Practice Questions

Question 1

The nurse is performing blunt percussion of a client’s kidneys. For what abnormal finding is the nurse primarily assessing?
a. dullness
b. tympany
c. tenderness
d. hyperressonance
e. none of these

Answer 1

C

Question 2

The nurse demonstrates understanding of the proper use of a stethoscope when making which statement? (Select all that apply)
a. “The plastic tubing should be longer than 2 feet.”
b. “I will use the bell to hear high-frequency sounds.”
c. “When using the bell, apply it lightly to the skin surface.”
d. “The diaphragm picks up low-frequency sounds.”
e. “I will use the bell to hear low frequency sounds”
f. “When using the diaphragm, I will apply light pressure to the skin surface”

Answer 2

c,e

Question 3

Which concept is defined: “An ever changing process involving both cognitive means and behavioral actions, in order to manage internal or external situations that are perceived as difficult and \or beyond beyond the individual’s current resources”
a. Stress & Coping
b. Coping
c. Affect
d. Communication

Answer 3

b

Question 4

A nurse is performing a physical examination on a new client. Which of the four basic physical examination techniques would the nurse perform third?
a. Auscultation
b. Percussion
c. Palpation
d. Inspection

Answer 4

b

Question 5

A nurse is treating a patient that is having a heart attack. The nurse would utilize which type of health assessment technique?
A. Comprehensive
B. Focused
C. Ongoing
D. Emergency

Answer 5

d

Question 6

When reviewing a client’s health history and physical examination results, which data would the nurse identify as being subjective? Select all that apply.
A.”I feel so tired sometimes.”
B.”I have a headache.”
C.”My father died of a heart attack.”
D.Lungs are clear to auscultation
E.”Weight is measured as 140 pounds.”

Answer 6

a,b,c

Question 7

Which phase of the nursing process would the nurse identify as being the foundation for all other phases?
A.Evaluation
B.Assessment
C.Planning
D.Implementation

Answer 7

b

Question 8

Which questions toward the patient below would indicate the nurse completing a comprehensive assessment?(Select all that apply)
a. “What is your health history?”
b. “What type of medications do you take at home?”
c. “Is the chest pain radiating down your arm?”
d. “Any drainage from the surgical site?”
e. “What is your date of birth?”

Answer 8

a,b,e

Question 9

Which action would the nurse complete next after getting a patient from the emergency room?
a. Validate the information
b. Document everything that was done in the Emergency room
c. Give the medications due now
d. Call the nurse back from the emergency room to tell them the patient arrived safely

Answer 9

a

Question 10

Which specific question toward the patient below would indicate the nurse is completing a focused assessment?
a. “Where is the wound for this massive amount of blood I see on the floor?”
b. “Do you have equal strength in both hand grips?”
c. “Are you ready for a complete neurological assessment now?”
d. “Do you have any pain?”

Answer 10

b

Question 11

A 4-year-old child is brought to the emergency department by the parents, who state that the child has been crying, saying his “head hurts”. Which method will be the most appropriate for the nurse to initially assess the problem?
a. Complete an eye test
b. Order a CT of the head now
c. Tell the parents to leave the room while you assess
d. Ask the child to point with a finger where it hurts

Answer 11

d

Question 12

Once a comprehensive initial assessment has been completed for a new client, what principle should guide the nurse when applying the nursing process?
a. It is done once per patient
b. Each step is independent of itself
c. It is ongoing and continuous
d. It is only done in an acute care environment

Answer 12

c

Question 13

When examining a client’s skin the nurse notes an elevated mass, irregular, with transient borders on the arm. How would this be documented?
a. cyst
b. plaque
c. papules
d. wheal

Answer 13

d

Question 14

When examining the patient’s coccyx area, the nurse notes a reddened area that is NOT blanchable. How would this be documented?
a. stage two pressure injury
b. stage one pressure injury
c. unstageable
d. within normal limits

Answer 14

b

Question 15

A geriatric patient comes in to the clinic. Which statement by the patient would indicate normal aging process?
a. every time I go for a walk I experience chest pain
b. I sweat less than my grandson
c. my neck is stiff today
d. I feel so lost some days

Answer 15

b

Question 16

Which statement best describes an S4 sound when auscultating heart sounds?
a. Heard late in Diastole
b. Heard early in Diastole
c. Heard just after S1
d. Heard just after S2

Answer 16

a

Question 17

The nurse palpating for fremitus would give what instructions to the client?
a. “Breathe normally as I assess”
b. “Say the number 99 for me.”
c. “Take a deep breath and hold it.”
d. “Say the letter F for me.”

Answer 17

b

Question 18

When palpating a patient’s posterior thorax, which sequence is best practice?
a. Left to right, down and out
b. Right to left, up and in
c. Each side separate
d. Start with the abnormal finding

Answer 18

a

Question 19

1. A nursing student is asked who would produce the least amount of sweat, which would be the correct answer below?
   A. 30 year old male
   B. 6 year old female
   C. 75 year old male
   D. 45 year old female

Answer 19

C

Question 20

Which of the following client situations would the nurse interpret as requiring an emergency assessment?

