test bank for health assessment for nursing practice 7th edition by wilson
You also want an ePaper? Increase the reach of your titles
YUMPU automatically turns print PDFs into web optimized ePapers that Google loves.
Test Bank for Health Assessment for
Nursing Practice 7th Edition by Wilson
This is a bank of tests (study questions) to help you
prepare for the tests.
To clarify, this is a test bank, not a textbook.
You have immediate access to download your test
bank. No
delays, loading is fast and instant immediately after
Purchase!
You will receive a full bank of tests; in other words, all
chapters will be there.
Test banks are presented in PDF format; therefore,
no special software is required to open them
Test Bank for Health Assessment for
Nursing Practice 7th Edition by Wilson.
Chapter 01: Introduction to Health Assessment
MULTIPLE CHOICE
1. A patient comes to the emergency department and tells the triage nurse that he
is “having a heart attack.” What is the nurse’s top priority at this time?
a. Determine the patient’s personal data and
insurance coverage.
b. Ask the patient to take a seat in the waiting
room until his name is called.
c. Request that a nurse collect data for a
comprehensive history.
d. Ask a nurse to start a focused assessment
of this patient now.
ANSWER: D
The nurse needs to begin an assessment as soon as possible that is focused on this patient’s
cardiovascular system. The type of health assessment performed by the nurse is also driven
by patient need. Personal data and insurance information will be obtained, but in this
situation, these data can wait until after the patient is assessed. Based also on Maslow’s
hierarchy of needs, physiologic needs take precedence. Rather than asking the patient to
wait, the nurse needs to begin data collection, such as vital signs, immediately to determine
the patient’s health status. Complications can be prevented if an immediate assessment is
made to analyze the patient’s symptoms. A comprehensive history is not indicated in this
situation at this time. Some subjective data will be collected, such as allergies and medical
history related to cardiovascular disease. Eyes, ears, or a complete musculoskeletal or
mental health assessment is not a priority at this time.
DIF: Cognitive Level: Apply REF: Box 1-3 | p. 3
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:
Establishing Priorities
2. Which situation illustrates a screening assessment?
a. A patient visits an obstetric clinic for the
first time and the nurse conducts a detailed
history and physical examination.
b. A hospital sponsors a health fair at a local
mall and provides cholesterol and blood
pressure checks to mall patrons.
c. The nurse in an urgent care center checks
the vital signs of a patient who is
complaining of leg pain.
d. A patient newly diagnosed with diabetes
mellitus comes to test his fasting blood
glucose level.
ANSWER: B
A health fair at a local mall that provides cholesterol and blood pressure checks is an
example of a screening assessment focused on disease detection. A detailed history and
physical examination conducted during a first-time visit to an obstetric clinic is an example
of a comprehensive assessment. Assessing a patient complaining of leg pain in the triage
area of an urgent care center is an example of a problem-based/focused assessment. A
patient’s return appointment 1 month after today’s office visit to report fasting blood
glucose levels is an example of an episodic or follow-up assessment.
DIF: Cognitive Level: Understand REF: Box 1-3 | p. 3
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Health Screening
3. For which person is a screening assessment indicated?
a. The person who had abdominal surgery
yesterday
b. The person who is unaware of his high
serum glucose levels
c. The person who is being admitted to a
long-term care facility
d. The person who is beginning rehabilitation
after a knee replacement
ANSWER: B
A screening assessment is performed for the purpose of disease detection. In this case this
person may have diabetes mellitus. A shift assessment is most appropriate for the person
who is recovering in the hospital from surgery. A comprehensive assessment is performed
during admission to a facility to obtain a detailed history and complete physical
examination. An episodic or follow-up assessment is performed after knee replacement to
evaluate the outcome of the procedure.
DIF: Cognitive Level: Understand REF: Box 1-3 | p. 3
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:
Establishing Priorities
4. For which person is a shift assessment indicated?
a. The person who had abdominal surgery
yesterday
b. The person who is unaware of his high
serum glucose levels
c. The person who is being admitted to a
long-term care facility
d. The person who is beginning rehabilitation
after a knee replacement
ANSWER: A
A shift assessment is most appropriate for the person who is recovering in the hospital from
surgery. A screening assessment is performed for the purpose of disease detection, in this
case diabetes mellitus. A comprehensive assessment is performed during admission to a
facility to obtain a detailed history and complete physical examination. An episodic or
follow-up assessment is performed after knee replacement to evaluate the outcome of the
procedure.
DIF: Cognitive Level: Understand REF: Box 1-3 | p. 4
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:
Establishing Priorities
5. For which person is a comprehensive assessment indicated?
a. The person who had abdominal surgery
yesterday
b. The person who is unaware of his high
serum glucose levels
c. The person who is being admitted to a
long-term care facility
d. The person who is beginning rehabilitation
after a knee replacement
ANSWER: C
A comprehensive assessment is performed during admission to a facility to obtain a
detailed history and complete physical examination. A shift assessment is most appropriate
for the person who is recovering in the hospital from surgery. A screening assessment is
performed for the purpose of disease detection, in this case diabetes mellitus. An episodic
or follow-up assessment is performed after knee replacement to evaluate the outcome of
the procedure.
DIF: Cognitive Level: Understand REF: Box 1-3 | p. 3
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:
Establishing Priorities
6. For which person is an episodic or follow-up assessment indicated?
a. The person who had abdominal surgery
yesterday
b. The person who is unaware of his high
serum glucose levels
c. The person who is being admitted to a
long-term care facility
d. The person who is beginning rehabilitation
after a knee replacement
ANSWER: D
An episodic or follow-up assessment is performed after the knee replacement to evaluate
the outcome of the procedure. A shift assessment is most appropriate for the person who is
recovering in the hospital from surgery. A screening assessment is performed for the
purpose of disease detection, in this case diabetes mellitus. A comprehensive assessment is
performed during admission to a facility to obtain a detailed history and complete physical
examination.
DIF: Cognitive Level: Understand REF: Box 1-3 | p. 3
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:
Establishing Priorities
7. Which is an example of data a nurse collects during a physical
examination?
a. The patient’s lack of hair and shiny skin
over both shins
b. The patient’s stated concern about lack of
money for prescriptions
c. The patient’s complaints of tingling
sensations in the feet
d. The patient’s mother’s statements that the
patient is very nervous lately
ANSWER: A
The lack of hair and shiny skin over both shins are objective data or signs that are part of
the physical examination. A patient’s concerns about lack of money are subjective data and
are part of the health history. A patient’s complaints of tingling sensations in the feet are
subjective data and are part of the health history. A patient’s family statements are
considered secondary data, are subjective data, and are part of the health history.
DIF: Cognitive Level: Apply REF: Box 1-3 | p. 3
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System
Specific Assessments
8. The nurse documents which information in the patient’s history?
a. The patient’s skin feels warm to the touch.
b. The patient is scratching his arm.
c. The patient’s temperature is 100° F.
d. The patient complains of itching.
ANSWER: D
A patient’s complaint of itching is subjective information, which means it is a symptom
and is documented in the history. The patient’s warm skin is objective information
gathered by the nurse through palpation, is also a sign, and is documented in the physical
examination. The patient’s scratching is objective information gathered by the nurse
through observation, is also a sign, and is documented in the physical examination. The
patient’s elevated temperature is objective information gathered by the nurse through
measurement, is also a sign, and is documented in the physical examination.
DIF: Cognitive Level: Apply REF: p. 1 | p. 2 and Box 1-2
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:
Establishing Priorities
9. Which patient information does the nurse document in the patient’s physical
assessment?
a. Slurred speech
b. Immunizations
c. Smoking habit
d. Allergies
ANSWER: A
Slurred speech should be noticed by the nurse and documented as objective data in the
physical assessment. Data on immunizations are collected from the patient, are subjective,
and documented in the history. A smoking habit is information that comes from the patient,
making it subjective data that is documented in the history. Allergies are information that
come from the patient, making it subjective data that is documented in the history.
DIF: Cognitive Level: Apply REF: p. 1-2 and Box 1-2
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:
Establishing Priorities
10. After collecting the data, the nurse begins data analysis with which action?
a. Clustering data
b. Documenting subjective data
c. Reporting information to other health team
members
d. Documenting objective information
ANSWER: A
After collecting data, the nurse organizes or clusters the data so that the problems appear
more clearly. To cluster data, the nurse interprets the assessment data collected.
Documenting subjective data is necessary for the medical record, but does not provide
analysis. Before reporting data to health team members, the nurse clusters and interprets
data. Documenting objective data is necessary for the medical record, but does not provide
analysis.
DIF: Cognitive Level: Understand REF: p. 4
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:
Establishing Priorities
11. Which activity illustrates the concept of primary prevention?
a. Monthly breast self-examination
b. Annual cervical (Papanicolaou test)
examination
c. Education about living with asthma
d. Exercising three times a week
ANSWER: D
Exercising is an example of primary prevention that prevents disease from developing by
maintaining a healthy lifestyle. Monthly breast self-examination is an example of
secondary prevention and screening efforts to promote early detection of disease. Annual
cervical (Papanicolaou test) examination is an example of secondary prevention and
screening efforts to promote early detection of disease. Teaching a patient how to live with
a chronic disease such as asthma is an example of tertiary prevention directed toward
minimizing the disability from chronic disease and helping the patient maximize his or her
health.
DIF: Cognitive Level: Understand REF: Table 1-1 | p. 5-6
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Health Promotion Programs
12. A nurse is teaching a patient how to manage chronic obstructive pulmonary
disease (COPD). This intervention is an example of which level of health promotion?
a. Primary prevention
b. Secondary prevention
c. Tertiary prevention
d. Risk factor prevention
ANSWER: C
Teaching a patient how to live with a chronic disease is an example of tertiary prevention
directed toward minimizing the disability from chronic disease and helping the patient
maximize his or her health. The focus of primary prevention is to prevent a disease from
developing by promoting a healthy lifestyle. Secondary prevention consists of efforts to
promote early detection of disease. Risk factor prevention is part of primary prevention that
focuses on preventing disease by managing risk factors.
DIF: Cognitive Level: Understand REF: Table 1-1 | p. 5-6
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Health Promotion Programs
13. Which activity illustrates the concept of secondary prevention?
a. Annual mammogram
b. Nutrition classes on low-fat cooking
c. Education on living with diabetes mellitus
d. Cardiac rehabilitation after coronary artery
bypass surgery
ANSWER: A
A mammogram screens for breast cancer and is an example of secondary prevention to
promote early detection of disease. Nutrition classes are an example of primary prevention
to prevent a disease from developing by promoting a healthy lifestyle. Education about
diabetes mellitus is an example of tertiary prevention directed toward minimizing the
disability from chronic disease and helping the patient maximize his or her health. Cardiac
rehabilitation after coronary artery bypass surgery is an example of tertiary prevention
directed toward minimizing the disability from chronic disease and helping the patient
maximize his or her health.
DIF: Cognitive Level: Understand REF: Table 1-1 | p. 5-6
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Health Promotion Programs
14. A community organization sponsors a health fair to increase awareness of colon
cancer. At the health fair, colorectal cancer screening kits are distributed, and health care
professionals answer questions, take blood pressure, and distribute literature. What level of
health prevention is being implemented by this community organization?
a. Primary
b. Secondary
c. Tertiary
d. Risk factor
ANSWER: B
Secondary prevention consists of screening efforts to promote early detection of disease —
in this scenario, colorectal cancer and hypertension. Primary prevention is focused on
preventing disease from developing through the promotion of a healthy lifestyle. Tertiary
Powered by TCPDF (www.tcpd f. o rg )
prevention is directed toward minimizing the disability from chronic disease and helping
the patient maximize his or her health. Risk factor prevention is part of primary prevention
that focuses on preventing disease by managing risk factors.
DIF: Cognitive Level: Apply REF: Table 1-1 | p. 5-6
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Health Promotion Programs
Chapter 02: Obtaining a Health History
MULTIPLE CHOICE
1. Which statement or question does the nurse use during the introduction
phase of the interview?
a. “I’m here to learn more about the pain
you’re experiencing.”
b. “Can you describe the pain that you’re
experiencing?”
c. “I heard you say that the pain is ‘all over’
your body.”
d. “What relieves the pain you are having?”
ANSWER: A
“I’m here to learn more about the pain you’re experiencing” is an example of the
introduction phase a nurse may use to explain the purpose of the interview to a patient.
“Can you describe the pain that you’re experiencing?” is an example of part of a symptom
analysis that occurs in the discussion phase. “I heard you say that the pain is ‘all over’ your
body” is an example of a summary statement by the nurse that occurs in the summary
phase. “What relieves the pain you are having?” is an example of part of a symptom
analysis that occurs in the discussion phase.
DIF: Cognitive Level: Apply REF: Box 2-1 | p. 8-9
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Psychosocial Integrity: Therapeutic Communications
2. Which statement is appropriate to use when beginning an interview with a
new patient?
a. “Have you ever been a patient in this clinic
before?”
b. “What is your purpose for coming to the
clinic today?”
c. “Tell me a little about yourself and your
family.”
d. “Did you have any difficulty finding the
clinic?”
