Question 1

When assessing the lower extremities for arterial function, which intervention should the nurse perform?

Accepted Answer

Answer reason: Pedal pulse palpation directly evaluates arterial perfusion to the lower extremities. Allen’s test assesses upper-extremity (radial/ulnar) patency, pitting edema reflects venous/volume status, and Homans’ sign screens for DVT (venous).

Question 2

Nurse Jawed was scheduled for a physical assessment. When percussing the client's chest, the nurse would expect to find which assessment data as a normal sign over his lungs?

Accepted Answer

Answer reason: Normal lung fields are resonant to percussion; hyperresonance suggests air trapping (e.g., emphysema/pneumothorax), tympany is typical over the abdomen, and dullness occurs over fluid or solid tissue.

Question 3

The sequence of physical examination techniques is as follow?

Accepted Answer

Answer reason: Standard general physical exam sequence is IPPA: inspection, palpation, percussion, then auscultation (abdomen is an exception).

Question 4

Mr. Teban is a 73-year old patient diagnosed with pneumonia. Which data would be of greatest concern to the nurse when completing the nursing assessment of the patient?

Accepted Answer

Answer reason: Cyanosis and delayed capillary refill indicate hypoxemia and poor perfusion in pneumonia and require immediate attention, outweighing normal mentation, normal exam findings, or near-normal labs.

Question 5

Evaluating the apical pulse is the most reliable noninvasive way to assess cardiac function. Which is the best area for auscultating the apical pulse?

Accepted Answer

Answer reason: The apical impulse is best heard at the mitral area (left 5th intercostal space, midclavicular line).

Question 6

Mania, a 68-year-old widower, has been stricken with cataracts about year ago. Which assessment date would the nurse expect when collecting the nursing history from the client?

Accepted Answer

Answer reason: Cataracts typically present with painless, progressive blurred vision and glare; pain, redness, and floaters are not expected findings of uncomplicated cataracts.

Question 7

During a cardiac examination, the nurse can best hear the S1 heart sound by placing the stethoscope at the clients?

Accepted Answer

Answer reason: S1 (closure of the mitral and tricuspid valves) is best heard at the cardiac apex (mitral area), typically the left 5th intercostal space at the midclavicular line.

Question 8

During your clinical duty a patient with neurologic concerns, what will be you assess for?

Accepted Answer

Answer reason: With neurologic concerns the nurse should prioritize a focused, complete neurologic assessment. Doing it last is not appropriate, and while a head-to-toe assessment is useful, a comprehensive neuro exam is specifically indicated.

Question 9

Close the patient's eyes, touch skin and withdraw the stimulus promptly; ask the person to put a finger where you touched. What is this?

Accepted Answer

Answer reason: Described maneuver tests cortical sensory function of tactile localization (point location), not cognition or a specific cranial nerve exam.

Question 10

Subjective data gathered during patient assessment includes?

Accepted Answer

Answer reason: Subjective data are what the patient or others report, obtained via interviews and health history. Laboratory/diagnostic findings and medical records are objective data, so only option B contains purely subjective sources.

Question 11

What does a sphygmomanometer measure?

Accepted Answer

Answer reason: A sphygmomanometer is the device used to measure arterial blood pressure; pulse or heart rate are not measured by this device, so 'All of the above' is incorrect.

Question 12

What does muscle strength grade 5 indicate?

Accepted Answer

Answer reason: Muscle strength grading: 0–no contraction, 1–trace, 2–poor, 3–fair, 4–good, 5–normal (full strength against full resistance).

Question 13

The nurse is taking the blood pressure of the obese client. If the blood pressure cuff is too small, the results will be?

Accepted Answer

Answer reason: Using a cuff that is too small for the arm overestimates intra-cuff pressure, producing an artificially high (false elevated) blood pressure reading.

Question 14

If the nurse is unable to elicit the deep tendon reflexes of the patella, the nurse should ask the client to?

Accepted Answer

Answer reason: Having the client interlock fingers and pull (Jendrassik maneuver) increases lower-extremity reflex activity and helps elicit the patellar deep tendon reflex.

