Question 1

Where is the best site for examining for the presence of petechiae in an African American client?

Accepted Answer

Answer reason: In dark-skinned clients, color changes and small hemorrhages are best assessed in less pigmented areas such as the palms and soles; among the options, the soles of the feet provide the best visualization for petechiae.

Question 2

The client is being evaluated for possible acute leukemia. Which inquiry by the nurse is most important?

Accepted Answer

Answer reason: Acute leukemia causes ineffective leukocytes and neutropenia, making infection—especially recurrent respiratory infections—a key and potentially life‑threatening manifestation. Assessing recent infections is the highest‑priority inquiry over nonspecific symptoms like sleep or weight changes.

Question 3

The client is admitted with left-sided congestive heart failure. In assessing the client for edema, the nurse should check the?

Accepted Answer

Answer reason: Dependent edema is assessed in the lowest extremities; in ambulatory clients this is the ankles/feet. Neck suggests JVD (not edema), hands are not dependent, and sacrum is checked mainly for bedbound clients.

Question 4

The best method of evaluating the amount of peripheral edema is?

Accepted Answer

Answer reason: Circumference measurements of the affected limb provide an objective, reproducible way to quantify and trend peripheral edema. Daily weight reflects overall fluid status, pitting indicates presence not amount, and intake/output is nonspecific for peripheral edema.

Question 5

The client with Alzheimer's disease is being assisted with activities of daily living when the nurse notes that the client uses her toothbrush to brush her hair. The nurse is aware that the client is exhibiting?

Accepted Answer

Answer reason: Using a toothbrush to brush hair indicates failure to recognize or correctly identify the object (toothbrush), which is agnosia. Apraxia is an inability to carry out purposeful motor acts, and aphasia/anomia involve language and naming, not object recognition.

Question 6

The 5-year-old is being tested for enterobiasis (pinworms). Which symptom is associated with enterobiasis?

Accepted Answer

Answer reason: Enterobiasis (pinworms) causes nocturnal perianal irritation as female worms lay eggs around the anus, leading to rectal itching; the other symptoms are not characteristic.

Question 7

Which action is contraindicated in the client with epiglottis?

Accepted Answer

Answer reason: In suspected epiglottitis, inserting a tongue blade to assess the throat can precipitate laryngospasm and complete airway obstruction; therefore it is contraindicated.

Question 8

A 25-year-old client with a goiter is admitted to the unit. What would the nurse expect the admitting assessment to reveal?

Accepted Answer

Answer reason: Goiter in a young adult is commonly due to Graves disease (hyperthyroidism), which characteristically presents with exophthalmos (bulging eyes). Slow pulse and weight gain suggest hypothyroidism, and anorexia is not typical of hyperthyroidism.

Question 9

Arterial ulcers are best described as ulcers that?

Accepted Answer

Answer reason: Arterial ulcers typically have well-defined, smooth, punched-out edges. Venous ulcers more often have irregular borders. While arterial ulcers may be painful and the extremity cool, the hallmark descriptor is smooth, even margins.

Question 10

What is the priority nursing assessment after transsphenoidal surgery to remove a pituitary tumor in a patient with acromegaly?

Accepted Answer

Answer reason: After transsphenoidal pituitary surgery, the immediate priority is frequent neurological assessment to detect increased intracranial pressure, hemorrhage, or CSF leak. Monitoring urine output for DI is important but secondary to neuro status.

Question 11

If a patient has a pacemaker, which ECG lead should the nurse particularly monitor?

Accepted Answer

Answer reason: Pacemaker spikes and capture are best visualized in the anterior/septal leads (V1–V2). Among the choices, V2 most reliably shows pacer spikes and ventricular capture.

Question 12

A client is admitted with a diagnosis of polycythemia vera. The nurse should closely monitor the client for?

Accepted Answer

Answer reason: Polycythemia vera increases red cell mass and blood viscosity, leading to hypervolemia and hypertension. O2 saturation is usually normal; decreased respirations and increased urine output are not typical findings.

Question 13

The nurse is completing an assessment history of a client with pernicious anemia. Which complaint differentiates pernicious anemia from other types of anemia?

Accepted Answer

Answer reason: Pernicious anemia (vitamin B12 deficiency) uniquely causes neurologic symptoms such as paresthesias. Dyspnea on exertion, tachycardia, and lightheadedness are common to many anemias and are not distinctive.