ANSWER: B
“What is your purpose for coming to the clinic today?” is an open-ended question that
focuses on the patient’s reason for seeking care. “Have you ever been a patient in this clinic
before?” is a close-ended question that yields a “yes” or “no” response. This question may
be asked on the first visit, but not as an opening question for a health interview. “Tell me a
little about yourself and your family” is an open-ended question, but it is too general, and it
is at least two questions: one about the patient and another about the family. “Did you have
any difficulty finding the clinic?” is a social question and does not focus on the patient’s
purpose for the visit.
DIF: Cognitive Level: Understand REF: p. 8
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Psychosocial Integrity: Therapeutic Communications
3. Which statement by the nurse demonstrates a patient-centered interview?
a. “I need to complete this questionnaire
about your medical and family history.”
b. “The hospital requires me to complete this
assessment as soon as possible.”
c. “Tell me about the symptoms you’ve been
having.”
d. “I’ve had the same symptoms that you’ve
described.”
ANSWER: C
“Tell me about the symptoms you’ve been having” focuses on the needs of the patient so
that the patient is free to share concerns, beliefs, and values in his or her own words. “I
need to complete this questionnaire about your medical and family history” focuses on the
nurse’s need to complete the assessment rather than the needs of the patient. “The hospital
requires me to complete this assessment as soon as possible” focuses on the nurse’s need to
meet hospital requirements rather than the needs of the patient. “I’ve had the same
symptoms that you’ve described” focuses on the nurse rather than on the patient.
DIF: Cognitive Level: Apply REF: p. 8
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Psychosocial Integrity: Therapeutic Communications
4. Which question is an example of an open-ended question?
a. “Have you experienced this pain before?”
b. “Do you have someone to help you at
home?”
c. “How many times a day do you use your
inhaler?”
d. “What were you doing when you felt the
pain?”
ANSWER: D
“What were you doing when you felt the pain?” is a broadly stated question that
encourages a free-flowing, open response. “Have you experienced this pain before?” is
closed-ended, which can obtain a “yes” or “no” answer to the question without any
additional data. “Do you have someone to help you at home?” is closed-ended, which can
obtain a “yes” or “no” answer to the question without any additional data. “How many
times a day do you use your inhaler?” is closed-ended, which can obtain an answer of a
specific number without any additional data.
DIF: Cognitive Level: Understand REF: pp. 10-11
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Psychosocial Integrity: Therapeutic Communications
5. A nurse suspects a female patient is a victim of physical abuse. Which
response is most likely to encourage the patient to confide in the nurse?
a. “You’ve got a huge bruise on your face.
Did your husband hit you?”
b. “That bruise looks tender. I don’t know
how people can do that to one another.”
c. “If your boyfriend hit you, you can get a
restraining order against him.”
d. “I’ve seen women who have been hurt by
boyfriends or husbands. Does anyone hit
you?”
ANSWER: D
“I’ve seen women who have been hurt by boyfriends or husbands” is an example of a
technique referred to as “permission giving” in which the nurse communicates that it is safe
to discuss uncomfortable topics. “You’ve got a huge bruise on your face. Did your husband
hit you?” assumes that domestic violence did occur, and the comment does not encourage
the patient to divulge additional information. “That bruise looks tender. I don’t know how
people can do that to one another” assumes that domestic violence did occur, and the
comment does not encourage the patient to divulge additional information. “If your
boyfriend has hit you, you can get a restraining order against him” assumes that domestic
violence did occur, and the comment does not encourage the patient to divulge additional
information.
DIF: Cognitive Level: Apply REF: p. 10
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Psychosocial Integrity: Abuse/Neglect
6. Which technique used by the nurse encourages a patient to continue talking
during an interview?
a. Laughing and smiling during conversation
b. Using phrases such as “Go on,” and
“Then?”
c. Repeating what the patient said, but using
different words
d. Asking the patient to clarify a point
ANSWER: B
Using phrases such as “Go on” and “Then?” encourages the patient to continue talking.
Laughing and smiling during conversation may show attentiveness during the interview,
but does not encourage more talking. Rephrasing what the patient has said is restatement.
It confirms your interpretation of what they said, but does not encourage additional talking.
Asking the patient to clarify a point is done when the information is conflicting, vague, or
ambiguous.
DIF: Cognitive Level: Remember REF: p. 11
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Psychosocial Integrity: Therapeutic Communications
7. During the history, the patient states that she does not use many drugs.
What is the nurse’s appropriate response to this statement?
a. “Tell me about the drugs you are using
currently.”
b. “To some people six or seven is not
many.”
c. “Do you mean prescription drugs or illicit
drugs?”
d. “How often are you using these drugs?”
ANSWER: A
“Tell me about the drugs you are using currently” is an open-ended question that allows
patients to provide further data. “To some people six or seven is not many” is a comment
that does not ask a question or obtain useful data. “Do you mean prescription drugs or
illicit street drugs?” is a closed-ended question that yields data about the type of drugs used
only. “How often are you using these drugs?” asks about frequency of drug use, which is
not useful until the drugs are known.
DIF: Cognitive Level: Apply REF: p. 11
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Psychosocial Integrity: Therapeutic Communications
8. A nurse is interviewing a patient who was diagnosed with type 2 diabetes
mellitus 6 months ago. Since that time, the patient has gained weight and her blood glucose
levels remain high. The nurse suspects that the patient is noncompliant with her diet.
Which response by the nurse enhances data collection in this situation?
a. “Tell me about what foods you eat and the
frequency of your meals.”
b. “What symptoms do you notice when your
blood sugar levels are high?”
c. “You need to follow what the doctor has
prescribed to manage your disease.”
d. “Tell me what you know about the cause of
type 2 diabetes.”
ANSWER: A
“Tell me about what foods you eat and the frequency of your meals” gathers more data
from the patient to help the nurse confirm if noncompliance is the reason for the weight
gain and high glucose levels. “What symptoms do you notice when your blood sugar levels
are high?” does not help the nurse determine if the patient is noncompliant. It may be
useful later when teaching the patient about her disease. “You need to follow what the
doctor has prescribed to manage your disease” does not provide additional data for the
nurse and may be viewed as authoritarian and paternalistic. “Tell me what you know about
the cause of type 2 diabetes” assumes that the reason for the weight gain and high glucose
levels is a lack of knowledge. A more therapeutic approach is to gather more data from the
patient about how the diabetes has been managed.
DIF: Cognitive Level: Apply REF: p. 11
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Psychosocial Integrity: Therapeutic Communications
9. A male patient tells the nurse that he rarely sleeps more than 4 hours a night
and has not experienced any problems because of the lack of sleep. Which response by the
nurse is most appropriate?
a. “That is interesting.”
b. “Only 4 hours of sleep? How do you stay
awake during the day?”
c. “Really? Everyone needs more sleep than
that.”
d. “Did I understand that you sleep 4 hours
every night?”
ANSWER: D
“Did I understand that you sleep 4 hours every night?” is a reflection technique that allows
the nurse to confirm and obtain additional information. “That is interesting” does not
provide an opportunity for the patient to explain any reason for the number of hours of
sleep. “Only 4 hours of sleep? How do you stay awake during the day?” questions the
accuracy of the patient’s data and may not encourage the patient to give further details.
“Really? Everyone needs more sleep than that” can be perceived as argumentative, but
does not encourage further data from the patient.
DIF: Cognitive Level: Apply REF: p. 11
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Psychosocial Integrity: Therapeutic Communications
10. Which technique should the nurse use to obtain more data about a patient’s
vague or ambiguous statement?
a. Laughing and smiling during conversation
b. Using phrases such as “Go on,” and
“Then?”
c. Repeating what the patient has said, but
using different words
d. Asking the patient to explain a point
ANSWER: D
Asking the patient to explain a point is clarification, which is used to obtain more
information about conflicting, vague, or ambiguous statements. Laughing and smiling
during conversation may show attentiveness during the interview, but does not help to
clarify vague information. Using phrases such as “Go on” and “Then?” encourages patients
to continue talking, but does not help clarify. Rephrasing what the patient has said is
restatement. It confirms your interpretation of what they said, but does not encourage
additional talking.
DIF: Cognitive Level: Understand REF: p. 11
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Psychosocial Integrity: Therapeutic Communications
11. What does the nurse say to obtain more data about a patient’s vague
statement about diet such as, “My diet’s okay”?
a. “Eating a variety of meats, fruits, and
vegetables each day is important.”
b. “Give me an example of the foods you eat
in a typical day.”
c. “Go on.”
d. “Does your diet meet your needs or does it
need improvement?”
ANSWER: B
“Give me an example of the foods you eat in a typical day.” This statement asks the patient
to clarify the vague statement, “My diet is okay.” “Eating a variety of meats, fruits, and
vegetables each day is important.” While this statement is true, it does not obtain data
about what foods the patient consumes. “Go on” encourages patients to continue talking,
but does not help clarify what foods are consumed. “Does your diet meet your needs or
does it need improvement?” This response does not help clarify what foods the patient eats.
Also it contains two questions rather than asking one question at a time.
DIF: Cognitive Level: Apply REF: p. 11
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Psychosocial Integrity: Therapeutic Communications
12. While giving a history, a male patient describes several events out of order
that occurred in different decades in his life. What technique does the nurse use to
understand the timeline of these events?
a. State the order of events as understood and
ask the patient to verify the order.
b. Draw conclusions about the order of events
from data given.
c. Ask the patient to elaborate about these
events.
d. Ask the patient to repeat what he said
about these events.
ANSWER: A
State the order of events as understood and ask patient to verify the order is correct. This
therapeutic technique is useful when interviewing a patient who rambles or does not
provide sequential data. Drawing conclusions about the order of events is interpretation. In
this example, the sequence of events is more relevant than an interpretation. The nurse may
have difficulty interpreting an unclear sequence of events. Asking the patient to elaborate
about these events will not provide order to the sequence of events. Asking the patient to
repeat what he said about these events will not necessarily provide a sequence of events.
DIF: Cognitive Level: Understand REF: p. 11
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Psychosocial Integrity: Therapeutic Communications
13. A male patient is very talkative and shares much information that is not
relevant to his history or the reason for his admission. Which action by the nurse improves
data collection in this situation?
a. Terminate the interview.
b. Use closed-ended questions.
c. Ask the patient to stay on the subject.
d. Ask another nurse to complete the
interview.
ANSWER: B
Using closed-ended questions is useful to obtain specific data when open-ended questions
are not obtaining the needed data. Terminating the interview is not beneficial to the patient
and does not allow data collection. Asking the patient to stay on the subject is not
therapeutic and may result in less data collection. Asking another nurse to complete the
interview may not be practical and interrupts the nurse-patient relationship that has been
established.
DIF: Cognitive Level: Understand REF: p. 11 | p. 12
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Psychosocial Integrity: Therapeutic Communications
14. A patient answers questions quietly and appears sad. While answering
questions about her marriage, she begins to cry. Which response by the nurse is appropriate
in this situation?
a. “Don’t cry! I’ll come back when you’ve
settled down.”
b. “I only have a few more questions to ask,
and then I’ll leave you alone for a while.”
c. “Everyone has ups and downs in their
marriage. What problems are you having?”
d. “I see that you are upset. Is there
something you’d like to discuss?”
ANSWER: D
“I see that you are upset. Is there something you’d like to discuss?” shows that the nurse is
attentive to the patient’s feelings and does not make assumptions about the reason why the
patient is crying. The crying may signify additional data the nurse needs to collect during
this interview. “Don’t cry! I’ll come back when you’ve settled down” is not a therapeutic
response. The nurse needs to support the patient rather than leave her. “I only have a few
more questions to ask, and then I’ll leave you alone for a while” is not a therapeutic
response. The nurse is more concerned about getting the history than the patient’s response.
“Everyone has ups and downs in their marriage. What problems are you having?” is not a
therapeutic response. The nurse is assuming there are problems in the marriage instead of
collecting more data.
DIF: Cognitive Level: Apply REF: pp. 11-12 | pp. 11-13
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Psychosocial Integrity: Therapeutic Communications
15. During an interview, a patient begins to cry and appears angry. Which
response by the nurse is most therapeutic?
a. “This topic prompted an emotional
response, tell me what you are feeling.”
b. “This topic does not usually cause such an
emotional response.”
c. “Calm down and tell me what is wrong.”
d. “I will leave you alone for a few minutes so
you can pull yourself together.”
ANSWER: A
Acknowledging the patient’s feelings and encouraging their expression communicates
acceptance of the emotion. Crying is a natural behavior and should be permitted. “This
topic does not usually cause such an emotional response” may be perceived by the patient
as judgmental and it does not help the patient meet the current need. Encouraging the
patient to stop crying so that the nurse can help is not supportive of the patient’s current
need. The therapeutic action is to postpone further questioning until the patient is ready to
proceed. Leaving the room so that the patient can be alone is not supportive of the patient.
