sequence is inspection, palpation, percussion, then auscultation (except abdomen). Therefore, the last step is auscultation.

Question 42

A client suspected of having Alzheimer's disease is evaluated using the Mini-Mental State Examination. At the beginning of the evaluation, the examiner names three objects. Later in the evaluation, he asks the client to name the same three objects. The examiner is testing the client's?

Accepted Answer

Answer reason: In the MMSE, asking for the three items later assesses short-term memory (recall). Immediate repetition of the items at the time they are presented tests registration.

Question 43

The nurse is using the Glasgow coma scale to assess the client's motor response. The nurse places pressure at the base of the client's fingernail for 20 seconds. The client's only response is withdrawal of his hand. The nurse interprets the client's response as?

Accepted Answer

Answer reason: Withdrawal from painful nail-bed pressure corresponds to Glasgow Coma Scale motor response M4 (flexion-withdrawal). It is not obeying commands (M6) or localizing pain (M5), and extension would be M2, not M3.

Question 44

The nurse is providing care for a 10-month-old diagnosed with Wilms tumor. Most parents of infants with Wilms tumor report finding the mass when?

Accepted Answer

Answer reason: Wilms tumor typically presents as a painless abdominal mass often first noticed by parents during bathing or diapering.

Question 45

The nurse is assessing a client with an altered level of consciousness. One of the first signs of altered level of consciousness is?

Accepted Answer

Answer reason: Early neurological deterioration often presents with subtle behavioral changes such as restlessness and irritability before focal deficits or pupillary changes appear.

Question 46

The nurse is caring for a client with Lyme's disease. The nurse should carefully monitor the client for signs of neurological complications, which include?

Accepted Answer

Answer reason: Neurologic Lyme disease commonly causes cranial nerve VII palsy (Bell’s palsy), presenting as facial weakness or paralysis with a pulling or "drawing" sensation on one side. The other options describe findings more consistent with multiple sclerosis (intention tremor, trigeminal neuralgia) or myasthenia/ALS-like features, not typical Lyme complications.

Question 47

A client is transferred to the intensive care unit following a coronary artery bypass graft. Which one of the post-surgical assessments should be reported to the physician?

Accepted Answer

Answer reason: A CVP of 15 (abnormal) indicates hemodynamic compromise such as fluid overload/right-sided strain; this should be reported. The other findings—urine output 50 mL/hr, temp 99°F, and strong pedal pulses—are expected/acceptable post-op.

Question 48

The nurse is caring for a client with a closed head injury. A late sign of increased intracranial pressure is?

Accepted Answer

Answer reason: Pupillary changes (unequal, sluggish or nonreactive) are a late sign of rising ICP. Headache, nausea/vomiting, and restlessness/irritability are early signs.

Question 49

The nurse is conducting an admission assessment of a client with vitamin B12 deficiency. Which finding reinforces the diagnosis of B12 deficiency?

Accepted Answer

Answer reason: Vitamin B12 deficiency (pernicious/megaloblastic anemia) commonly presents with glossitis, described as a smooth beefy red tongue. Elevated BP and bradycardia are not typical features; splenomegaly is not a key confirming sign.

Question 50

The nurse is conducting a physical assessment on a client with anemia. Which of the following clinical manifestations would be most indicative of the anemia?

Accepted Answer

Answer reason: Anemia decreases oxygen-carrying capacity, leading to hypoxia with tachypnea/shallow respirations. Hypertension, weight gain, and a pink complexion are not typical indicators; pallor rather than pinkness is expected.

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