Question 14

A client is admitted with suspected abdominal aortic aneurysm (AAA). A common complaint of the client with an abdominal aortic aneurysm is?

Accepted Answer

Answer reason: AAA often presents with a palpable/visible pulsating mass in the periumbilical area; back pain may occur but is not typically relieved by standing, and decreased urine output or extremity numbness are not common initial complaints.

Question 15

A 5-month-old infant is admitted to the ER with a temperature of 103.6°F and irritability. The mother states that the child has been listless for the past several hours and that he had a seizure on the way to the hospital. A lumbar puncture confirms a diagnosis of bacterial meningitis. The nurse should assess the infant for?

Accepted Answer

Answer reason: Meningitis can increase intracranial pressure in infants; a key sign is bulging/tenseness of the anterior fontanel. Periorbital edema is unrelated, a positive Babinski is normal in infants, and the scarf sign relates to gestational maturity, not meningitis.

Question 16

A toddler with otitis media has just completed antibiotic therapy. A recheck appointment should be made to?

Accepted Answer

Answer reason: Post-treatment follow-up for acute otitis media is to assess the ear and verify resolution of infection/persistent effusion. It is not primarily for compliance checks, routine hearing testing, or obtaining a new prescription.

Question 17

A client is admitted with a diagnosis of myxedema. An initial assessment of the client would reveal the symptoms of?

Accepted Answer

Answer reason: Myxedema is severe hypothyroidism. Expected findings include decreased metabolic rate with weight gain, lethargy, slow speech, bradycardia/hypoventilation. Option B matches these features.

Question 18

A 2-year-old is hospitalized with suspected intussusception. Which finding is associated with intussusception?

Accepted Answer

Answer reason: Intussusception causes bowel ischemia and mucosal sloughing leading to blood and mucus in the stool—classically described as "currant jelly." Projectile vomiting suggests pyloric stenosis; ribbonlike stools are seen with Hirschsprung disease; a flank mass suggests Wilms tumor.

Question 19

Which finding is the best indication that a client with ineffective airway clearance needs suctioning?

Accepted Answer

Answer reason: Adventitious/coarse breath sounds directly indicate retained secretions in the airway and are the most specific trigger for suctioning. Oxygen saturation, respiratory rate, and ABGs are less specific and may change later.

Question 20

A trauma client is admitted to the emergency room following a motor vehicle accident. Examination reveals that the left side of the chest moves inward when the client inhales. The finding is suggestive of?

Accepted Answer

Answer reason: Paradoxical chest wall movement—affected segment moving inward during inspiration—is classic for flail chest from multiple adjacent rib fractures.

Question 21

A neurological consult has been ordered for a pediatric client with suspected absence seizures. The client with absence seizures can be expected to have?

Accepted Answer

Answer reason: Absence (petit mal) seizures present as brief lapses in consciousness with minimal motor activity, unlike myoclonic jerks, clonic bilateral jerking, or atonic drop attacks.

Question 22

The nurse is caring for a client admitted with suspected myasthenia gravis. Which finding is usually associated with a diagnosis of myasthenia gravis?

Accepted Answer

Answer reason: Myasthenia gravis is characterized by fluctuating skeletal muscle weakness that worsens with activity and later in the day (fatigability). Option B describes Guillain–Barré syndrome, and option C describes Parkinsonism. Diplopia can occur in MG, but the hallmark finding is fatigueable weakness worsening by day's end.

Question 23

An elderly client has a stage II pressure ulcer on her sacrum. During assessment of the client's skin, the nurse would expect to find?

Accepted Answer

Answer reason: Stage II pressure injury is partial-thickness skin loss and typically appears as an abrasion, blister, or shallow crater with surrounding erythema/induration. Options A and B describe deeper craters (stage III/IV), and D describes stage I nonblanchable erythema.

Question 24

Pulse deficit refers to the difference between which two pulses?

Accepted Answer

Answer reason: Pulse deficit is the difference between the apical heart rate and the peripheral radial pulse rate, typically measured simultaneously to detect beats not reaching the periphery (e.g., atrial fibrillation).

Question 25

Which sign in a child with meningitis is characterized by pain or resistance on extending the legs at the knee when the child is lying supine?