Question 15

The nurse is assessing the client admitted for possible oral cancer. The nurse identifies which of the following to be a late-occurring symptom of oral cancer?

Accepted Answer

Answer reason: Oral cancer lesions are typically painless early; pain develops later as the tumor invades deeper tissues and nerves, making pain a late sign.

Question 16

The nurse is assessing the abdomen. The nurse knows the best sequence to perform the assessment is?

Accepted Answer

Answer reason: For the abdominal exam the sequence is inspection first, then auscultation before palpation to avoid stimulating or altering bowel sounds. Among choices, this is option A.

Question 17

The client presents to the emergency room with a "bull's eye" rash. Which question would be most appropriate for the nurse to ask the client?

Accepted Answer

Answer reason: A bull's-eye rash suggests erythema migrans from Lyme disease; the most relevant assessment is recent tick exposure.

Question 18

A 70-year-old male who is recovering from a stroke exhibits signs of unilateral neglect. Which behavior is suggestive of unilateral neglect?

Accepted Answer

Answer reason: Unilateral neglect causes inattention to one side of the body/environment after stroke; a classic sign is grooming only one side, such as shaving only one side of the face.

Question 19

The nurse is performing an assessment on a client with possible pernicious anemia. Which data would support this diagnosis?

Accepted Answer

Answer reason: Pernicious anemia (vitamin B12 deficiency) often presents with neurologic findings such as paresthesias due to demyelination. Weight loss is nonspecific, a red beefy tongue may occur but is less diagnostic, and a hemoglobin of 12 g/dL is not anemic for many adults.

Question 20

The nurse is caring for a client scheduled for a surgical repair of a saccular abdominal aortic aneurysm. Which assessment is most crucial during the preoperative period?

Accepted Answer

Answer reason: For abdominal aortic aneurysm repair, documenting baseline peripheral pulses preoperatively is crucial to evaluate postoperative perfusion and detect graft occlusion or embolization. The other assessments are less critical for immediate surgical risk and postoperative monitoring.

Question 21

A 6-month-old client is admitted with possible intussusception. Which question during the nursing history is least helpful in obtaining information regarding this diagnosis?

Accepted Answer

Answer reason: Diagnosis of intussusception is guided by symptoms such as colicky abdominal pain, vomiting, and abdominal distension/mass. Asking about diet does not directly aid this assessment, making it the least helpful question.

Question 22

The nurse is caring for a client with ascites. Which is the best method to use for determining early ascites?

Accepted Answer

Answer reason: Serial abdominal girth measurements detect small increases in fluid before enlargement is visible. Inspection and the fluid wave require larger volumes, and palpation for hepatomegaly assesses the liver, not early ascites.

Question 23

A client with bacterial pneumonia is admitted to the pediatric unit. What would the nurse expect the admitting assessment to reveal?

Accepted Answer

Answer reason: Bacterial pneumonia commonly presents with acute high fever and a productive cough. Nonproductive cough and rhinitis are more consistent with viral upper respiratory infections, and vomiting/diarrhea are not typical primary findings of bacterial pneumonia.

Question 24

A 5-year-old client with hyperthyroidism is admitted to the pediatric unit. What would the nurse expect the admitting assessment to reveal?

Accepted Answer

Answer reason: Hyperthyroidism presents with sympathetic overactivity: tachycardia, weight loss with increased appetite, and characteristic exophthalmos (Graves disease). The other options reflect hypothyroidism.

Question 25

The nurse is caring for a client admitted to labor and delivery. The nurse is aware that the infant is in distress if she notes?

Accepted Answer

Answer reason: Absent variability in the fetal heart rate is a nonreassuring pattern indicating possible fetal hypoxia/distress. Contractions every 3 minutes, accelerations with movement, and a baseline FHR of 120–130 bpm are reassuring/normal findings.

Question 26

A 5-year-old child is hospitalized for correction of congenital hip dysplasia. During the assessment of the child, the nurse can expect to find the presence of?

Accepted Answer

Answer reason: Developmental dysplasia of the hip in older children presents with weak hip abductors and a positive Trendelenburg sign. The other listed signs relate to neonatal maturity (scarf), transient newborn color change (harlequin), and intra-abdominal bleeding/pancreatitis (Cullen).