DIF: Cognitive Level: Apply REF: p. 12
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Psychosocial Integrity: Therapeutic Communications
16. In which situation is the nurse’s use of closed-ended questions most
appropriate?
a. When clarifying vague or conflicting data
b. When obtaining a history from an overly
talkative patient
c. When encouraging a patient to elaborate
on details of his or her history
d. When collecting data about the current
health problem
ANSWER: B
When obtaining a history from an overly talkative patient, a nurse can resort to closedended
questions to complete the data collection in a timely manner. When clarifying vague and
conflicting data, the nurse needs to use open-ended questions to obtain data. When
encouraging the patient to elaborate on details of his or her history, the nurse needs to use
open-ended questions to obtain the details. When collecting data about the current problem,
the patient needs to describe the symptoms that brought him or her to seek help. These
details are not collected with closed-ended questions.
DIF: Cognitive Level: Understand REF: p. 12
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Psychosocial Integrity: Therapeutic Communications
17. The nurse is interviewing a woman with her husband present. The husband
answers the questions for the wife most of the time. What is the most appropriate
therapeutic nursing action to hear the patient’s viewpoint?
a. Continue the interview.
b. Ask the husband to step out of the room.
c. Ask another nurse to complete the
interview.
d. Tell the woman to speak up for herself.
ANSWER: B
Asking the husband to step out of the room will allow the patient to answer questions in her
own way. Continuing the interview is not a therapeutic action because the nurse needs to
obtain the patient’s answers to the questions. Asking another nurse to complete the
interview does not solve the problem that the husband is answering questions for his wife.
Telling the woman to speak up for herself does not solve the problem and may interfere
with the therapeutic relationship between the patient and the nurse.
DIF: Cognitive Level: Remember REF: pp. 12-13
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Psychosocial Integrity: Therapeutic Communications
18. A female Korean patient accompanied by her husband and son comes to the
emergency department (ED) complaining of abdominal pain. The patient speaks and
understands Korean only. Which person is the appropriate choice for the nurse to use to get
a history from this patient?
a. The patient’s husband who speaks Korean
and English
b. The patient’s son who speaks Korean and
English
c. A male technician who works in the ED
who speaks Korean and English
d. A female interpreter who speaks Korean
and English and is available by phone
ANSWER: D
A female interpreter who speaks Korean and English and is available by phone is the best
choice because she can communicate with the patient and is the same gender as the patient.
The patient’s husband who speaks Korean and English is not the best choice because he is
a family member and may alter the meaning of what is said. The patient’s son who speaks
Korean and English is not the best choice because he is a family member and may alter the
meaning of what is said. A male technician working in the ED who speaks Korean and
English is not a good choice because the patient may feel uncomfortable giving a history to
a stranger who is male.
DIF: Cognitive Level: Understand REF: p. 13
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Psychosocial Integrity: Cultural Diversity | NCLEX Patient
Needs: Psychosocial Integrity: Therapeutic Communications
19. Which nurse demonstrates culturally competent care for a female patient
from Russia?
a. Nurse A who asks the patient about
cultural factors that influence health care
b. Nurse B who interacts with every patient
from Russia in the same manner
c. Nurse C who learns the cultural variables
of every culture, including Russia
d. Nurse D who relies on her previous
experience with patients from Russia
ANSWER: A
Asking the patient about cultural factors that influence health care is demonstrating
culturally competent care, along with interacting with each patient as a unique person who
is a product of past experiences, beliefs, and values. Interacting with every patient from
Russia in the same manner does not allow for the uniqueness of each person within the
same culture. Learning the cultural variables of every group encountered can be valuable
but it is impractical to learn about all cultures because each patient is unique. A better
approach is to ask patients about their beliefs. Relying on previous experience with patients
from Russia does not allow for the uniqueness of each person within the same culture.
DIF: Cognitive Level: Understand REF: p. 13
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Psychosocial Integrity: Cultural Diversity
20. For which patient is a focused health history most appropriate?
a. A new patient at the health clinic for an
annual examination
b. A patient admitted to the hospital with
vomiting and abdominal pain
c. A patient at the health care provider’s
office for a sport physical
d. A patient discharged 11 months ago who is
being readmitted today
ANSWER: B
A patient admitted to the hospital with vomiting and abdominal pain benefits from a
focused health history that limits data to the immediate problem. A new patient at the
health clinic for an annual examination needs a comprehensive history that includes
biographic data, reason for seeking care, present health status, past medical history, family
history, personal and psychosocial history, and a review of all body. A patient with a
specific need, such as a sport physical, needs a history for an episodic assessment. A
patient discharged months ago who is being readmitted needs a history for a follow-up
assessment that generally focuses on the specific problem or problems that caused the
patient to be readmitted.
DIF: Cognitive Level: Understand REF: pp. 13-14
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Psychosocial Integrity: Therapeutic Communications
21. A patient tells the nurse at the clinic, “I can never seem to get warm lately
and feel tired all the time.” The nurse records these data under which section of the health
history?
a. Past health history
b. Present health status
c. Reason for seeking care (chief complaint)
d. Subjective assessment data
ANSWER: C
The reason for seeking care (chief complaint) is the patient’s reason for seeking care (also
called the presenting problem). The patient’s reason for seeking care is often recorded as a
direct quote. The past health history includes data about immunizations, surgeries,
accidents, and childhood illnesses. The present health status includes data the nurse obtains
from the patient, often using a symptom analysis in which more data are collected about the
patient’s reason for seeking care. Subjective assessment data include information from the
patient. In this example, the patient expresses the reason for seeking care, which is directly
quoted and placed in quotation marks in the chief complaint section of the data sheet so
that the patient’s reason for seeking care can be easily identified.
DIF: Cognitive Level: Apply REF: p. 14
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Psychosocial Integrity: Therapeutic Communications
22. A patient comes to the ambulatory surgery center for an elective procedure this
morning. While giving the admission history, the patient states she is allergic to latex.
What is the most appropriate response by the nurse at this time?
a. Removing all latex products from the
patient’s room
b. Using powdered gloves when providing
care to this patient
c. Informing the surgeon that the patient has
type I hypersensitivity to latex
d. Questioning the patient about symptoms
experienced in the past with latex
ANSWER: D
Questioning the patient about symptoms experienced in the past with latex is the
appropriate response. When patients indicate an allergy to a medication or substance, ask
them to describe what happens with exposure to determine whether the reaction is a side
effect or an allergic reaction. Removing all latex products from the patient’s room is
unnecessary at this time because the latex allergy has not been confirmed. Using powdered
gloves when providing care to this patient is unnecessary at this time because the latex
allergy has not been confirmed. Informing the surgeon that the patient has type I
hypersensitivity to latex is unnecessary at this time because the latex allergy has not been
confirmed.
DIF: Cognitive Level: Understand REF: p. 15
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Safety and Infection
Control: Injury Prevention
23. A nurse is interviewing a male patient who reports he has not had a tetanus
immunization in about 15 years because he had a “bad reaction” to the last tetanus
immunization. What is the most appropriate response by the nurse in this case?
a. Notify the health care provider that this
immunization cannot be given.
b. Document that the patient is allergic to the
tetanus vaccine.
c. Give the vaccine after explaining that
adverse reactions are rare.
d. Ask the patient to describe the “bad
reaction” to the vaccine in more detail.
ANSWER: D
The nurse needs to collect more data about the reaction from the patient to determine the
type of reaction experienced. The nurse is trying to assess the relationship between the
“reaction” reported by the patient and an allergic reaction. The immunization should not be
eliminated at this time. Additional facts are needed to determine the type of reaction the
patient experienced. Documenting an allergy to the tetanus vaccine may be an error
because there are insufficient data to make that determination at this time. Giving the
vaccine may be an error if the patient is allergic to the vaccine and additional data indicates
that may be the case.
DIF: Cognitive Level: Apply REF: p. 15
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Health Promotion and
Disease Prevention
24. A patient admitted with pneumonia reports that she takes insulin for
diabetes mellitus. In which section of the history does the nurse document the insulin and
diabetes?
a. Past health history
b. Present health status
c. Reason for seeking care (chief complaint)
d. History of present illness
ANSWER: B
The present health status documents the current health conditions, which include chronic
diseases and medications taken. In this case, diabetes and taking insulin are not the reason
for seeking care, but need to be managed while the patient’s pneumonia is being treated
because they may affect the patient’s recovery from pneumonia. The past health history
includes categories of childhood illness, surgeries, hospitalizations, accidents or injuries,
immunizations, and obstetric history. The reason for seeking care (chief complaint) is a
brief statement of the patient’s purpose for requesting the services of a health care provider.
History of present illness further investigates the history of the present problem; best
accomplished by conducting a symptom analysis.
DIF: Cognitive Level: Understand REF: p. 15
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Collaboration with
Interdisciplinary Team
25. A nurse is getting a history from a patient who is disabled from rheumatoid
arthritis. Which question will provide data about this patient’s functional ability?
a. “When did your arthritis symptoms
begin?”
b. “How has your arthritis affected your daily
life?”
c. “Why did you come to the clinic today?”
d. ”How do you feel about your diagnosis of
rheumatoid arthritis?”
ANSWER: B
“How has your arthritis affected your daily life?” is a question that leads to data about the
patient’s ability to perform self-care activities or functional abilities. “When did your
arthritis symptoms begin?” is a question asked as part of the history, but does not collect
data about functional ability. “Why did you come to the clinic today?” is a question asked
to obtain the chief complaint about a current problem, but does not focus directly on the
functional assessment. “How do you feel about your diagnosis of rheumatoid arthritis?”
is a question to ask in the psychosocial history, but does not focus directly on the functional
assessment.
DIF: Cognitive Level: Apply REF: p. 17
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Psychosocial Integrity: Therapeutic Communications
26. An example of a health promotion question included in the health
history
is:
a. “Do you have any allergies?”
b. “How often are you exercising?”
c. “What are you doing to relieve your leg
pain?”
d. “What kind of herbs are you using?”
ANSWER: B
“How often are you exercising?” is a question about activities patients regularly perform to
maintain health. “Do you have any allergies?” is a question for the present health status
rather than health promotion. “What are you doing to relieve your leg pain?” is a question
that is part of the symptom analysis. “What kind of herbs are you using?” is a question for
the present health status rather than health promotion.
DIF: Cognitive Level: Remember REF: p. 17
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Psychosocial Integrity: Therapeutic Communications
27. The patient reports having a persistent cough for the past 2 weeks
and that the cough disrupts sleep and has not been helped by over-the-counter
cough medicines. Which question is most appropriate for the nurse to ask next?
a. “So what do you think is causing this
persistent cough?”
b. “Have you tried taking sleeping pills to
help you sleep?”
c. “Did you think this will just go away on its
own?”
d. “What other symptoms have you noticed
related to this cough?”
ANSWER: D
“What other symptoms have you noticed related to this cough?” is part of a symptom
analysis to provide more data. The answer to the question “So what do you think is causing
this persistent cough?” is a guess by the patient and does not provide useful data. “Have
you tried taking sleeping pills to help you sleep?” does not focus on the cough, which is
what is disturbing the patient’s sleep. “Did you think this will just go away on its own?”
does not provide useful data and criticizes the patient’s lack of action.
DIF: Cognitive Level: Apply REF: p. 18 | Box 2-3
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Psychosocial Integrity: Therapeutic Communications
MULTIPLE RESPONSE
1. Which data do nurses document under the heading of Past Health History?
(Select all that apply.)
a. Father has Alzheimer disease.
b. Last tetanus in 2009
c. Had chicken pox as a child
d. Drinks three to four beers each day
e. Had a dental examination 6 months ago
ANSWER: B, C, E
Last tetanus is an immunization, chicken pox as a child is a childhood illness, and last
examinations, including dental, are documented under the heading of Past Health History.
Family History documents father’s Alzheimer disease; patient drinking three to four beers
each day refers to alcohol use, which is documented under the heading Personal and
Psychosocial History.
DIF: Cognitive Level: Understand REF: pp. 15-16
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Psychosocial Integrity: Therapeutic Communications
2. Which data do nurses document under the heading of Personal and
Psychosocial History? (Select all that apply.)
a. Walks for 45 minutes each day
b. Eats meats, vegetables, and fruit at two
meals daily
c. Is allergic to milk and milk products
d. Is married and has two daughters whom he
is close to
e. Smokes marijuana once a week
f. Grandfather died from prostate cancer
ANSWER: A, B, D, E
Walks for 45 minutes each day is documented under health promotion activity in Personal
and Psychosocial History; eats meats, vegetables, and fruit at two meals daily is
documented about diet activity in Personal and Psychosocial History; is married and has
two daughters whom he is close to is documented under family and social relationship
activity in Personal and Psychosocial History; smokes marijuana once a week is
documented under personal habits activity in Personal and Psychosocial History. Allergic
to milk and milk products is an allergy, which is documented under the heading Present
Health Status; Grandfather died from prostate cancer is documented under the heading
Family History.