Accepted Answer

Answer reason: Kernig’s sign is pain or resistance with knee extension (often with hip flexed) in the supine patient, indicating meningeal irritation. Brudzinski’s is neck flexion causing hip/knee flexion; MacEwen suggests hydrocephalus; Chvostek’s indicates hypocalcemia.

Question 26

Which of the following causes crackles in breath sounds?

Accepted Answer

Answer reason: Crackles (rales) are produced when air moves through fluid or reopens collapsed, fluid-coated alveoli; thus moisture in the air passages causes crackles. Narrowed bronchioles cause wheezes; dryness or pulmonary emboli do not typically produce crackles.

Question 27

What is considered the fifth vital sign?

Accepted Answer

Answer reason: Pain is routinely assessed as the fifth vital sign along with temperature, pulse, respirations, and blood pressure.

Question 28

Which of the following is false regarding the examination of a patient with prolapse?

Accepted Answer

Answer reason: UTI screening and appropriate cervical screening (Pap test if due) are part of evaluating women with pelvic organ prolapse, especially before treatment. The other statements correctly describe exam techniques (standing straining with empty bladder, assessment of anal sphincter tone, and stress testing with prolapse reduction to detect occult SUI).

Question 29

Detailed nursing assessment of specific body system(s) relating to the presenting problem or current concern(s) of the patient. This may involve one or more body system is?

Accepted Answer

Answer reason: A focused assessment targets specific body system(s) related to the presenting problem or concern, rather than a complete head-to-toe evaluation.

Question 30

While performing physical examination of abdomen the sequence of physical examination must be?

Accepted Answer

Answer reason: For abdominal assessment, auscultation should follow inspection and precede percussion and palpation to avoid altering bowel sounds. Among the choices, option C is the only sequence that places auscultation before the manipulative steps.

Question 31

A patient came into the outpatient department with a complain of hearing problem. After history the nurse assesses air conduction with bone conduction the test named as?

Accepted Answer

Answer reason: The Rinne test directly compares air conduction (AC) to bone conduction (BC) using a tuning fork to evaluate conductive vs. sensorineural hearing loss.

Question 32

While auscultation of abdominal gut sounds you have heard Borborygmus sounds, which is 5-35/mint, being a nurse you have report the physician, your statement about above sounds are?

Accepted Answer

Answer reason: Bowel sounds of about 5–35 per minute are normal. Borborygmi are audible peristaltic (gut) sounds, not vascular bruits, so this finding is normal.

Question 33

The nurse is planning to assess a patient with the complain of indigestion, nausea, vomiting, and anorexia. The nurse pursues the steps to prepare the patient for abdominal assessment except one?

Accepted Answer

Answer reason: For accurate abdominal assessment the patient should be relaxed, the bladder emptied, and the room kept warm to avoid guarding. Abdominal tensing interferes with inspection, auscultation, and palpation; it is not a preparation step.

Question 34

Percussion helps you to assess the amount and distribution of gas in the abdomen and to identify possible masses that are solid or fluid filled. On percussion the nurse will find ---------- due to fluid and feces?

Accepted Answer

Answer reason: On abdominal percussion, areas with fluid or feces yield a dull sound, whereas gas produces tympany; flatness is over bone, resonance over lung tissue.

Question 35

The nurse assesses the patient with abdominal ascites. After mapping the borders of tympany and dullness, the nurse ask the patient to turn onto one side. She percusses and marks the borders again. The name of this test is?

Accepted Answer

Answer reason: Re-percussing after turning the patient looks for movement of fluid and change in areas of dullness vs tympany—classic technique for detecting ascites known as shifting dullness.

Question 36

A nurse is assessing a patient with myocardial infarction in the emergency department. The nurse shares with the doctor the hemodynamic and respiratory status of the patient as: BP 140/90, HR 90/m, respirations 21/m, SpO2 94%. What is the type of data collected by the nurse?

Accepted Answer

Answer reason: Vital signs are measurable, observable findings obtained by the nurse; these constitute objective assessment data.

Question 37

During History taking nurse assess memory of a patient she ask a question, When you celebrate your birthday? Nurse purpose is to assess?

Accepted Answer

Answer reason: Asking for the date of one’s birthday assesses long-term past information, which is remote memory.

Question 38

A 54 years old male patient is admitted in Neuro medicine ward with complain of left sided weakness, attendant stated that he is now unable to move his left side; you are ready for Sensory & Neuro assessment, following are the test for this patient except one?

