Assessment Questions
A 55-year-old female patient was in a motor vehicle accident and is admitted to a surgical unit after repair of a fractured left arm and left leg. She also has a laceration on her forehead. An intravenous (IV) line is infusing in the right antecubital fossa, and pneumatic compression stockings are on the right lower leg. She is receiving oxygen via a simple face mask. Which sites do you instruct the nursing assistant to use for obtaining the patient's blood pressure and temperature? 1. Right antecubital and tympanic membrane 2. Right popliteal and rectal 3. Left antecubital and oral 4. Left popliteal and temporal artery
1
The licensed practical nurse (LPN) provides you with the change-of-shift vital signs on four of your patients. Which patient do you need to assess first? 1. 84-year-old man recently admitted with pneumonia, RR 28, SpO2 89% 2. 54-year-old woman admitted after surgery for fractured arm, BP 160/86 mm Hg, HR 72 3. 63-year-old man with venous ulcers from diabetes, temperature 37.3° C (99.1° F), HR 84 4. 77-year-old woman with left mastectomy 2 days ago, RR 22, BP 148/62
1
The nurse is teaching a patient how to perform a testicular self-examination. Which statement made by the patient indicates a need for further teaching? 1. "I'll recognize abnormal lumps because they are very painful." 2. "I'll start performing testicular self-examination monthly after I turn 15." 3. "I'll perform the self-examination in front of a mirror." 4. "I'll gently roll the testicle between my fingers."
1
The nurse prepares to conduct a general survey on an adult patient. Which assessment is performed first while the nurse initiates the nurse-patient relationship? 1. Appearance and behavior 2. Measurement of vital signs 3. Observing specific body systems 4. Conducting a detailed health history
1
Which of the following patients are at most risk for tachypnea? (Select all that apply.) 1. Patient just admitted with four rib fractures 2. Woman who is 9 months' pregnant 3. Adult who has consumed alcoholic beverages 4. Adolescent waking from sleep 5. Three-pack-per-day smoker with pneumonia
1, 2, 5
A healthy adult patient tells the nurse that he obtained his blood pressure in "one of those quick machines in the mall" and was alarmed that it was 152/72 when his normal value ranges from 114/72 to 118/78. The nurse obtains a blood pressure of 116/76. What would account for the blood pressure of 152/92? (Select all that apply.) 1. Cuff too small 2. Arm positioned above heart level 3. Slow inflation of the cuff by the machine 4. Patient did not remove his long-sleeved shirt 5. Insufficient time between measurements
1, 5
The nurse is assessing the cranial nerves. Match the cranial nerve with its related function. Cranial Nerves 1. XII Hypoglossal 2. V Trigeminal 3. VI Adducens 4. IV Trochlear 5. X Vagus Cranial Nerve Function a. Motor innervation to the muscles of the jaw b. Lateral movement of the eyeballs c. Sensation of the pharynx d. Downward, inward eye movements e. Position of the tongue
1E, 2A, 3B, 4D, 5C
The nurse is performing an abdominal assessment on a patient. In what order does the nurse perform the steps? 1. Percussion 2. Inspection 3. Auscultation 4. Palpation
2, 3, 1, 4
A patient is admitted for dehydration caused by pneumonia and shortness of breath. He has a history of heart disease and cardiac dysrhythmias. The nursing assistant reports his admitting vital signs to the nurse. Which measurements should the nurse reassess? (Select all that apply.) 1. Right arm BP: 118/72 2. Radial pulse rate: 72 and irregular 3. Temporal temperature: 37.4° C (99.3° F) 4. Respiratory rate: 28 5. Oxygen saturation: 99%
2, 4, 5
The nursing assistive personnel (NAP) reports to you that the blood pressure (BP) of the patient in Question 11 is 140/76 on the left arm and 128/72 on the right arm. What actions do you take on the basis of this information? (Select all that apply.) 1. Notify the health care provider immediately 2. Repeat the measurements on both arms using a stethoscope 3. Ask the patient if she has taken her blood pressure medications recently 4. Obtain blood pressure measurements on lower extremities 5. Verify that the correct cuff size was used during the measurements 6. Review the patient's record for her baseline vital signs 7. Compare right and left radial pulses for strength
2, 6
The nurse is teaching a patient to prevent heart disease. Which information should the nurse include? (Select all that apply.) 1. Limit intake of cholesterol to less than 400 mg/day. 2. Talk with your health care provider about taking a daily low dose of aspirin. 3. Work with your health care provider to develop a regular exercise program. 4. Limit daily intake of fats to less than 25% to 35% of total calories. 5. Review strategies to encourage the patient to quit smoking.