DIF: Cognitive Level: Understand REF: p. 16
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Psychosocial Integrity: Therapeutic Communications
3. Which questions are pertinent to ask when obtaining a symptom analysis
from a patient who reports breathing problems? (Select all that apply.)
a. How long have you had this problem with
your breathing?
b. Do you have a family history of breathing
problems?
c. Does this breathing problem come and go
or is it constant?
d. What do you do to make your breathing
better?
e. How does this breathing problem affect
your work or daily activities?
f. How many packs of cigarettes do you
smoke a day?
ANSWER: A, C, D, E
How long have you had this problem with your breathing?, Does this breathing problem
come and go or is it constant?, What do you do to make your breathing better?, and How
does this breathing problem affect your work or daily activities? are questions asked in a
symptom analysis. Use the mnemonic of OLD CARTS (e.g., onset of symptoms, location
and duration of symptoms, characteristics, aggravating factors, related symptoms,
treatment used, and severity of symptoms). Do you have a family history of breathing
problems? This question relates to the patient’s history; How many packs of cigarettes do
you smoke a day? This question relates to the patient’s history.
DIF: Cognitive Level: Apply REF: p. 17 | Box 2-3
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System
Specific Assessments
4. Which questions are pertinent to ask when obtaining a symptom analysis
from a patient who reports a headache? (Select all that apply.)
a. Describe what the headache feels like.
b. When was your last eye examination?
c. What makes the headaches worse?
d. How do you rate the headaches on a scale
of 0 (meaning no pain) to 10 (meaning the
worse pain ever)?
e. Do you have any symptoms with the
headaches, such as nausea?
f. When did you first notice the headaches?
ANSWER: A, C, D, E, F
Describe what the headache feels like?, What makes the headaches worse?, How do you
rate the headaches on a scale of 0 (meaning no pain) to 10 (meaning the worse pain ever)?,
Do you have any symptoms with the headaches, such as nausea?, and When did you first
notice the headaches? are questions asked in a symptom analysis. Use the mnemonic of
OLD CARTS (e.g., onset of symptoms, location and duration of symptoms, characteristics,
aggravating factors, related symptoms, treatment used, and severity of symptoms). When
was your last eye examination? assumes that the headaches are related to a vision problem.
Last eye examination is documented in the history under the heading of Past Health
History.
DIF: Cognitive Level: Apply REF: p. 15 | Box 2-3
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System
Specific Assessments
5. Which questions are pertinent for a nurse to ask a patient while performing
a review of the cardiovascular system? (Select all that apply.)
a. Do you remember what your last
cholesterol value was?
b. Have you had chest pain or shortness of
breath?
c. Do you have trouble breathing when you
lie down?
d. Are your feet cold, numb, or do they
change color?
e. How much do you weigh?
f. Have you noticed edema in your ankles at
the end of the day?
ANSWER: B, C, D, F
Have you had chest pain or shortness of breath?, Do you have trouble breathing when you
lie down?, Are your feet cold, numb, or do they change color?, and Have you noticed
edema in your ankles at the end of the day? are questions asked to give the patient an
opportunity to report symptoms of the cardiovascular system. Do you remember what your
last cholesterol value was? relates to a lab value, which is objective data not documented in
the history; How much do you weigh? is objective data not documented in the history.
DIF: Cognitive Level: Remember REF: p. 18
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System
Specific Assessments
Chapter 3: Techniques and Equipment for Physical Assessment
Test Bank
MULTIPLE CHOICE
1. What is the most important nursing action to reduce transmission of microorganisms during a
physical assessment?
a. Clean the bell and diaphragm of the stethoscope between patients.
b. Perform hand hygiene.
c. Wear gloves when anticipating exposure to body fluids.
d. Wear eye protection when anticipating spatter of body fluids.
ANSWER: B
A
B
C
D
Feedback
Cleaning the bell and diaphragm of the stethoscope between patients is important
to prevent the spread of microorganisms when auscultating only.
Consensus recommendations of the World Health Organization include use of
hand hygiene techniques to prevent spread of microorganisms before palpating,
percussing, or auscultating patients, and during patient care.
Wearing gloves when anticipating exposure to body fluids is important to prevent
the spread of microorganisms from the patient while giving care.
Wearing eye protection when anticipating spatter of body fluids is important to
prevent the spread of microorganisms from the patient while giving care.
DIF: Cognitive Level: Remember REF: 21
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Safety and Infection Control:
Standard Precautions/Transmission-Based Precautions/Surgical Asepsis
2. When examining a patient, the nurse remembers to follow which principle of Standard
Precautions?
a. Wear gloves throughout the entire examination of the patient.
b. Wear gloves when in contact with the patient’s mucous membranes.
c. Wear gloves to reduce the need for handwashing.
d. Wear eye protection and a gown during the examination of the patient.
ANSWER: B
A
B
C
D
Feedback
Wearing gloves throughout the examination of the patient is unnecessary.
Referring to the Standard Precautions for the correct answer; nurses use judgment
to determine when contact with body fluids is possible.
Specifically, this applies to contact with blood, body fluids (e.g., urine, feces,
sputum, wound drainage), nonintact skin, and mucous membranes.
Hands must be washed after removal of gloves.
The nurse should wear a mask with eye protection or a face shield during
procedures that may result in splashes or sprays of the patient’s blood, body
fluids, secretions, or excretions.
DIF: Cognitive Level: Understand REF: 22
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Safety and Infection Control:
Standard/Transmission-Based/Other Precautions
3. How do nurses prevent a latex allergy?
a. They use nonlatex gloves for all procedures.
b. They protect their hands using oil-based hand lotion applying latex gloves.
c. They use a powder-free, low-allergen latex gloves.
d. They wash their hands with mild soap and dry thoroughly before applying latex
gloves.
ANSWER: C
A
B
C
D
Feedback
Nonlatex gloves may be used only for activities that are not likely to involve
contact with infectious materials.
NIOSH recommends not using oil-based hand lotions when wearing latex gloves.
Use of these types of gloves is recommended by The National Institute for
Occupational Safety and Health (NIOSH).
NIOSH recommends washing hands after removing latex gloves, not before
applying them.
DIF: Cognitive Level: Remember REF: 22, Box 3-2
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Safety and Infection Control:
Standard Precautions/Transmission-Based Precautions/Surgical Asepsis
4. Which explanation is most appropriate for a nurse preparing to palpate a patient’s neck?
a. “I need to feel for tumors in your neck.”
b. “I’m going to feel your neck for any abnormalities.”
c. “I need to press deeply on your neck so please hold still.”
d. “Is there any tenderness in your neck?”
ANSWER: B
A
B
C
D
Feedback
I need to feel for tumors in your neck” uses the term “tumors” and may alarm the
patient unnecessarily.
Palpating the neck enters the patient’s personal space and may have cultural
significance. Thus it is important to inform patients of the impending action and
its purpose.
“I need to press deeply on your neck so please hold still” may alarm the patient
and is not accurate. To palpate the neck, light palpation is used to detect
abnormalities such as enlarged nodes. Deep palpation is used on the abdomen.
“Is there any tenderness in your neck?” obtains subjective data, but does not tell
the patient what the nurse is planning to do.
DIF: Cognitive Level: Apply REF: 23
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
5. Which nurse is performing the technique of light palpation appropriately?
a. Nurse A applies the bimanual technique to determine size and location of the
patient’s heart.
b. Nurse B uses the fingertips to feel for temperature differences on the patient’s legs.
c. Nurse C places the ulnar surface of the hands on the patient’s thorax to detect
vibrations.
d. Nurse D depresses the patient’s abdomen approximately 4 cm to assess pulsations.
ANSWER: C
A
B
C
D
Feedback
The bimanual technique is used to entrap an organ or mass (such as the uterus or
a growth) between the fingertips to determine size and location and is not
palpation.
Temperature differences are best detected using the dorsal surface of the hand;
this technique is not palpation.
Nurse C places the ulnar surface of the hands on the patient’s thorax to detect
vibrations. This is considered a light palpation.
Light pulsation is performed by pressing in to a depth of approximately 1 cm,
rather than 4 cm.
DIF: Cognitive Level: Understand REF: 23
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
6. How does the nurse perform the bimanual technique of palpation to assess organs?
a. Using the palmar surface of the dominant hand to press inward to a depth of about
1 cm
b. Holding a light source in one hand while stroking the skin lightly with the
dominant hand
c. Using the ulnar surfaces of both hands to press inward 4 to 5 cm
d. Using both hands, one anterior and one posterior, to entrap an organ between the
fingertips
ANSWER: D
A
B
C
D
Feedback
Using the palmar surface of the dominant hand to press inward to a depth of
about 1 cm describes light palpation, which is different from the bimanual
technique.
Holding a light source in one hand while stroking the skin lightly with the
dominant hand is used when inspecting rather than palpating.
Using the ulnar surfaces of both hands to press inward 4 to 5 cm describes an
incorrect technique.
Using both hands, one anterior and one posterior, to entrap an organ between the
fingertips is the correct technique for bimanual palpation.
DIF: Cognitive Level: Apply REF: 23-24
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
7. While assessing a patient’s lower extremities, the nurse suspects the lower extremities feel
cooler than the upper extremities. To confirm this suspicion, how does the nurse compare the
temperatures of the lower extremities with the upper extremities?
a. Using the backs (dorsum) of the hands to detect differences
b. Using the ulnar surface of the hands to detect differences
c. Using the pads of the fingers to detect differences
d. Using the palmar surface (underside) of the hands to detect differences
ANSWER: A
A
B
C
D
Feedback
The dorsal surfaces of the hands detect temperature best.
The ulnar surfaces of the hands are the most sensitive to vibration.
The pads of the fingers are used in palpation.
The palmar surfaces (underside) of the fingers and finger pads are better for
determining position, texture, size, consistency, masses, fluid, and crepitus.
DIF: Cognitive Level: Apply REF: 23
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
8. How does a nurse assess for fluid in a patient’s abdomen?
a. Placing the nondominant hand (pleximeter) over the area to be percussed, and
striking the index finger of the pleximeter with the pad of the middle finger of the
dominant hand
b. Applying indirect percussion by tapping one finger lightly on the abdominal wall
with the plexor
c. Placing the middle finger of the nondominant hand (pleximeter) over the area to be
percussed, and striking that finger with the tip of the middle finger of the dominant
hand
d. Using direct percussion by placing one hand over the abdomen and striking lightly
with the other hand
ANSWER: C
A
B
C
D
Feedback
Only the finger being struck touches the area to be percussed; the other fingers
are raised off the skin and the middle finger is struck with the tip of the finger of
the other hand.
Percussing the abdomen requires both hands, one as the plexor and the other as
the pleximeter.
Placing the middle finger of the nondominant hand (pleximeter) over the area to
be percussed, and striking that finger with the tip of the middle finger of the
dominant hand describes the correct technique.
Using direct percussion by placing one hand over the abdomen and striking
lightly with the other hand does not describe the correct technique.
DIF: Cognitive Level: Apply REF: 24
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
9. What assessment data do nurses obtain through striking a hand directly against the flank or
costovertebral angle of a patient’s body?
a. Fluid in the lungs
b. Tenderness over the kidneys
c. Air in the abdomen
d. Tenderness over the liver
ANSWER: B
A
B
C
D
Feedback
Fluid in the lungs is detected by indirect percussion.
Tenderness over the kidneys is detected by direct percussion over the
costovertebral angle.
Air in the abdomen is detected by indirect percussion.
Tenderness over the liver is detected by palpation.
DIF: Cognitive Level: Apply REF: 24
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
10. A patient has been complaining of abdominal cramping and gas; the nurse notes that his
abdomen is slightly distended. Which sound does the nurse expect to hear during percussion
of this patient’s abdomen?
a. Flatness
b. Dullness
c. Resonance
d. Tympany
ANSWER: D
A
B
C
D
Feedback
Flatness is heard over bones and muscle.
Dullness is heard over the liver.
Resonance is heard over normal lung tissue.
Tympany is a loud, high-pitched sound heard over the abdomen.
DIF: Cognitive Level: Apply REF: 24-25
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
11. The nurse is unable to hear the patient’s breath sounds. What checks does the nurse make of
the stethoscope to determine the cause of this problem?
a. Ensure the stethoscope tubing is at least 20 inches long.
b. Ensure the valve is open to the diaphragm on the head of the stethoscope.
c. Ensure the earpieces are pointed toward the back of the ears.
d. Ensure the bell is placed firmly against the patient’s skin.
ANSWER: B
Feedback
A Tubing should be no longer than 12 to 18 inches. If the tubing is longer than 18
inches, the sounds may become distorted.
B The diaphragm is used to hear high-pitched sounds, such as breath sounds, bowel
sounds, and normal heart sounds. Its structure screens out low-pitched sounds.
C Earpieces are angled toward the nose so that sound is projected toward the
tympanic membrane.
D The bell of the stethoscope is used to hear soft, low-pitched sounds such as extra
heart sounds or vascular sounds (bruit).
DIF: Cognitive Level: Apply REF: 27
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
12. What part of the stethoscope do nurses use to auscultate the chest?
a. Press the bell firmly against the skin to hear sounds and vibrations.
b. The bell of the stethoscope is used to hear breath sounds.
c. The diaphragm of the stethoscope is used to hear heart sounds.
d. Either the bell or the diaphragm is used to auscultate the chest.