Accepted Answer

Answer reason: Heel-to-shin, finger-to-nose, and pronation drift are motor/cerebellar tests used to evaluate limb weakness. An ophthalmoscope exam assesses the fundus/optic nerve and is not a motor or sensory test for limb weakness, so it is the exception.

Question 39

While exploring the patient health status, patient complains of head ach what is supposed to be followed next?

Accepted Answer

Answer reason: On complaint of headache, the immediate priority is to obtain objective data for potential acute causes (e.g., fever, hypertension) by checking vital signs before further focused questions or interventions.

Question 40

Lift a fold of skin and note the ease with which it lifts up (mobility) and the speed with which it returns into place?

Accepted Answer

Answer reason: Skin turgor is assessed by lifting and releasing a skin fold; the speed of return indicates turgor (hydration), whereas mobility refers only to how easily the skin lifts.

Question 41

Map out the lower lung border, both in expiration and in inspiration; ask him to exhale and hold it while you percuss down the scapular line until the sound changes from resonant to dull on each side and make a spot. Now make him take a deep breath and hold it, percussing down from your first mark and mark the level sound change to dull; it should be equal bilaterally. This procedure is called?

Accepted Answer

Answer reason: The described technique maps the lower lung border during expiration and inspiration using percussion to measure diaphragm movement, which is diaphragmatic excursion.

Question 42

A client is being admitted to the hospital with a diagnosis of urolithiasis and ureteral colic. The nurse assesses the client for pain that is?

Accepted Answer

Answer reason: Ureteral colic from renal stones produces severe colicky pain that comes in waves and typically radiates from the flank toward the groin/genitalia. The other patterns do not describe classic renal colic.

Question 43

A nurse is assessing a client who is diagnosed with cystitis. Which assessment finding would not be present with the typical clinical manifestations noted in this disorder?

Accepted Answer

Answer reason: Typical cystitis findings include dysuria (burning), frequency/urgency, suprapubic discomfort, and possible hematuria; urinary retention is not a usual symptom and suggests obstruction or another problem rather than uncomplicated cystitis.

Question 44

The physician suspects acute pyelonephritis based on the patient's physical examination. Which clinical manifestation should the nurse expect to assess?

Accepted Answer

Answer reason: Acute pyelonephritis typically presents with flank pain/CVA tenderness, urinary symptoms, and leukocytosis. Options with suprapubic pain suggest cystitis; groin pain suggests stones; frequency with casts alone is incomplete.

Question 45

The client arrives at the emergency department with complaints of low abdominal pain and hematuria. The client is afebrile. The nurse next assesses the client to determine a history of?

Accepted Answer

Answer reason: Afebrile patient with lower abdominal pain and hematuria suggests a lower urinary tract source; recent genitourinary or abdominal trauma is a key cause to assess. Pyelo and glomerulonephritis typically present with fever and systemic signs; family history of renal cancer is not the immediate priority in acute assessment.

Question 46

A nurse is assigned to care for a client with nephrotic syndrome. The nurse assesses which important parameter on a daily basis?

Accepted Answer

Answer reason: Nephrotic syndrome causes significant fluid retention and edema. Daily weight is the most sensitive bedside measure of fluid status and response to therapy; albumin/BUN are labs not typically checked daily.

Question 47

A client is admitted to the health care facility with a diagnosis of a bleeding gastric ulcer. The nurse expects this client's stools to be?

Accepted Answer

Answer reason: A bleeding gastric ulcer causes upper GI bleeding; digested blood in the stool produces melena, which is black and tarry. Coffee-ground refers to emesis, clay-colored suggests biliary obstruction, and bright red indicates lower GI bleeding.

Question 48

In assessing the client’s chest, which position best show chest expansion as well as its movements?

Accepted Answer

Answer reason: The sitting position allows optimal inspection and palpation of thoracic movement and symmetry of chest expansion, especially of the posterior chest. Other positions limit visualization of chest movement.

Question 49

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

Accepted Answer

Answer reason: Cervical lymph nodes are best palpated from behind the seated client, allowing bilateral comparison and access to superficial and deep nodes.

Question 50

What equipment would be necessary to complete an evaluation of cranial nerves 9 and 10 during a physical assessment?

Accepted Answer

Answer reason: Cranial nerves IX and X are assessed by observing soft palate/uvula movement and gag reflex; a tongue depressor and light are used to visualize the oropharynx and elicit the gag reflex.

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