2,3,4,5
A patient has been hospitalized for the past 48 hours with a fever of unknown origin. His medical record indicates tympanic temperatures of 38.7° C (101.6° F) (0400), 36.6° C (97.9° F) (0800), 36.9° C (98.4° F) (1200), 37.6° C (99.6° F) (1600), and 38.3° C (100.9° F) (2000). How would you describe this pattern of temperature measurements? 1. Usual range of circadian rhythm measurements 2. Sustained fever pattern 3. Intermittent fever pattern 4. Resolving fever pattern
3
A patient presents in the clinic with dizziness and fatigue. The nursing assistant reports a slow but regular radial pulse of 44. What is your priority intervention? 1. Request that the nursing assistant repeat the pulse check 2. Call for a stat electrocardiogram (ECG) 3. Assess the patient's apical pulse and evidence of a pulse deficit 4. Prepare to administer cardiac-stimulating medications
3
As you are obtaining the oxygen saturation on a 19-year-old college student with severe asthma, you note that she has black nail polish on her nails. You remove the polish from one nail, and she asks you why her nail polish had to be removed. What is the best response? 1. Nail polish attracts microorganisms and contaminates the finger sensor. 2. Nail polish increases oxygen saturation. 3. Nail polish interferes with sensor function. 4. Nail polish creates excessive heat in sensor probe.
3
During assessment of the skin, the nurse assesses a lesion on the arm of the patient. The lesion is irregularly shaped, elevated with edema, and about 3 cm. What type of lesion does the patient have? 1. Nodule 2. Macule 3. Wheal 4. Pustule
3
How should the patient be positioned to best palpate for lumps or tumors during an examination of the right breast? 1. Supine with both arms overhead with palms upward 2. Sitting with hands clasped just above the umbilicus 3. Supine with the right arm abducted and hand under the head and neck 4. Lying on the right side, adducting the right arm on the side of the body
3
The nurse is assessing a patient who returned 1 hour ago from surgery for an abdominal hysterectomy. Which assessment finding would require immediate follow-up? 1. Auscultation of an apical heart rate of 76 2. Absence of bowel sounds on abdominal assessment 3. Respiratory rate of 8 breaths/min 4. Palpation of dorsalis pedis pulses with strength of +2
3
The nurse is observing the student nurse perform a respiratory assessment on a patient. Which action by the student nurse requires the nurse to intervene? 1. The student stands at a midline position behind the patient observing for position of the spine and scapula. 2. The student palpates the thoracic muscles for masses, pulsations, or abnormal movements. 3. The student places the bell of the stethoscope on the anterior chest wall to auscultate breath sounds. 4. The student places the palm of the hand over the intercostal spaces and asks the patient to say "ninety-nine."
3
The nurse observes a nursing student taking a blood pressure (BP) on a patient. The nurse notes that the student very slowly deflates the cuff in an attempt to hear the sounds. The patient's BP range over the past 24 hours is 132/64 to 126/72 mm Hg. Which of the following BP readings made by the student is most likely caused by an incorrect technique? 1. 96/40 mm Hg 2. 110/66 mm Hg 3. 130/90 mm Hg 4. 156/82 mm Hg
3
The nurse plans to assess the patient's memory. Which task should the nurse ask the patient to perform? 1. "Tell me where you are." 2. "What can you tell me about your illness?" 3. "Repeat these numbers back to me: 7...5...8." 4. "What does this mean: 'A stitch in time saves nine?'"