ANSWER: C
A
B
C
D
Feedback
The bell should be pressed lightly on the skin with just enough pressure to ensure
that a complete seal exists around the bell. If the bell is pressed too firmly on the
skin, the concave surface is filled with skin, and the bell functions like a
diaphragm and inhibits vibrations.
The bell is used to hear soft, low-pitched sounds such as extra heart sounds or
vascular sounds (bruit).
The diaphragm is used to hear breath sounds, bowel sounds, and normal heart
sounds (high-pitched sounds).
Either the bell or the diaphragm is used to auscultate the chest. The diaphragm is
used to hear breath sounds, bowel sounds, and normal heart sounds (high-pitched
sounds).
DIF: Cognitive Level: Understand REF: 27
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
13. How does the nurse detect an extra heart sound in an adult?
a. Using the bell of a stethoscope
b. With a pulse oximeter
c. Using the diaphragm of a stethoscope
d. With a Doppler ultrasound probe
ANSWER: A
A
B
C
D
Feedback
The bell of the stethoscope is used to hear soft, low-pitched sounds such as extra
heart sounds or vascular sounds (bruit).
Pulse oximetry is a noninvasive measurement of arterial oxygen saturation in the
blood.
The diaphragm is used to hear high-pitched sounds such as breath sounds, bowel
sounds, and normal heart sounds.
A Doppler ultrasound probe is used to detect difficult-to-hear vascular sounds
such as fetal heart tones or peripheral pulses.
DIF: Cognitive Level: Remember REF: 27
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
14. A nurse is preparing to take a patient’s blood pressure. The blood pressure cuff is 5 inches
wide and the patient’s upper arm circumference is 20 inches. How accurate will this patient’s
blood pressure be using this blood pressure cuff?
a. Accurate, the actual value
b. Higher than the actual value
c. Lower than the actual value
d. Unable to determine accuracy with available data
ANSWER: B
A
B
C
D
Feedback
For an arm circumference that is 20 inches, the proper size cuff is at least 8 inches
(20 0.40 = 8). Therefore the blood pressure measurement will not be accurate.
For an arm circumference that is 20 inches, the proper size cuff is at least 8 inches
(20 0.40 = 8). The cuff is 5 inches, which is too narrow. A cuff that is too
narrow will overestimate the blood pressure and report a falsely high value.
For an arm circumference that is 20 inches, the proper size cuff is at least 8 inches
(20 0.40 = 8). Therefore the blood pressure measurement will be higher than the
actual value.
Sufficient data provided to determine accuracy. For an arm circumference that is
20 inches, the proper size cuff is at least 8 inches (20 0.40 = 8).
DIF: Cognitive Level: Analyze REF: 29
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
15. Where does the nurse attach the sensor probe of the pulse oximeter to measure a patient’s
oxygen saturation?
a. The chest over the patient’s heart
b. Over the patient’s abdominal aorta
c. Over the patient’s radial pulse
d. Around the patient’s index finger nail
ANSWER: D
A
B
C
D
Feedback
The chest over the patient’s heart is an incorrect option because the LED would
not be able to reflect off oxygenated and deoxygenated hemoglobin molecules
circulating in blood.
Over the patient’s abdominal aorta is an incorrect option because the LED would
not be able to reflect off oxygenated and deoxygenated hemoglobin molecules
circulating in blood.
Over a patient’s radial pulse is an incorrect option because the LED would not be
able to reflect off oxygenated and deoxygenated hemoglobin molecules
circulating in blood.
The sensor is taped to a highly vascular area, such as around the index finger nail
that allows the light-emitting diode (LED) to reflect off oxygenated and
deoxygenated hemoglobin molecules circulating in blood.
DIF: Cognitive Level: Remember REF: 29
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
16. The patient asks about the meaning of his visual assessment of 20/40 using a Snellen visual
acuity chart. What is the nurse’s appropriate response?
a. “20/40 means your vision is about two times normal.”
b. “A person with corrected vision can see at 20 feet what you can see at 40 feet.”
c. “A person with normal vision can see at 20 feet what you can see at 40 feet.”
d. “A person with normal vision can see at 40 feet what you can see at 20 feet.”
ANSWER: D
A
B
C
D
Feedback
This is an incorrect interpretation of the data.
This is an incorrect interpretation of the data.
This is an incorrect interpretation of the data.
The top number of the recording indicates the distance between the patient and
the chart, and the bottom number indicates the distance at which a person with
normal vision should be able to read certain letters of the chart.
DIF: Cognitive Level: Apply REF: 30-31
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
17. The nurse is using the Snellen chart to assess a patient’s vision. The patient states that the
green line on the chart is shorter than the red line. What is the interpretation of this finding?
a. This patient has normal color perception and abnormal field perception.
b. This patient is color blind but has normal field perception.
c. This patient’s color perception and field perception are normal.
d. This patient is color blind and has abnormal field perception.
ANSWER: A
A
B
C
D
Feedback
Naming the colors of the horizontal lines is a screening for color perception. The
top line is green, and the bottom line is red. Asking which line is longer is a
screening for field perception measurement. The green line is longer.
This is an incorrect interpretation of the data.
This is an incorrect interpretation of the data.
This is an incorrect interpretation of the data.
DIF: Cognitive Level: Apply REF: 31
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
18. What tool does the nurse use to assess the patient’s near vision?
a. A Snellen eye chart placed about 12 inches from the patient’s face.
b. An ophthalmoscope with the diopter set at 0 (zero).
c. A Jaeger or Rosenbaum chart placed about 2 feet from the patient’s face.
d. A newspaper held about 14 inches from the patient’s face.
ANSWER: D
A
B
C
D
Feedback
A Snellen chart is used to assess distant vision.
An ophthalmoscope is used to assess the internal eye.
This is incorrect because of the distance specified. These charts can be used to
assess near vision when placed at 14 inches from the patient’s face.
This can be an alternative to using a Jaeger or Rosenbaum chart held at 14 inches
from the face.
DIF: Cognitive Level: Remember REF: 31
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
19. Using an ophthalmoscope, how does the nurse bring a patient’s interior eye structures into
focus?
a. Using the red filter
b. Adjusting the diopters
c. Dilating the patient’s pupils
d. Using the wide-beam light
ANSWER: B
A
B
Feedback
The red filter facilitates the identification of pallor of the disc and permits the
recognition of retinal hemorrhages by making the blood appear black.
The lens selector dial (diopter) allows the nurse to adjust a set of lenses that
controls focus.
C
D
When the patient’s pupils are dilated, a larger light may be used for the internal
eye examination.
The wide beam light can be used when the patient’s pupils are dilated for better
visualization of internal structures.
DIF: Cognitive Level: Understand REF: 31
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
20. Which action by the nurse describes the correct technique for using an otoscope on an adult?
a. Using the pneumatic attachment to observe for tympanic fluctuation
b. Striking the otoscope against the hand to engage
c. Instructing the adult to raise one finger when a sound is heard
d. Selecting the largest size speculum that fits into the adult’s ear canal
ANSWER: D
A
B
C
D
Feedback
The pneumatic attachment is used to evaluate the fluctuation of the tympanic
membrane in children.
The otoscope is not struck. The instrument that is struck before hearing
assessment is a tuning fork.
Instructing the patient to raise one finger when a sound is heard is done when
using an audiometer to assess hearing.
Using the largest speculum allows visualization, while using a smaller speculum
limits inspection and using a speculum that is too large is uncomfortable to the
adult.
DIF: Cognitive Level: Understand REF: 31
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
21. A nurse is preparing to assess a patient’s ability to detect vibrations. Which piece of
equipment is appropriate for this assessment?
a. Reflex hammer
b. Tuning fork
c. Goniometer
d. Monofilament
ANSWER: B
A
B
C
D
Feedback
A reflex hammer is used to test for deep tendon reflexes.
The tuning fork is used to assess the patient’s ability to detect vibration.
A goniometer is used to measure the degrees of flexion and extension of a joint.
A monofilament is used to test for sensation on the lower extremities.
DIF: Cognitive Level: Remember REF: 33
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
22. To test deep tendon reflexes, the nurse uses which instrument?
a. Goniometer
b. Calipers
c. Reflex hammer
d. Monofilament
ANSWER: C
A
B
C
D
Feedback
A monofilament is used to test for sensation on the lower extremities.
Calipers are used to measure thickness of subcutaneous tissue to estimate the
amount of body fat.
A reflex hammer is used to test deep tendon reflexes.
A monofilament is used to test for sensation on the lower extremities.
DIF: Cognitive Level: Remember REF: 33
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
23. A nurse is using the finger pads to palpate a patient’s dorsalis pedis pulses and is unable to
feel any pulses. Which action is appropriate for the nurse to perform next?
a. Document that the dorsalis pedis pulses are not palpable.
b. Have the patient stand and try again to palpate the pulses.
c. Use a Doppler to detect the presence of the pulses.
d. Palpate the dorsalis pedis pulses using the ulnar surface of the hand.
ANSWER: C
A
B
C
D
Feedback
Document that the dorsalis pedis pulses are not palpable. Although the pulse may
not be palpable, the nurse always tries a Doppler to determine if the pulse can be
heard, even when it cannot be felt.
Have the patient stand and try again to palpate the pulses. Changing positions will
not facilitate palpation of a pulse.
Use a Doppler to detect the presence of the pulses. The Doppler uses ultrasonic
waves to detect difficult-to-hear vascular sounds, such as peripheral pulses.
Palpate the dorsalis pedis pulses using the ulnar surface of the hand. The ulnar
surface of the hand is used to palpate for vibrations rather than pulsations.
DIF: Cognitive Level: Analyze REF: 33
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
24. How does the nurse detect a pulse when using a Doppler?
a. The pulsation is felt.
b. The pulsation is heard.
c. The pulse wave is seen on a screen.
d. The pulse wave is printed out on special paper.
ANSWER: B
A
B
C
D
Feedback
A Doppler is used when the pulses cannot be palpated.
A Doppler amplifies sounds difficult to hear with an acoustic stethoscope.
A Doppler amplifies the sound of the pulsation.
A Doppler amplifies the sound of the pulsation
DIF: Cognitive Level: Remember REF: 33
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
25. A nurse is assessing joint function of a patient with severe rheumatoid arthritis. Which
instrument/tool does the nurse use to measure the degree of flexion and extension of the
patient’s knee joints?
a. Calipers
b. Ruler or tape measure
c. Goniometer
d. Doppler
ANSWER: C
A
B
C
D
Feedback
Calipers are used to estimate the amount of body fat.
A ruler or tape measure cannot accurately measure the degree of flexion and
extension of joints.
A goniometer is used to measure the degree of flexion and extension of a joint.
Doppler is used to detect the presence of pulses.
DIF: Cognitive Level: Understand REF: 33
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
26. When does a nurse choose to use skinfold calipers when collecting assessment data?
a. Calculating the patient’s body mass index
b. Inspecting the patient’s skin
c. Determining the amount of the patient’s lean body tissue
d. Estimating the amount of the patient’s body fat
ANSWER: D
A
B
C
Feedback
Body mass index is a formula for determining obesity that is calculated by
dividing a person’s weight in kilograms by the height in meters.
Calipers estimate body fat. They are not needed to inspect skin.
There is no specific method to determine the amount of lean body tissue.
D
Estimating the amount of the patient’s body fat is the purpose of using skin
calipers.
DIF: Cognitive Level: Remember REF: 34
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
27. When does a nurse use a Pederson or Graves speculum for examination of a patient?
a. To inspect the external ear
b. To assess the vaginal canal
c. To inspect nasal passages
d. To assess the oropharynx
ANSWER: B
A
B
C
D
Feedback
The external ear is inspected using an otoscope.
The vaginal canal and cervix are inspected using a Pederson or Graves speculum
or a pediatric or virginal speculum.
The nasal passages are inspected using a nasal speculum.
The oropharynx is inspected using a tongue blade and penlight.
DIF: Cognitive Level: Remember REF: 34
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
28. What are characteristics of an audioscope?
a. Screens for hearing ability
b. Allows visualization into the ear canal
c. Must be calibrated before use
d. Uses vibration to estimate hearing loss
ANSWER: A
A
B
C
D
Feedback
An audioscope screens for hearing ability.
The otoscope allows inspection of the ear canal.
Calibration is unnecessary. An audioscope needs batteries that are charged.
The tuning fork is the tool that uses vibration to detect hearing loss.
DIF: Cognitive Level: Remember REF: 35
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
29. A patient with type 2 diabetes mellitus has an infected lesion on his foot. During the history of
his present illness, he reports, “I had a cut on my foot, but I did not even feel it.” What
equipment does the nurse use to gather more data about his foot?
a. A Wood lamp
b. Transilluminator
c. Monofilament
d. Reflex hammer
ANSWER: C
A
B
C
D
Feedback
A Wood lamp is used to detect fungal infection on the skin.