Question 27

The physician has diagnosed a client with cirrhosis characterized by asterixis. If the nurse assesses the client with asterixis, he can expect to find?

Accepted Answer

Answer reason: Asterixis is a flapping tremor of the hands at the wrists seen in hepatic encephalopathy; other options describe different cirrhosis signs (gynecomastia, caput medusae, palmar erythema).

Question 28

The nurse is assessing a client with portal hypertension. Which of the following findings would the nurse expect?

Accepted Answer

Answer reason: Portal hypertension increases portal venous pressure and reduces oncotic pressure from hypoalbuminemia, leading to accumulation of fluid in the peritoneal cavity (ascites). The other findings are unrelated.

Question 29

The nurse is caring for a client with Legionnaire's disease. Which of the following physical findings would require the nurse's IMMEDIATE attention?

Accepted Answer

Answer reason: Legionnaires' disease is a severe pneumonia; airway and breathing are the priority. Decreased chest wall expansion signals impaired ventilation and possible respiratory failure, which requires immediate attention. The other findings are less urgent.

Question 30

The nurse is assessing a client with a deep vein thrombosis. Which of the following signs and/or symptoms would the nurse anticipate finding?

Accepted Answer

Answer reason: Deep vein thrombosis commonly presents with unilateral leg swelling and pain distal to the thrombus; the other findings are nonspecific or unrelated (tachypnea suggests PE, diaphoresis is nonspecific, Babinski is a neurologic sign).

Question 31

A client was admitted with a diagnosis of pneumonia. When auscultating the client's breath sounds, the nurse hears inspiratory crackles in the right base. Temperature is 102.3 orally. The nurse would expect to find which of the following?

Accepted Answer

Answer reason: Pneumonia with fever and crackles can cause hypoxia; in adults, hypoxemia often presents as altered mental status/mental confusion. Bradycardia and hypotension are not typical early findings, and flushed skin is nonspecific to pneumonia.

Question 32

The nurse is caring for a child who is having an acute episode of reactive airway disease. Which of the following findings would the nurse anticipate finding?

Accepted Answer

Answer reason: Acute reactive airway disease (asthma) causes lower-airway obstruction and bronchospasm, producing expiratory wheezes. Inspiratory stridor indicates upper-airway obstruction; apnea and a productive cough are not expected hallmark findings.

Question 33

The nurse is admitting a client with the diagnosis of Parkinson's disease. When assessing mobility, the nurse would anticipate finding?

Accepted Answer

Answer reason: Parkinson’s disease commonly presents with a festinating, shuffling gait. Weakness and muscle spasms are not defining features, and intention tremor suggests cerebellar disease; PD has resting tremor.

Question 34

The nurse is assessing a 15 month-old child with otitis media. Which of the following symptoms would the nurse anticipate finding?

Accepted Answer

Answer reason: Acute otitis media commonly presents with irritability, nasal discharge, and a bulging tympanic membrane; other options include findings inconsistent with AOM such as translucent/retracted or pearly white tympanic membranes or unrelated symptoms.

Question 35

The nurse is performing an admission assessment on a client with chronic glaucoma. Which of the following statements by the client would the nurse anticipate?

Accepted Answer

Answer reason: Chronic open-angle glaucoma causes gradual peripheral vision loss (tunnel vision), so clients compensate by turning their head to view their surroundings. The other options describe findings more consistent with cataracts, stroke-related hemianopsia, or vitreous floaters.

Question 36

The nurse is caring for a client with left ventricular heart failure. Which one of the following assessments is an early indication of inadequate oxygen transport?

Accepted Answer

Answer reason: Early hypoxia impairs cerebral oxygenation, producing neurologic changes such as confusion and restlessness before overt respiratory or circulatory signs.

Question 37

A client with asthma has low pitched wheezes present on the final half of exhalation. One hour later the client has high pitched wheezes extending throughout exhalation. What does this change in assessment indicate to the nurse?

Accepted Answer

Answer reason: High-pitched wheezes that extend throughout exhalation indicate narrower airways and increased airflow obstruction, signifying worsening asthma.