3
Which patient is at highest risk for tachycardia? 1. A healthy basketball player during warmup exercises 2. A patient admitted with hypothermia 3. A patient with a fever of 39.4° C (103° F) 4. A 90-year-old male taking beta blockers
3
While auscultating the adult patient's lungs, the nurse hears loud, bubbly sounds during inspiration that did not disappear after the 607patient coughed. Which finding should the nurse document from the lung assessment? 1. Rhonchi 2. Coarse crackles 3. Sibilant wheeze 4. Pleural friction rub
3
The faith community nurse is teaching the community center women's group about breast cancer risk factors. Which factors does the nurse include? (Select all that apply.) 1. First child at the age of 26 years 2. Menopause onset at the age of 49 years 3. Family history with BRCA1 inherited gene mutation 4. Age over 40 years 5. Onset of menses before the age of 12 6. Recent use of oral contraceptives
3, 4, 5, 6
A patient has undergone surgery for a femoral artery bypass. The surgeon's orders include assessment of dorsalis pedis pulses. The nurse will use which of the following techniques to assess the pulses? (Select all that apply.) 1. Place the fingers behind and below the medial malleolus. 2. Have the patient slightly flex the knee with the foot resting on the bed. 3. Have the patient relax the foot while lying supine. 4. Palpate the groove lateral to the flexor tendon of the wrist. 5. Palpate along the top of the foot in a line with the groove between extensor tendons of great and first toes.
3, 5
What does full movement of the eyes in the six cardinal fields of gaze reflect? A. Both B and C B. Proper functioning of the oculomotor, trochlear, and abducens nerves C. Proper functioning of the extraocular muscles D. Proper functioning of the olfactory and optic nerves
Answer: A Rationale: Proper functioning of the oculomotor, trochlear, and abducens nerves plus proper functioning of the extraocular muscles is reflected by full movement of the eyes in the six cardinal fields of gaze. Proper functioning of the olfactory and optic nerves is reflected by an accurate sense of smell and accurate vision on the Snellen and Rosenbaum charts, not the movement of the eyes in the six cardinal fields of gaze.
What are the Snellen and Rosenbaum charts used to assess? A. Optic nerve B. Trigeminal nerve C. Abducens nerve D. Facial nerve
Answer: A Rationale: The Snellen and Rosenbaum charts are used to assess the optic nerve. The Snellen chart tests distance vision, and the Rosenbaum chart tests near vision.
During vocalization, the soft palate: A. Lowers symmetrically B. Raises symmetrically C. Vibrates D. Has a gag reflex
Answer: B
What is a depression that is left after pressing a finger or thumb on swollen tissue called? A. Cyanosis B. Pitting edema C. A thrill D. A varicosity
Answer: B
What should the nurse do if a patient displays staggering or loss of balance during the Romberg test? A. Give the patient a gentle push to further assess balance. B. Delay other balance tests. C. Have the patient stand on one foot with the eyes closed. D. Have the patient hop on one foot.
Answer: B
When examining the eyes, which of the following is an expected finding? A. Reddened conjunctivae B. Equal pupils C. Crusted eyelashes D. Periorbital edema
Answer: B
When should you check the patient's blood pressure to assess for orthostatic hypotension?. A. After the patient has been walking around the room B. While the patient is sitting and standing C. After bloodwork has been done D. Immediately after the initial blood pressure reading
Answer: B
Which observation indicates that a patient's pain medication has been effective in managing pain that she rated a 6 out of 10 on a pain rating scale before the intervention? A. The patient is seen quietly reading a magazine. B. The patient rates her current pain as 3 out of 10 on the pain rating scale. C. The patient is overheard telling her family that she is "feeling better today." D. The patient is observed sleeping, with a respiratory rate assessed at 18/minute, compared with 22/minute before the intervention.
Answer: B
Which of the following is the correct way to assess a patient's nose for patency? A. Have the patient breathe rapidly through both nares. B. Occlude one naris, and have the patient breathe through the open naris. C. Occlude both nares, and have the patient breathe through the mouth. D. Have the patient blow out through both nares.