A transilluminator differentiates the characteristics of tissue, fluid, and air within
a specific body cavity.
A monofilament is used to test for sensation on the lower extremities. Because
this patient could not feel the cut on his foot, perhaps he has lost sensation.
A reflex hammer is used to test for deep tendon reflexes.
DIF: Cognitive Level: Apply REF: 35
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
30. A patient is complaining of pain over the maxillary sinuses. Which device does the nurse use
to determine if there is air or fluid in the patient’s sinuses?
a. Magnification device
b. Transilluminator
c. Monofilament
d. Wood lamp
ANSWER: B
A
B
C
D
Feedback
A magnification device helps visualize the tissue, but will not determine if sinuses
are filled with air or fluid.
A transilluminator disseminates its light source under the surface of the skin to
determine if the areas under the surface, such as the sinuses, are filled with air,
fluid, or tissue.
A monofilament is used to test for sensation on the lower extremities.
A Wood lamp is used to detect fungal infections.
DIF: Cognitive Level: Understand REF: 35
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
31. A nurse suspects that a large skin lesion on the patient’s forearm is a fungal infection. Which
device does the nurse use to confirm his suspicion?
a. Pen light
b. Magnification device
c. Transilluminator
d. Wood lamp
ANSWER: D
Feedback
A
B
C
D
A pen light is used to highlight a lesion for inspection, but will not determine if it
is caused by a fungus.
A magnification device helps visualize the lesion, but will not determine if it is
caused by a fungus.
A transilluminator disseminates its light source under the surface of the skin to
determine if the area under the surface is filled with air, fluid, or tissue.
Skin lesions caused by a fungal infection exhibit a fluorescent yellow-green or
blue-green color when examined with a Wood lamp.
DIF: Cognitive Level: Understand REF: 36
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
Chapter 4: General Inspection and Measurement of Vital Signs
Test Bank
MULTIPLE CHOICE
1. Which body system does the nurse assess primarily by inspection?
a. Respiratory
b. Gastrointestinal
c. Skin
d. Cardiovascular
ANSWER: C
A
B
C
D
Feedback
The respiratory system is assessed primarily using auscultation, but also
percussion and inspection when observing pale or cyanotic skin from hypoxia.
The gastrointestinal system is assessed primarily by auscultation and palpation,
but also with inspection when looking at the contour of the abdomen.
Skin is assessed primarily using inspection, but also palpation.
The cardiovascular system is assessed primarily with auscultation and palpation,
but also by inspection when looking at the color of extremities for evidence of
perfusion or edema.
DIF: Cognitive Level: Remember REF: 37
TOP: Nursing Process: Assessment
MSC: NCLEX: Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific
Assessments
2. A patient is sitting slightly forward bracing his arms on his knees in a tripod position. This
position is associated with which symptom?
a. Abdominal pain
b. Spinal deformity
c. Back pain
d. Breathing difficulty
ANSWER: D
A
B
C
D
Feedback
Positions used by patients with abdominal pain vary depending upon what organ
is involved. For example, patients with appendicitis tend to lie very still; those
with acute pancreatitis prefer the fetal position for pain relief.
Spinal deformity usually affects the patient’s gait or causes a slumped posture.
Back pain usually affects the patient’s gait or causes a slumped posture.
Breathing difficulty is associated with the tripod position, which allows maximal
expansion of the muscles of respiration.
DIF: Cognitive Level: Remember REF: 37
TOP: Nursing Process: Assessment
MSC: NCLEX: Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific
Assessments
This study source was downloaded by 100000838401522 from CourseHero.com on 03-03-2022 08:50:15 GMT -06:00
https://www.coursehero.com/file/20908989/c4/
3. The temperature of a patient is measured every 6 hours at 6 AM, 12 PM, 6 PM, and 12 AM.
Which temperature reading is expected to be low due to a normal variation?
a. The measurement at 6 AM
b. The measurement at 12 PM
c. The measurement at 6 PM
d. The measurement at 12 AM
ANSWER: A
A
B
C
D
Feedback
Early in the morning is the time of the lowest temperature of the day due to
circadian rhythms.
A low temperature due to circadian rhythms is not expected at this time.
The highest temperature occurs in the late afternoon and early evening due to
circadian rhythms.
A low temperature due to circadian rhythms is not expected at this time.
DIF: Cognitive Level: Understand REF: 38
TOP: Nursing Process: Assessment
MSC: NCLEX: Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific
Assessments
4. Which statement is correct regarding taking or interpreting axillary temperatures?
a. Axillary temperatures should not be used in patients less than 2 years of age.
b. Readings may be less accurate.
c. The thermometer is left in place for no more than 3 minutes.
d. The thermometer is placed in the axilla with the shoulder abducted.
ANSWER: B
A
B
C
D
Feedback
The axilla is a common site for temperature measurement on infants and children.
Multiple studies have shown temperature measurements at the axillary site are
less accurate compared with alternative sites.
The thermometer is left in place until the audible signal occurs and the
temperature appears on the screen.
Place the probe in the middle of the axilla, with the arm held against the body
(adducted).
DIF: Cognitive Level: Understand REF: 39
TOP: Nursing Process: Assessment
MSC: NCLEX: Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific
Assessments
5. A temperature of 99.8° F taken in the axilla is equivalent to which temperature value taken
orally?
a. 100.8° F
b. 99.8° F
c. 98.8° F
d. 97.8° F
This study source was downloaded by 100000838401522 from CourseHero.com on 03-03-2022 08:50:15 GMT -06:00
https://www.coursehero.com/file/20908989/c4/
ANSWER: A
A
B
C
D
Feedback
Normal temperature readings from the axilla are about 1° F below the normal oral
temperature.
Normal temperature readings from the axilla are about 1° F below the normal oral
temperature.
Normal temperature readings from the axilla are about 1° F below the normal oral
temperature.
Normal temperature readings from the axilla are about 1° F below the normal oral
temperature.
DIF: Cognitive Level: Apply REF: 39
TOP: Nursing Process: Assessment
MSC: NCLEX: Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific
Assessments
6. The nurse suspects an irregularity in the rhythm of the patient’s radial pulse. What is the most
appropriate action for this nurse to take at this time?
a. Document this rhythm as normal for the patient.
b. Use a Doppler to check the brachial pulse.
c. Count the patient’s apical pulse for a full minute.
d. Count the radial pulse again for 15 seconds and multiply by 4.
ANSWER: C
A
B
C
D
Feedback
An irregular rhythm is not a normal finding. The pulsation between each beat
should be the same or regular.
A Doppler is not indicated in this case; it is used when the pulse cannot be
palpated.
When an irregular pulse is palpated, the nurse counts the number of pulsations for
a full minute.
Counting the radial pulse again for 15 seconds and multiplying by 4 may
reconfirm the initial findings, but does not provide additional data for the nurse
on this patient.
DIF: Cognitive Level: Apply REF: 39
TOP: Nursing Process: Assessment
MSC: NCLEX: Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific
Assessments
7. The patient with a respiratory rate that is within normal limits is the whose respiratory
rate is breaths/min.
a. 16-month-old; 36
b. 6-year-old; 20
c. 14-year-old;26
d. 40-year-old; 10
ANSWER: B
This study source was downloaded by 100000838401522 from CourseHero.com on 03-03-2022 08:50:15 GMT -06:00
https://www.coursehero.com/file/20908989/c4/
Feedback
A A toddler’s respiratory rate ranges from 24 to 32.
B A school-age child’s respiratory rate ranges from 18 to 26.
C An adolescent’s respiratory rate ranges from 12 to 16.
D An adult’s respiratory rate ranges from 12 to 20.
DIF: Cognitive Level: Apply REF: 40
TOP: Nursing Process: Assessment
MSC: NCLEX: Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific
Assessments
8. A nurse is taking vital signs of an adult patient whose oxygen saturation is 96%. The patient’s
temperature is 102° F, blood pressure is 130/86, pulse is 100 beats/min, and respiratory rate is
26 breaths/min. Which factor may be contributing to the elevated respiratory rate?
a. The patient’s temperature
b. The patient’s oxygen saturation
c. The patient’s pulse rate
d. The patient’s blood pressure
ANSWER: A
Feedback
A Fever is a factor that may increase respiratory rate, and this patient’s temperature
is 102° F.
B The patient’s oxygen saturation is a measure of the oxygen carried by hemoglobin
and it is within expected limits—above 90%.
C The patient’s pulse rate may be due to the high temperature, but a pulse of 100
does not contribute to an elevated respiratory rate in this case.
D The patient’s blood pressure is higher than normal, but does not contribute to an
elevated respiratory rate in this case.
DIF: Cognitive Level: Apply REF: 40
TOP: Nursing Process: Assessment
MSC: NCLEX: Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific
Assessments
9. Nurses understand that a patient’s diastolic pressure represents which physiologic function?
a. The pressure needed to open the aortic and pulmonic valves
b. The pressure in blood vessels when the ventricles contract
c. The pressure of the blood returning to the heart from the venous system
d. The pressure in blood vessels when the ventricles are relaxed
ANSWER: D
A
B
C
Feedback
The pressure needed to open the aortic and pulmonic valves is called the
afterload.
The pressure in blood vessels when the ventricles contract is the definition of the
systolic pressure.
The pressure of the blood returning to the heart from the venous system is
incorrect.
This study source was downloaded by 100000838401522 from CourseHero.com on 03-03-2022 08:50:15 GMT -06:00
https://www.coursehero.com/file/20908989/c4/
D
The pressure in blood vessels when the ventricles are relaxed is the definition of
the diastolic pressure.
DIF: Cognitive Level: Understand REF: 41
TOP: Nursing Process: Assessment
MSC: NCLEX: Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific
Assessments
10. According to research findings, which site is preferred for measuring blood pressure when the
nurse is unable to use the patient’s upper arms?
a. Ankle
b. Thigh
c. Calf
d. Wrist
ANSWER: A
A
B
C
D
Feedback
A study comparing accuracy among sites recommended the ankle as an
alternative site for blood pressure measurement.
The thigh is an alternative site, but the ankle is the preferred site.
A study comparing accuracy among sites recommended the ankle site in
preference to the calf as an alternative site for blood pressure measurement if the
upper arm is unavailable.
Approaches to measuring blood pressure using the wrist and finger sites have
been developed, but these lack acceptable accuracy and cost efficiency to be
recommended for clinical practice.
DIF: Cognitive Level: Remember REF: 41
TOP: Nursing Process: Assessment
MSC: NCLEX: Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific
Assessments
11. A patient’s blood pressure has been averaging 120/72 when using the upper arms. Today the
nurse uses this patient’s thigh to measure the blood pressure. What is the expected systolic
pressure using the thigh that is equivalent to a systolic pressure of 120?
a. A systolic reading of 110 mm Hg
b. A systolic reading of 120 mm Hg
c. A systolic reading of 140 mm Hg
d. A systolic reading of 170 mm Hg
ANSWER: C
A
B
C
D
Feedback
A systolic reading of 110 mm Hg is too low.
A systolic reading of 120 mm Hg is too low.
Normally the systolic blood pressure is 10 to 40 mm Hg higher in the leg than in
the arm.
A systolic reading of 170 mm Hg is too high.
DIF: Cognitive Level: Apply REF: 41
This study source was downloaded by 100000838401522 from CourseHero.com on 03-03-2022 08:50:15 GMT -06:00
https://www.coursehero.com/file/20908989/c4/
TOP: Nursing Process: Assessment
MSC: NCLEX: Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific
Assessments
12. A nurse notices that the patient has gained 11 lb. If this increase in weight is related to fluid
retention, the patient is retaining approximately how many liters of fluid?
a. 1 L
b. 5 L
c. 11 L
d. 24 L
ANSWER: B
Feedback
A Every kg equals a liter of fluid. Thus, 11 lb ÷ 2.2 = 5 L.
B Every kilogram (kg) equals a liter of fluid. Thus, 11 lb ÷ 2.2 = 5 L.
C Every kg equals a liter of fluid. Thus, 11 lb ÷ 2.2 = 5 L.
D Every kg equals a liter of fluid. Thus, 11 lb ÷ 2.2 = 5 L. This answer is obtained
by multiplying 11 by 2.2 instead of dividing.
DIF: Cognitive Level: Apply REF: 43
TOP: Nursing Process: Assessment
MSC: NCLEX: Patient Needs: Physiologic Integrity: Physiologic Adaptation: Fluid and Electrolyte
Imbalances
MULTIPLE RESPONSE
1. Which method of temperature measurement indirectly reflects inner core temperature?
Select all that apply.
a. Axillary temperature
b. Oral temperature
c. Tympanic temperature
d. Rectal temperature
e. Temporal artery temperature
ANSWER: B, E
Correct: Inner core temperature is measured indirectly because the probe is placed near an
artery. For oral temperature, the probe is placed near the carotid artery and the temporal artery
is used for the temporal artery temperature.
Incorrect: For axillary, tympanic, and rectal temperatures, the probe is not placed close to any
major blood vessels.