A. A client with severe sunburn
B. A client needing an employment physical
C. A client who took a drug overdose
D. A client who wants a pregnancy test

Answer 20

C

Question 21

A nurse is completing an assessment that will involve gathering subjective and objective information. Which data would the
nurse identify as objective? Select all that apply.

A. Review of systems (ROS)
B. physician’s report
C. BP 135/78, heart rate 74 beats/min, respirations 16 breaths/min
D. family history
E. client’s name, age, and occupation

Answer 21

B,C

Question 22

Which statement by the new nurse demonstrates an understanding of the nurse’s responsibility to conduct an effective health
assessment of the client?

A. “A health assessment requires both a client history as well as a physical examination.”
B. “I always allow sufficient time to conduct the history portion of the assessment effectively.”
C. “I am always trying to improve my assessment skills.”
D. “The health assessment is the foundation of quality client care.”

Answer 22

C

Question 23

What are the nursing goals for the introductory phase of the nurse-client interview?

A. Establishing a trusting, respectful rapport with the client.
B. Inviting the client to tell their story.
C. Responding therapeutically to the client’s emotional cues.
D. Reviewing the client’s records.

Answer 23

A

Question 24

While conducting a comprehensive health history the client says a few sentences about the current problem but then
explains how her deceased mother used to have the same problem because of having diabetes. What action should the
nurse take?

A. begin drawing the genogram
B. refocus the client on the current problem
C. expresses sympathy for the loss of her mother
D. ask about the health of other family members

Answer 24

A

Question 25

The nurse is assessing the gastrointestinal system of an 81-year-old client. What age-related change should the nurse consider when collecting and analyzing assessment data?
a. the client is more vulnerable to impaired nutrition due to decreased appetite
b. the client derives less nutritional value from food because of decreased enzyme production
c. the client’s liver will be significantly larger than that of a younger client.
d. the client will have greater bowel motility than a younger adult

Answer 25

a

Question 26

The nurse is performing light palpation of the client’s abdomen. How can the nurse best prevent voluntary guarding during this phase of assessment?
a. ask the client to breathe slowly and deeply
b. perform auscultation prior to palpation
c. explain the procedure to the client before palpating
d. position the client sitting upright

Answer 26

a

Question 27

An adult client states that his mother has been living with peptic ulcer disease, and he is motivated to ensure that he does not develop the disease as he ages. What health promotion advice should the nurse provide?
a. quit smoking as soon as possible
b. exercise for a least 30 minutes, three times per week
c. eat several small meals a day rather than three larger meals
d. attend screening clinics at least twice per year

Answer 27

a

Question 28

An older adult client states, “Sometimes when I sneeze, I notice that I wet my pants.” How would the nurse interpret this finding?
a. reflex incontinence
b. stress incontinence
c. urge incontinence
d. total incontinence
e. both reflex and stress incontinence

Answer 28

b

Question 29

When examining a newborn male infant, the nurse notices that neither testicle is descended. How would the nurse document this finding?
a. epididymitis
b. orchitis
c. cryptorchidism
d. varicocele

Answer 29

c

Question 30

The nurse is assessing a client who is suspected of having an incarcerated scrotal hernia. Which finding would help confirm this suspicion?
a. the mass cannot be pushed up into the abdomen.
b. the area around the hernia is ecchymotic
c. the client complains of tenderness and nausea
d. the scrotal bulge disappears when the client lies down

Answer 30

a

Question 31

A client’s electronic health record reveals that he had surgery as an infant to correct the fact that his urethra was located on the ventral side of his penis. The nurse should recognize that this client had what condition?
a. epispadias
b. hypospadias
c. paraphimosis
d. phimosis

Answer 31

b

Question 32

An adult male client reports hesitancy when urinating. The nurse would further assess this client for which complication?
a. scrotal hernia
b. sexually transmitted infection
c. prostate enlargement
d. testicular tumor

Answer 32

c

Question 33

A nurse is preparing to assess the cranial nerves of a client. The nurse is about to test CN I. What would the nurse do?
a. use a Snellen chart to test visual acuity
b. ask a client to identify scents
c. test extraocular eye movements
d. perform the Weber test

Answer 33

b

Question 34

What is the difference between conductive hearing loss and sensorineural hearing loss?

Answer 34

Conductive Hearing Loss:

• Conductive hearing loss occurs when there is a problem with the outer or middle ear that interferes with sound transmission to the inner ear.
• Common causes of conductive hearing loss include ear infections, earwax buildup, perforated eardrum, fluid in the middle ear, or problems with the ossicles (small bones in the middle ear).
• Conductive hearing loss typically results in a reduction in the loudness of sounds but generally does not affect the clarity of speech.

Sensorineural Hearing Loss:

• Sensorineural hearing loss occurs when there is damage to the inner ear (cochlea) or the auditory nerve, which transmits sound signals from the cochlea to the brain.
• Causes of sensorineural hearing loss include aging, exposure to loud noise, genetic factors, head trauma, viral infections, and certain medications.
• Sensorineural hearing loss typically results in difficulty hearing faint sounds and understanding speech, even when it’s loud enough.