Answer: B
John Joseph 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? A. Dullness B. Resonance C. Hyper resonance D. Tympany
Answer: B Normally, when percussing a client's chest, percussion over the lungs reveals resonance, a hollow or loud, low-pitched sound of long duration. Tympany is typically heard on percussion over such areas as a gastric air bubble or the intestine. Dullness is typically heard on percussion of solid organs, such as the liver or areas of consolidation. Hyperresonance would be evidenced by percussion over areas of overinflation such as an emphysematous lungs.
What questions can you ask a patient to assess his or her state of consciousness? A. Ask the patient about his or her thoughts, feelings, and emotions. B. Ask for the date, his or her name, and the location. C. Ask the patient to repeat a series of five numbers. D. Ask the patient to write his or her name and address.
Answer: B Rationale: Begin with asking the patient today's date, then ask the patient to state his or her name. A patient should be oriented to time, place, and person and be able to respond appropriately to questions about the environment.
Which of the following tips will assist with eliciting the patellar and Achilles deep tendon reflexes? A. Have the patient sit with his or her feet flat on the floor. B. Have the patient focus on pulling his or her clasped hands apart. C. Have the patient flex his or her knees at a 45-degree angle. D. Strike the knee above the patella.
Answer: B Rationale: With the patient in a seated position, have him or her focus on pulling his or her clasped hands apart; this will take focus away from the test of deep tendon reflexes. The patient should sit so that the upper legs are supported and the lower legs hang loosely. The patient should flex his or her knees at a 90-degree angle. Strike the knee just below the patella.
A patient with a herniated disk is scheduled for surgery to fuse two vertebrae in her cervical spine. Which activity is most likely to be a palliative factor for this patient? A. Repainting her new apartment B. Lifting moving boxes on and off of a truck C. Performing neck, back, and shoulder exercises prescribed by a physical therapist D. Performing yoga exercises from the patient's favorite set of videotapes
Answer: C
An ABNORMAL angle between the nail base and the nail is called clubbing and may indicate which of the following conditions? A. Poor hygiene B. Dehydration C. Cardiopulmonary disorder D. Skin cancer
Answer: C
Hearing a bruit in an artery is a sign of which of the following conditions? A. Adequate blood flow B. A clot C. An obstruction D. A pulse deficit
Answer: C
The nurse notices that his patient has none of the signs and symptoms normally associated with pain, such as diaphoresis, tachycardia, and hypertension. The patient does, however, seem moody and a bit uncooperative. What conclusion does the nurse draw? A. It is likely the patient is a drug seeker and has little or no pain. B. The patient's problem is more mental than physical. C. The absence of physiological signs and symptoms is associated with chronic pain. D. The patient's pain cannot be accurately assessed until the patient has been treated for anxiety.
Answer: C
A deep tendon reflex with a normal response is scored as: A. 0 B. 1+ C. 2+ D. 3+
Answer: C Rationale: 2+ is considered an active or expected response for deep tendon reflex; this is a normal response. 0 indicates no response for deep tendon reflex; this is an abnormal response. 1+ indicates a sluggish or diminished response for deep tendon reflex; this is an abnormal response. 3+ is a brisker-than-expected or slightly hyperactive response; this is an abnormal response.
What term refers to the constriction of the pupils when a patient focuses on an object held about 10 centimeters from the nose? A. Ptosis B. Glaucoma C. Accommodation D. Peripheral vision
Answer: C Rationale: Accommodation is the correct term for constriction of the pupils when focusing on an object held about 10 centimeters from the nose. Ptosis is drooping of the upper eyelid, not constriction of the pupils. Glaucoma is a condition that causes damage to the eye's optic nerve, not constriction of the pupils when focusing on an object 10 centimeters from the nose. Peripheral vision is the part of vision that occurs outside the center of the gaze, not constriction of the pupils.