DIF: Cognitive Level: Understand REF: 38
TOP: Nursing Process: Assessment
MSC: NCLEX: Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific
Assessments
2. Which method of temperature measurement does a nurse choose when assessing children?
Select all that apply.
a. Axillary temperature
b. Rectal temperature
This study source was downloaded by 100000838401522 from CourseHero.com on 03-03-2022 08:50:15 GMT -06:00
https://www.coursehero.com/file/20908989/c4/
c. Temporal artery temperature
d. Oral temperature
e. Tympanic membrane temperature
ANSWER: A, C, D, E
Correct: Axillary, temporal artery, oral, and tympanic membrane temperatures are appropriate
for children.
Incorrect: Rectal temperature measurement is considered safe and accurate for adults only.
DIF: Cognitive Level: Apply REF: 38-39
TOP: Nursing Process: Assessment
MSC: NCLEX: Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific
Assessments
3. Which action by the nurse results in the patient’s blood pressure measurement being falsely
high? Select all that apply.
a. Using a blood pressure cuff that is too narrow for the patient’s upper arm
b. Deflating the blood pressure cuff too rapidly
c. Wrapping the blood pressure cuff too loosely
d. Reinflating the blood pressure cuff before it completely deflates
e. Positioning the patient’s arm above the level of the heart
ANSWER: A, C, D, E
Correct: Using a blood pressure cuff that is too narrow for the patient’s upper arm, wrapping
the cuff too loosely, reinflating the cuff before it completely deflates, and positioning the
patient’s arm above the level of the heart all result in readings that are falsely high.
Incorrect: Deflating the blood pressure cuff too rapidly causes the blood pressure reading to
be falsely low.
DIF: Cognitive Level: Remember REF: 43
TOP: Nursing Process: Assessment
MSC: NCLEX: Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific
Assessments
4. Which action by the nurse results in the patient’s blood pressure measurement being falsely
low? Select all that apply.
a. Using a blood pressure cuff that is too wide for the patient’s arm
b. Not inflating the blood pressure cuff enough
c. Positioning the patient’s arm above the level of the heart
d. Wrapping the cuff too loosely around the arm
e. Deflating the cuff too rapidly
ANSWER: A, B, E
Correct: Using a blood pressure cuff that is too wide for the patient’s arm, not inflating the
blood pressure cuff enough, and deflating the cuff too rapidly could result in a false low
reading.
Incorrect: Positioning the patient’s arm above the level of the heart and wrapping the cuff too
loosely around the arm causes the blood pressure to be falsely high.
DIF: Cognitive Level: Remember REF: 43
TOP: Nursing Process: Assessment
MSC: NCLEX: Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific
This study source was downloaded by 100000838401522 from CourseHero.com on 03-03-2022 08:50:15 GMT -06:00
https://www.coursehero.com/file/20908989/c4/
Assessments
5. The nurse taking a patient’s blood pressure recognizes that several factors may cause an
increased blood pressure reading. Which factors below can increase blood pressure? Select all
that apply.
a. The patient rates pain at a level of 7 on a scale of 0 to 10.
b. The cuff was reinflated before being completely deflated.
c. The patient drank cold milk just before the reading.
d. The time of day is late afternoon.
e. The cuff is too wide for the extremity.
ANSWER: A, B, D
Correct: Rating pain at a level of 7 on a scale of 0 to 10, reinflating the cuff before being
completely deflated, and taking the reading in late afternoon are all factors that can increase
blood pressure.
Incorrect: Drinking cold milk just before the reading will not affect blood pressure, but
drinking caffeine such as coffee or cola may increase blood pressure. A wide cuff makes the
reading lower than it actually is rather than higher.
DIF: Cognitive Level: Apply REF: 43
TOP: Nursing Process: Assessment
MSC: NCLEX: Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific
Assessments
COMPLETION
1. A female patient admitted with fluid retention has been in diuretic therapy to remove fluid.
She weighed 187 lb on admission. Today she weighs 179 lb. Since admission, this patient has
lost L from fluid loss.
ANSWER:
3.6
1 kg (2.2 lb) = 1 L; 187 – 179 = 8 lb weight loss divided by 2.2 = 3.6 L.
DIF: Cognitive Level: Apply REF: 43
TOP: Nursing Process: Assessment
MSC: NCLEX: Patient Needs: Physiologic Integrity: Physiologic Adaptation: Fluid and Electrolyte
Imbalances
This study source was downloaded by 100000838401522 from CourseHero.com on 03-03-2022 08:50:15 GMT -06:00
https://www.coursehero.com/file/20908989/c4/
Chapter 5: Ethnic, Cultural, and Spiritual Considerations
Test Bank
MULTIPLE CHOICE
1. What are the characteristics of one’s culture?
a. Color of skin and hair
b. System of beliefs and practices
c. Food preferences
d. Language and religion
ANSWER: B
A
B
C
D
Feedback
Skin and hair color are examples of racial characteristics based on genetics.
System of beliefs and practices is part of the definition of culture.
Food preferences are an example of ethnicity.
Language and religion are examples of ethnicity.
DIF: Cognitive Level: Remember REF: 47
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Psychosocial Integrity: Cultural Diversity
2. Which example below best characterizes a patient’s race?
a. The language spoken in the patient’s home is Tagalog.
b. The patient’s family follows a kosher diet.
c. The patient and his family have blonde hair and fair skin.
d. The patient’s grandparents came to the United States from Germany.
ANSWER: C
A
B
C
D
Feedback
The language spoken at home refers to ethnicity.
A kosher diet refers to ethnicity.
Blonde hair and fair skin indicate genetics and race.
Although the patient and grandparents may share the same race, that the
grandparents came to the United States from Germany does not relate to race.
DIF: Cognitive Level: Understand REF: 47
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Psychosocial Integrity: Cultural Diversity
3. After the death of a Native American man, the nurse opened a window to allow spirits to
leave. This action is an example of which attribute of the concept of cultural competence?
a. Adapting interventions based on cultural practices (Tailoring)
b. Gaining information about cultural differences (Knowledge)
c. Considering the effects of another’s values and experiences (Understanding)
d. Showing appreciation for cultural differences (Respect)
ANSWER: A
This study source was downloaded by 100000838401522 from CourseHero.com on 03-03-2022 08:49:55 GMT -06:00
https://www.coursehero.com/file/20909004/c5/
A
B
C
D
Feedback
The nurse changed (adapted) the usual procedure after death by opening the
window, which was a practice of this Native American family.
Gaining information is the first step, but is insufficient to adapt an intervention as
described in this example.
Understanding develops after knowledge, but does not involve taking action.
Respect is the step before Adaptation, when nurses comprehend the cultural
differences, but do not adapt nursing care.
DIF: Cognitive Level: Apply REF: 49
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Psychosocial Integrity: Cultural Diversity
4. A Hispanic patient tells an African American nurse, “You are African American and can’t
possibly understand how a person like me feels.” What is an appropriate response by the nurse
at this time?
a. Find a nurse who is not African American to interview the patient.
b. Ask the patient, “Why do you think that, since we just met?”
c. Note that the patient is very defensive about being racially different.
d. Encourage the patient to describe what he means by his statement.
ANSWER: D
A
B
C
D
Feedback
Finding a nurse who is not African American to interview the patient is neither
necessary nor practical.
Asking the patient “Why do you think that, since we just met?” sounds defensive
and may not facilitate further communication.
Making an assumption “that the patient is very defensive about being racially
different” is not based on any data.
By encouraging the patient to describe what he means by his statement, the nurse
is demonstrating cultural awareness and sensitivity by gathering more data about
the unique beliefs and value systems of this patient.
DIF: Cognitive Level: Apply REF: 50
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Psychosocial Integrity: Cultural Diversity
5. A male nurse is assigned to the care of a gay male with alcoholism. This sexual orientation is
inconsistent with the beliefs of the nurse. What actions, if any, can the nurse take to provide
patient-centered care to this patient?
a. No action is necessary at this time.
b. Examine his own feelings about alcoholism and homosexuality.
c. Determine the patient’s degree of risk for contracting the human immunodeficiency
virus.
d. Discuss homosexuality and alcoholism with the patient.
ANSWER: B
Feedback
This study source was downloaded by 100000838401522 from CourseHero.com on 03-03-2022 08:49:55 GMT -06:00
https://www.coursehero.com/file/20909004/c5/
A
B
C
D
Not acting will not facilitate patient-centered care. The nurse needs to reflect on
his feelings about this patient.
Examining one’s own feelings about alcoholism and gay men specifically and
identifying one’s own beliefs and values generally is part of the process for
developing cultural competence, which should allow one to recognize the
uniqueness of patients and to demonstrate respect for individuals.
Determining the patient’s degree of risk for contracting the human
immunodeficiency virus is based on an assumption that because the patient is gay,
he has or will have the human immunodeficiency virus.
A discussion with the patient may help the nurse understand him, but will not
necessarily provide insight into the nurse’s beliefs and feelings.
DIF: Cognitive Level: Apply REF: 50
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Psychosocial Integrity: Cultural Diversity
6. Which nursing behaviors indicate culturally competent care?
a. Recognizing that there are different definitions of health and illness
b. Complying with the stated plan of treatment despite the patient’s differing opinion
c. Understanding that there is diversity even among people of the same cultural group
d. Helping patients of different cultures adopt the beliefs and behaviors of the
dominant culture
ANSWER: C
A
B
C
D
Feedback
Recognizing that there are many different definitions of health and illness is not
sufficient for culturally competent care.
Complying with the stated plan of treatment despite the patient’s differing opinion
is not a culturally competent behavior. The patient needs to understand, support,
and participate in the plan of care.
Understanding that there is diversity even among people of the same cultural
group prevents assumptions and stereotypes that inhibit culturally competent care.
Helping patients of different cultures adopt the beliefs and behaviors of the
dominant culture is an example of the opposite of cultural competence; it assumes
that all persons should adopt certain beliefs and behaviors.
DIF: Cognitive Level: Understand REF: 50
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Psychosocial Integrity: Cultural Diversity
7. A nurse is conducting an assessment of an American Indian woman who has come to the
clinic complaining of persistent headaches. The patient tells the nurse that the medicines
prescribed by the tribal healer have done “some good.” What is the appropriate response of
the nurse at this time?
a. “I advise you to stop taking those medicines from the tribal healer.”
b. “Perhaps you should increase the frequency of the healer’s medicines.”
c. “Tell me about these medicines and how often you are using them.”
d. “Could your headaches be caused by the healer’s medicines?”
This study source was downloaded by 100000838401522 from CourseHero.com on 03-03-2022 08:49:55 GMT -06:00
https://www.coursehero.com/file/20909004/c5/
ANSWER: C
A
B
C
D
Feedback
Advising the patient to stop taking any nonprescription medicines is inappropriate
until the nurse knows the details about all medicines used by the patient.
Telling the patient to increase the frequency of the healer’s medicines is
inappropriate until the nurse knows details about the medicines.
Asking the patient about the nature of these medicines and how often the patient
uses them allows the nurse to collect data about the medicines and their uses, to
learn more about the practices used by this patient to improve her health, and to
check for potential drug interaction before prescribing other medications or
treatment.
Suggesting the patient’s headaches are caused by the healer’s medicines is
inappropriate until the nurse knows details about the medicines.
DIF: Cognitive Level: Apply REF: 51
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Psychosocial Integrity: Cultural Diversity
8. Which question is the most appropriate to learn about a patient’s religious practices?
a. “How often do you go to church?”
b. “Where is your church located?”
c. “Do you mind telling me about your religion?”
d. “Do you have any specific religious or spiritual practices or beliefs?”
ANSWER: D
A
B
C
D
Feedback
Asking the patient about his or her church makes the assumption that the patient
worships in a church, which may not be correct.
Asking the patient about the location of his or her church makes the assumption
that the patient worships in a church, which may not be correct.
The question is not an efficient way to learn about religious or spiritual practices.
“Do you have any specific religious or spiritual practices or beliefs?” is a broad,
open-ended question that allows the patient to describe his or her religious
beliefs. The question makes no reference to any particular faith.
DIF: Cognitive Level: Apply REF: 51
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Psychosocial Integrity: Cultural Diversity
9. A patient tells the nurse that her religion prohibits her from eating food prepared outside of a
special kitchen. What is the nurse’s appropriate action to meet this patient’s needs?
a. Call the dietary department to cancel the patient’s meal tray.
b. Tell the patient that her diet must be carefully monitored and prepared at the
hospital.
c. Tell the patient that because of her illness, a few changes to her religious
requirements will be necessary.
d. Ask the patient to describe the requirements for the special kitchen.
ANSWER: D
This study source was downloaded by 100000838401522 from CourseHero.com on 03-03-2022 08:49:55 GMT -06:00
https://www.coursehero.com/file/20909004/c5/
A
B
C
D
Feedback
Cancelling the patient’s food tray does not meet the patient’s needs.
Telling the patient that her diet must be carefully monitored and prepared at the
hospital is inappropriate because it does not consider the ethnicity of the patient
and is not culturally competent care.
Asking the patient to change her religious requirements does not respect her
ethnicity and is not culturally competent care.