Question 38

The nurse is assessing an infant with developmental dysplasia of the hip. Which of the following findings would the nurse anticipate?

Accepted Answer

Answer reason: Developmental dysplasia of the hip commonly presents with apparent leg-length discrepancy (Galeazzi sign). Other classic findings are limited abduction and asymmetrical gluteal folds; diminished femoral pulses are not typical.

Question 39

The nurse is caring for a client with benign prostatic hypertrophy. Which of the following assessments would the nurse anticipate finding?

Accepted Answer

Answer reason: BPH causes bladder outlet obstruction leading to overflow symptoms such as urinary frequency and nocturia in small amounts; not large volumes, stress incontinence, or dark concentrated urine.

Question 40

The nurse is assessing a 2 year-old client with a possible diagnosis of congenital heart disease. Which of the following is MOST likely related to this diagnosis?

Accepted Answer

Answer reason: Children with congenital heart disease often have exercise intolerance and self-limit activity; frequent rest during play is typical. The other options are nonspecific.

Question 41

The charge nurse on the eating disorder unit instructs a new staff member to weigh each client in his or her hospital gown only. What is the rationale for this nursing intervention?

Accepted Answer

Answer reason: Clients with eating disorders may attempt to falsify weight by hiding objects in clothing; weighing in a gown helps ensure an accurate assessment.

Question 42

While caring for a client with hypertension, the nurse notes the following vital signs: BP of 140/20, pulse 120, respirations 36, temperature 100.8°F. The nurse’s initial action should be to?

Accepted Answer

Answer reason: The BP reading (140/20) is highly unusual and may be erroneous. The priority is to validate abnormal assessment data before notifying the provider or ordering tests.

Question 43

When obtaining the nursing history of a client who has diabetes mellitus, which early symptom of renal insufficiency should the nurse assess?

Accepted Answer

Answer reason: Early renal insufficiency impairs the kidney’s ability to concentrate urine, leading to polyuria and often nocturia. Oliguria occurs in later stages; dysuria suggests infection; hematuria is not a typical early finding.

Question 44

Which assessment process is performed last in abdominal assessment?

Accepted Answer

Answer reason: Abdominal exam sequence is inspect, auscultate, percuss, then palpate; palpation is last to avoid altering bowel sounds or causing guarding.

Question 45

The absence of which pulse may not be a significant finding when a patient is admitted to the hospital?

Accepted Answer

Answer reason: Pedal pulses (dorsalis pedis/posterior tibial) can be difficult to palpate or congenitally absent in some healthy individuals, so their absence may not be significant on admission. Absence of apical, radial, or femoral pulses would be concerning.

Question 46

Assessment of the diabetic client for common complications should include examination of the?

Accepted Answer

Answer reason: Diabetes commonly leads to diabetic retinopathy; routine assessment should include eye examinations. The other options are not primary targets for common diabetic complications.

Question 47

Which of the following is used to assess the level of consciousness?

Accepted Answer

Answer reason: The Glasgow Coma Scale assesses level of consciousness via eye, verbal, and motor responses. Apgar scores newborn status, tonometry measures intraocular pressure, and the Snellen chart tests visual acuity.

Question 48

What is the most reliable index of cerebral status?

Accepted Answer

Answer reason: Level of consciousness is the earliest and most sensitive indicator of cerebral function; changes precede alterations in pupils, reflexes, or muscle strength.

Question 49

What is the initial sign of respiratory distress?

Accepted Answer

Answer reason: Tachypnea is typically the earliest sign of respiratory distress; cyanosis is late, and grunting and nasal flaring occur as compensatory signs later, especially in children.

Question 50

During the two-month well-baby visit, the mother complains that formula seems to stick to her baby's mouth and tongue. Which of the following would provide the MOST valuable nursing assessment?

Accepted Answer

Answer reason: Wiping with a soft cloth distinguishes milk residue, which wipes off, from oral candidiasis (thrush), which adheres and cannot be removed easily. Cultures and saline flushing are unnecessary initially, and inspection alone may not differentiate them.

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