Which of the following cranial nerves is assessed by holding a scented object under the patient's nose? A. Facial nerve B. Oculomotor nerve C. Olfactory nerve D. Acoustic nerve
Answer: C Rationale: The olfactory nerve is assessed by having a patient close his or her eyes, inhale deeply, and identifying the smell. The facial nerve is assessed by observing the patient making specific facial movements. The oculomotor nerve is assessed by inspecting the eyelids and by checking the pupils. The acoustic nerve is assessed by performing the whispered voice test.
A nurse is inspecting the patient's ears with an otoscope. Which of the following findings would be considered abnormal? A. Visible cone of light B. Pearly gray tympanic membrane C. Perforation of the tympanic membrane D. Small amount of cerumen
Answer: C Rationale: The tympanic membrane should not have any perforations. A visible cone of light is a normal finding in an otoscopic examination. The tympanic membrane should appear pearly gray. A small amount of cerumen is a normal finding in an otoscopic examination.
Assessment of the ears includes which of the following? A. Inspection B. Palpation C. Examination with an otoscope D. All of the above
Answer: D
Normal capillary refill is less than 2 seconds and is assessed by: A. Pressing on the radial artery until a pulse is no longer felt B. Palpating all superficial veins in the legs to check for tenderness C. Palpating all of the pulses bilaterally to check that they are equal D. Pressing on the nail bed until it blanches, and observing how quickly full color returns
Answer: D
Skin inspection and palpation includes assessment for: A. Color, uniformity, and symmetry B. Skin lesions C. Skin temperature D. All of the above
Answer: D
When using the Snellen chart, what does a vision evaluation of 20/50 mean? A. The patient has difficulty seeing far objects clearly. B. The patient can read at 20 feet what most people can read at 50 feet. C. The patient can read at 50 feet what most people can read at 20 feet. D. Both A and B.
Answer: D
Which are the best places to check the skin for tenting, which is a sign of dehydration? A. Top of the hand and foot B. Neck and top of the head C. Shoulder and thigh D. Forearm and sternum
Answer: D
Which of the following are included in the assessment of mental status? A. Speech and language B. Emotional stability C. Physical appearance and behavior D. All of the above
Answer: D
Which of the following are risk factors for glaucoma? A. Age over 40 years B. Diabetes C. High blood pressure D. All of the above
Answer: D
Which structures are included in a complete assessment of the mouth? A. Lips, mucosa, teeth, and gums B. Tongue and floor of the mouth C. Hard and soft palates D. All of the above
Answer: D
Which test or tests assess accuracy of movement? A. Finger-to-finger test B. Finger-to-nose test C. Heel-to-shin test D. All of the above
Answer: D Rationale: All of the above tests can be used to assess accuracy of movement. The finger-to-finger test is used to assess accuracy of movement. The patient's movements should be rapid, smooth, and accurate with no past pointing. The finger-to-nose test is used to assess accuracy of movement. The patient's movements should be rapid, smooth, and accurate, even with increasing speed. The heel-to-shin test is used to assess accuracy of movement. The patient should move his heel in a straight line without deviations to the side.
The ABCD rule of melanoma includes: A. Asymmetry of shape B. Border irregularity and color variation C. Diameter larger than the eraser of a pencil D. All of the above
Answer: D Rationale: Asymmetry of shape, irregular border or color variation, and a diameter larger than the eraser of a pencil are all included in the ABCD rule of melanoma. Asymmetry of shape is the A of the ABCD rule of melanoma. Border irregularity is the B and color variation is the C of the ABCD rule of melanoma. Diameter larger than the eraser of a pencil is the D of the ABCD rule of melanoma.
The nurse plans to assess a patient's respiratory rate; however, the patient has just returned from ambulating to the bathroom. What should the nurse do to minimize the effect of exercise on the patient's respiratory rate? A. Assess the pulse for a full 60 seconds before assessing respiration. B. Compare the postexercise respiratory rate with his baseline findings. C. Encourage the patient to rest for 10 minutes before assessing respiration. D. Compare the postexercise findings with the previous at-rest findings.
C
Which of the following is an important part of performing an abdominal assessment? Go to question 3. A. Completing the assessment as quickly as possible B. Stopping the assessment if the patient has any tenderness C. Explaining each step of the assessment to the patient D. Having the patient breathe normally at all times
C
During the assessment of a patient's respiratory rate, when the second hand reaches the 15-second mark, the respiratory count is 8. What should the nurse do at this time? A. Stop the assessment. B. Stop the assessment, and multiply the number 8 by 2. C. Stop the assessment, and multiply the number 8 by 6. D. Continue to count the patient's breaths for a full 60 seconds.
D
Moderate and deep palpation of the abdomen: Back to Top A. May cause tenderness B. Should not detect masses C. May locate the margins of the liver D. All of the above
D
On the last assessment of a patient's respiration, her respiratory rate was 10 breaths per minute. What should the nurse do when conducting the next assessment of this patient's respiratory rate? A. Count breaths for 10 seconds and multiply by 6. B. Count breaths for 15 seconds and multiply by 4 C. Count breaths for 30 seconds and multiply by 2. D. Count breaths for 60 seconds.
D
What should you do if a patient is ticklish when you are palpating the abdomen? Go to question 2. A. Distract the patient by talking to him or her. B. Do not palpate the abdomen in the upper quadrants. C. Do only deep palpation of all four quadrants. D. Place your hand over the patient's hand during palpation.
D
When auscultating the lungs, it is important to: A. Compare each side bilaterally. B. Note abnormal sounds. C. Ask the patient to take slow, deep breaths. D. All of the above.
D
When palpating the thorax, which of the following would be an abnormal finding? A. Tenderness B. Pulsations C. Masses D. All of the above
D
When percussing the thorax, which of the following would be a normal finding? A. Dullness over the lung fields B. Resonance over the lung fields C. Dullness over the ribs, heart, and diaphragm D. Both B and C
D
A 52-year-old woman is admitted with dyspnea and discomfort in her left chest with deep breaths. She has smoked for 35 years and recently lost over 10 lbs. Her vital signs on admission are: HR 112, BP 138/82, RR 22, tympanic temperature 36.8° C (98.2° F), and oxygen saturation 94%. She is receiving oxygen at 2 L via a nasal cannula. Which vital sign reflects a positive outcome of the oxygen therapy? 1. Temperature: 37° C (98.6° F) 2. Radial pulse: 112 3. Respiratory rate: 24 4. Oxygen saturation: 96% 5. Blood pressure: 134/78
4
A patient has been admitted for a cerebrovascular accident (stroke). She cannot move her right arm, and she has a right-sided facial droop. She is able to eat with her dentures in place and 531swallow safely. The nursing assistive personnel (NAP) reports to you that the patient will not keep the oral thermometer probe in her mouth. What direction do you provide to the NAP? 1. Direct the NAP to hold the thermometer in place with her gloved hand 2. Direct the NAP to switch the thermometer probe to the left sublingual pocket 3. Direct the NAP to obtain a right tympanic temperature 4. Direct the NAP to use a temporal artery thermometer from right to left
4
Which statement made by the patient indicates an understanding about teaching related to early detection of colorectal cancer? 1. "I'll make sure to schedule my colonoscopy annually after the age of 60." 2. "I'll make sure to have a computed tomography (CT) colonoscopy every 5 years." 3. "I'll make sure to have a flexible sigmoidoscopy every year once I turn 55." 4. "I'll make sure to have a fecal occult blood test annually once I turn 50."
4
The nursing assistive personnel (NAP) informs you that the electronic blood pressure machine on the patient who has recently returned from surgery following removal of her gallbladder is flashing a blood pressure of 65/46 and alarming. Place your care activities in priority order. 1. Press the start button of the electronic blood pressure machine to obtain a new reading. 2. Obtain a manual blood pressure with a stethoscope. 3. Check the patient's pulse distal to the blood pressure cuff. 4. Assess the patient's mental status. 5. Remind the patient not to bend her arm with the blood pressure cuff.
4, 1, 3, 2, 5
How often should normal bowel sounds be heard in each quadrant of the abdomen? Go to question 5. A. 5-35 times per minute B. Less than 5 times per minute C. 15-20 times per minute D. 20-40 times per minute
A
Normal breath sounds include: A. Vesicular sounds B. Rhonchi C. Wheezes D. Crackles
A
When measuring a patient's respiratory rate, the nurse will count the number of completed respiratory cycles per minute. What is the definition of a respiratory cycle? A. The number of inspirations and expirations per minute. B. The number of expirations per minute. C. The number of sighs per minute. D. The number of inspirations per minute.
A
Which of the following indicates normal respiratory function? A. Symmetrical chest expansion B. Nasal flaring C. Use of accessory muscles D. Lip pursing
A
A nurse decides to use the CAGE screening questionnaire with a client admitted for substance abuse. What is the client abusing? 1. Alcohol 2. Barbiturates 3. Hallucinogens 4. Multiple drugs
Answer: 1 The CAGE questionnaire is one of the simplest and most reliable screening tools for alcohol abuse. CAGE is an acronym for the key words ( Cut down, Annoyed, Guilty, and Eye-opener) in the four questions asked of people suspected of abusing alcohol. The CAGE questionnaire is not designed to screen clients for barbiturate, hallucinogen, or multiple drug abuse.
A young adult who is unconscious after an accident is brought to the emergency department. The client's pupils are equal and responsive to light. As part of the neurologic assessment, the nurse applies a painful stimulus to the client's left lower leg. Which is an expected response in a healthy adult? 1. Withdrawing the leg 2. Making no movement 3. Plantar flexing the left foot 4. Flexing the upper extremities
Answer: 1 Withdrawing the leg is an appropriate response, a purposeful withdrawal from pain. Making no movement may indicate cortical or midbrain compression. Plantar flexion occurs with flexion posturing (decorticate posturing) or extension posturing (decerebrate posturing); these are associated with brain dysfunction. Flexing the upper extremities, with leg extension and plantar flexion, indicates flexion posturing (decorticate posturing); this indicates dysfunction of the cerebral cortex or lesions of the corticospinal tracts above the brainstem.
A nurse is reviewing several charts. Which condition is an autoimmune disorder? 1. Addison's disease 2. Cushing's syndrome 3. Hashimoto's disease 4. Sheehan's syndrome
Answer: 3 Hashimoto's disease is an autoimmune disorder, wherein the immune system attacks the thyroid gland. Addison's disease is caused by adrenal insufficiency. Cushing's syndrome is caused by increased body levels of cortisol. Sheehan's syndrome is hemorrhage-associated hypopituitarism after delivery of a child.
A nurse is caring for a patient who has just had major abdominal surgery to resect a portion of his colon. What is the most reliable sign that the patient has significant postoperative pain? A. The patient rates his pain a 7 on a scale of 0 to 10. B. The patient winces and guards the area as the nurse gently palpates the abdomen. C. The patient is having trouble sleeping and has become irritable. D. The patient is moaning softly and frowning, with a pinched expression on his face.
Answer: A
In which position should the patient be placed in order to palpate the popliteal pulse? A. Have the patient lie prone with the knee flexed. B. Have the patient lie prone with the leg straight. C. Have the patient lie supine with the knee flexed. D. Have the patient lie supine with the leg straight.
Answer: A
The Rinne and Weber tests measure which of the following? A. Air and bone conduction B. Movement of the tympanic membrane C. Tenderness of the mastoid area D. Nodules in the auricles
Answer: A
What is the correct way to palpate the frontal sinuses? A. Press the thumbs against the brow bones. B. Press the thumbs along the sides of the nose. C. Press the bridge of the nose between the thumb and first finger. D. Press the tip of the nose between the thumb and first finger.
Answer: A
What will the nurse instruct nursing assistive personnel (NAP) to do regarding the management of a patient's pain? A. "Let me know at least 30 minutes before you transport her so I can administer her pain medication." B. "Be sure to keep the room temperature high and the TV on at all times." C. "Be sure to tell me if you notice grimacing, guarding, or any unusual behavior." D. "I've given her some medication; please report to me whether it seems to have relieved her pain within an hour or so."
Answer: A
Which of the following is considered an ABNORMAL finding in an older adult? A. Malignant melanoma B. Cherry angioma C. Seborrheic keratoses D. Lentigines
Answer: A Rationale: A malignant melanoma is a type of skin cancer, which is an ABNORMAL finding. A cherry angioma is a normal finding in older adults. It is a tiny, round, red or brown papule often found on the trunk and extremities. Seborrheic keratoses are a normal finding in older adults. They are warty lesions that typically affect the face and trunk. Lentigines are a normal finding in older adults and are also called age spots. They appear as irregular, gray-brown lesions usually occurring in sun-exposed areas.
Which of the following actions are part of the assessment of the glossopharyngeal and vagus nerves? A. Testing the gag reflex B. Having the patient swallow C. Touching the patient's face with dull and sharp objects D. Both A and B
Answer: D Rationale: Both testing the gag reflex and having the patient swallow are part of a thorough assessment of the glossopharyngeal and vagus nerves. Testing the gag reflex is part of a thorough assessment of the glossopharyngeal and vagus nerves. When the posterior wall of the pharynx is touched, the patient should gag and the uvula should stay midline. Having the patient swallow is part of a thorough assessment of the glossopharyngeal and vagus nerves. Have the patient drink some water while you observe her ability to swallow.
Which of the following methods is correct for examining the ear of an adult patient with an otoscope? A. Gently pull the auricle up and back. B. Gently pull the auricle down and back. C. Use the largest speculum that will fit comfortably in the patient's ear. D. Both A and C.
Answer: D Rationale: Gently pulling the auricle up and back in the adult will straighten the auditory canal. Using the largest speculum that will fit comfortably is part of the otoscopic examination. Gently pulling the auricle down and back is the correct procedure for examining a child.
A whispered voice test includes which of the following? A. Having the patient wiggle a finger in the opposite ear. B. Whispering while standing 1 to 2 feet from the patient's ear. C. Playing soothing music in the examination room. D. Both A and B.
Answer: D Rationale: Having the patient wiggle a finger in opposite ear ensures that patient is hearing the whisper in the ear being tested. A whispered voice test is performed while standing 1 to 2 feet from the patient's ear. Music can be a distraction or interference with a whispered voice test.
The gag reflex should be: A. Tested with a tongue blade on each side of the oropharynx B. Present on both sides C. Tested in the midline of the oropharynx only D. Both A and B
Answer: D Rationale: Testing with a tongue blade on each side of the oropharynx is part of assessing the gag reflex. The gag reflex should be present on both sides. Testing with a tongue blade on each side of the oropharynx is part of assessing the gag reflex. There should be a bilateral response to the gag reflex. Testing in the midline of the oropharynx is not part of assessing the gag reflex.
How would you assess sensitivity to superficial pain? A. Touch the patient with the sharp side of a broken tongue blade. B. Have the patient keep his or her eyes open. C. Allow 2 seconds between stimuli. D. Both A and C.
Answer: D Rationale: Touching the patient with the sharp side of a broken tongue blade and allowing 2 seconds between stimuli are both part of a thorough assessment for superficial pain sensation. Assessment of superficial pain can be done by touching the patient with the sharp side of a broken tongue blade. With the patient's eyes closed, ask the patient to identify if the sensation is dull or sharp. Assessment of superficial pain is performed with the patient's eyes closed. For assessment of superficial pain, randomly apply the sharp and dull stimuli, allowing 2 seconds between stimuli to avoid a summative effect.
What is the correct order for abdominal assessment? Go to question 4. A. Inspection, palpation, auscultation, percussion B. Inspection, auscultation, percussion, palpation C. Auscultation, inspection, palpation, percussion D. Palpation, inspection, auscultation, percussion
B
Which action can the nurse take to keep a patient from consciously controlling his or her breathing during an assessment? A. Take the patient's temperature while counting the respiratory rate. B. Assess respiration after measuring the pulse. C. Assess respiration after taking the blood pressure. D. Assess respiration before measuring the blood pressure.
B