Asking the patient to describe the requirements for the special kitchen allows the
nurse to collect more data about the needs of the patient.
DIF: Cognitive Level: Apply REF: 52
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Psychosocial Integrity: Religious and Spiritual Influences on Health
10. Which question is most effective in assessing a patient’s personal beliefs about health and
illness?
a. “What or who do you believe controls your health?”
b. “Do you see your health care provider annually?”
c. “Do you have specific beliefs about health and illness?”
d. “Who makes the health decisions in your family?”
ANSWER: A
A
B
C
D
Feedback
What or who do you believe controls your health?” is a broad question that allows
the patient to describe his or her beliefs.
Asking if the patient visits his or her health care provider annually assumes the
patient has a health care provider, and it is a closed-ended question that yields
little data.
“Do you have specific beliefs about health and illness?” will yield a “yes” or “no”
answer, but does not provide information needed.
“Who makes the health decisions in your family?” does not provide information
about the beliefs of the patient
DIF: Cognitive Level: Understand REF: 51
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Psychosocial Integrity: Religious and Spiritual Influences on Health
11. An Asian woman comes to the clinic with a complaint of back pain. During the history, she
tells the nurse that she usually uses acupuncture for her pain. What is the nurse’s best
response?
a. “When have you used acupuncture, and what effects did it have?”
b. “Acupuncture is good for some problems, but for major illnesses it’s best to use
medications.”
c. “Why did you use acupuncture?”
d. “I have heard that many Asian people use acupuncture.”
ANSWER: A
This study source was downloaded by 100000838401522 from CourseHero.com on 03-03-2022 08:49:55 GMT -06:00
https://www.coursehero.com/file/20909004/c5/
A
B
C
D
Feedback
Asking about the use and effectiveness of acupuncture acknowledges the patient’s
choice of treatment and allows the nurse to gather more data about its
effectiveness for this patient.
Asking “Why did you use acupuncture?” is a nontherapeutic response and
questions the patient’s reason for her health care decisions.
Asking “Why did you use acupuncture?” is a nontherapeutic response and
questions the patient’s reason for her health care decisions.
Commenting that, “I have heard that many Asian people use acupuncture” is an
example of stereotyping.
DIF: Cognitive Level: Apply REF: 51
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Psychosocial Integrity: Cultural Diversity
12. A nurse is caring for a woman who has given birth to a healthy baby. The woman’s husband
and mother are in the room, and more family members are in the lobby. Which comment by
the nurse demonstrates culturally competent care?
a. “We need to take your baby to the nursery now for a physical examination.”
b. “Are there any ceremonies or other practices that are important to you at this
time?”
c. “We can only allow immediate family in the room with you at this time.”
d. “Because breastfeeding is the best way to feed your baby, we’ll bring your baby to
you when she is hungry.”
ANSWER: B
A
B
C
D
Feedback
Although a physical examination is important, it is not necessary for culturally
competent care and can be performed at another time.
Asking about ceremonies or other practices collects data about culturally-based
behaviors of this patient and family surrounding childbirth.
Limiting visitors based on an arbitrary or subjective definition of “immediate
family” may interfere with culturally competent care.
Breastfeeding is a choice the mother makes, not the nurse.
DIF: Cognitive Level: Apply REF: 51
TOP: Nursing Process: Intervention
MSC: NCLEX Patient Needs: Psychosocial Integrity: Cultural Diversity
13. A nurse can improve cultural awareness with which behavior?
a. Being sensitive to differences between the cultures of the nurse and patient
b. Making generalizations about various ethnic and cultural groups
c. Learning everything about the various cultural groups in the nurse’s city
d. Taking a foreign language class
ANSWER: A
A
Feedback
Being sensitive to differences between the cultures of the nurse and patient. This
allows the nurse to be open and to collect data about each unique patient.
This study source was downloaded by 100000838401522 from CourseHero.com on 03-03-2022 08:49:55 GMT -06:00
https://www.coursehero.com/file/20909004/c5/
B
C
D
Making generalizations about various ethnic and cultural groups leads to
stereotyping.
Learning everything about the various cultural groups in the nurse’s city provides
useful information about a specific city, but does not necessarily improve cultural
awareness of cultures in other cities.
Learning a foreign language may help a nurse learn information about one
culture, but does not improve cultural awareness of other cultures.
DIF: Cognitive Level: Understand REF: 52
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Psychosocial Integrity: Cultural Diversity
MULTIPLE RESPONSE
1. Which of the components described below represent the Filipino culture? Select all that apply.
a. Tagalog and Cebuano are the primary dialects spoken.
b. Orientation to the past is evident in their respect for elders.
c. The family, rather than the individual, is the unit.
d. Most Filipinos are Catholic.
e. Filipinos like to eat rice with most meals.
f. Sharing is common since interdependence is important.
ANSWER: B, C, F
Correct: Respect for elders is an example of values and beliefs, a part of culture. Value of
family represents beliefs and customs of culture. Interdependence is a value of Filipinos.
Incorrect: Language, religion, and food preferences are part of ethnicity, rather than culture.
DIF: Cognitive Level: Apply REF: 47
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Psychosocial Integrity: Cultural Diversity
2. During the first prenatal visit for a 20-year-old Hispanic woman, the nurse assesses the
patient’s health beliefs and practices. Which questions are appropriate as part of this
assessment? Select all that apply.
a. “You are Hispanic, do you need me to find an interpreter?”
b. “What is the language that is usually spoken in your home?”
c. “How do you define health and illness?”
d. “Which Catholic church do you attend?”
e. “Do you have specific beliefs or preferences concerning food or food preparation?”
f. “Do you or the members of your family have certain beliefs and practices
surrounding pregnancy and childbirth?”
ANSWER: B, C, E, F
Correct: “What is the language that is usually spoken in your home?” “How do you define
health and illness?” “Do you have specific beliefs or preferences concerning food or food
preparation?” “Do you or the members of your family have certain beliefs and practices
surrounding pregnancy and childbirth?” These four questions support culturally sensitive
nursing care.
This study source was downloaded by 100000838401522 from CourseHero.com on 03-03-2022 08:49:55 GMT -06:00
https://www.coursehero.com/file/20909004/c5/
Incorrect: “You are Hispanic, do you need me to find an interpreter?” assumes that all
Hispanic persons speak Spanish only and is an example of stereotyping. “Which Catholic
church do you attend?” assumes that all Hispanics are Catholics and is an example of
stereotyping.
DIF: Cognitive Level: Apply REF: 51
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Psychosocial Integrity: Cultural Diversity
This study source was downloaded by 100000838401522 from CourseHero.com on 03-03-2022 08:49:55 GMT -06:00
https://www.coursehero.com/file/20909004/c5/
Chapter 6: Pain Assessment
Test Bank
MULTIPLE CHOICE
1. How do nurses assess a patient’s pain?
a. By assessing physiologic changes of the patient
b. By understanding the sensory experience related to the amount of tissue damage
c. By the patient’s medical diagnosis or surgical procedure
d. By asking the patient to rate the pain being experienced
ANSWER: D
A
B
C
D
Feedback
The pain perceived is unrelated to the physiologic changes of the patient.
Although pain occurs when tissues are damaged, there is no correlation between
the amount of tissue damage and the degree and intensity of pain experienced.
There is no correlation between pain perceived and a medical diagnosis or
surgical procedure.
Pain is whatever the patient says it is. One person cannot judge the perception or
meaning of pain of another person.
DIF: Cognitive Level: Understand REF: 54| 59
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Basic Care and Comfort: Assessing Pain
2. The nurse notes in the patient’s history that the patient has persistent, malignant pain. What is
the meaning of this type of pain?
a. The pain has been present for at least 2 weeks.
b. The pain began after recent surgery and is associated with healing incisions.
c. The pain has been present for 6 or more months.
d. The pain has been present since surgery to remove cancer.
ANSWER: C
A
B
C
D
Feedback
This time frame is too short. Chronic pain may be intermittent or continuous pain
lasting more than 6 months.
This is a description of acute pain rather than chronic.
This is the definition of persistent or chronic pain.
Surgery to remove malignant tissue does not necessarily equate to malignant pain.
DIF: Cognitive Level: Remember REF: 55
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Basic Care and Comfort: Assessing Pain
3. A patient has had chronic back pain for several years. On assessment, the nurse notes that the
patient sits quietly in a chair, reads a book, talks with a companion, and does not appear to be
in pain. When questioned, the patient rates the pain as a 6 on a scale of 0 to 10. How does the
nurse interpret these data?
This study source was downloaded by 100000838401522 from CourseHero.com on 03-03-2022 08:52:20 GMT -06:00
https://www.coursehero.com/file/20909012/c6/
a. Many patients cannot be believed when they complain of severe pain lasting many
months.
b. Patients may not have the same objective responses to chronic pain because of
compensation over time.
c. The patient probably has already taken a very effective pain medication.
d. This patient is probably not having as much pain as reported initially, and more
assessment is required.
ANSWER: B
A
B
C
D
Feedback
Pain is whatever the patient says it is. Patients with chronic pain adapt to the pain
and have more subtle manifestations than patients with acute pain.
Clinical manifestations of chronic pain are not those of physiologic stress because
the patient adapts to the pain.
Patients with chronic pain adapt to the pain and have more subtle manifestations
than patients with acute pain despite the effects of pain medication.
Pain is whatever the patient says it is. Patients with chronic pain adapt to the pain
and have more subtle manifestations than patients with acute pain.
DIF: Cognitive Level: Apply REF: 55
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Basic Care and Comfort: Assessing Pain
4. Which patient would be expected to experience acute pain?
a. A patient who had abdominal surgery 8 hours ago
b. A patient who has cancer and has been receiving treatment for 4 months
c. A patient who states that he or she has lived with severe pain for many years
d. A patient who has been treated unsuccessfully over the past year for back pain
ANSWER: A
A
B
C
D
Feedback
Acute pain has a recent onset and results from tissue damage; is usually selflimiting;
and ends when the tissue heals.
Acute pain has a recent onset and results from tissue damage; is usually selflimiting;
and ends when the tissue heals.
This patient has experienced chronic pain for years. Acute pain has a recent onset
and results from tissue damage; is usually self-limiting; and ends when the tissue
heals.
This patient has experienced chronic pain for one year. Acute pain has a recent
onset and results from tissue damage; is usually self-limiting; and ends when the
tissue heals.
DIF: Cognitive Level: Apply REF: 55
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Basic Care and Comfort: Assessing Pain
5. Which patient has pain caused by abnormal processing of sensory input from the peripheral
nervous system?
a. The patient who has aching pain from muscle strain
This study source was downloaded by 100000838401522 from CourseHero.com on 03-03-2022 08:52:20 GMT -06:00
https://www.coursehero.com/file/20909012/c6/
b. The patient who has burning pain along the sciatic nerve
c. The patient who has cramping pain from a tumor in the colon
d. The patient who has throbbing pain from arthritis
ANSWER: B
A
B
C
D
Feedback
The patient who has aching pain from muscle strain has nociceptor, somatic pain.
The patient who has burning pain along the sciatic nerve has neuropathic pain.
The patient who has cramping pain from a tumor in the colon has nociceptor,
visceral pain.
The patient who has throbbing pain from arthritis has nociceptor, somatic pain.
DIF: Cognitive Level: Analyze REF: 55-56
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
6. A patient reports “right shoulder pain that comes and goes” as the chief complaint. During the
physical examination, the patient asks why the upper right abdomen is being examined for
shoulder pain. What is the appropriate response from the nurse?
a. “A comprehensive examination is required to determine the cause of your pain.”
b. “There may be associated problems that have not produced any symptoms yet that
we want to identify.”
c. “Yes, this can be confusing, but if you will be patient I’m sure we can find
something to help you.”
d. “It does seem odd, but the gallbladder doesn’t have pain receptors of its own, so the
pain shows up in the shoulder.”
ANSWER: D
A
B
C
D
Feedback
A focused examination is indicated at this time, not a comprehensive
examination.
This patient’s pain is due to referred pain, not to associated problems that have
not produced any symptoms of pain.
This response reflects concern for the patient’s pain, but does not address the
patient’s questions about examining the abdomen.
Referred pain is pain felt at a site different from that of an injured or diseased
organ. It commonly occurs during visceral pain because many organs have no
pain receptors; thus, when afferent nerves enter the spinal cord, they stimulate
sensory nerves from unaffected organs in the same spinal cord segment as those
neurons in areas where injury or disease is located.
DIF: Cognitive Level: Apply REF: 55
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
This study source was downloaded by 100000838401522 from CourseHero.com on 03-03-2022 08:52:20 GMT -06:00
https://www.coursehero.com/file/20909012/c6/
7. A patient who had an amputation of his lower leg comes to the clinic with a complaint of pain.
He asks, “How I can be feeling pain in my foot—my foot is gone!” What is the appropriate
response from the nurse?
a. “After your amputation, pain perception increases.”
b. “Amputating your leg caused abnormal processing of sensory input by the
peripheral nervous system.”
c. “Stimulation of nerves from your leg sends impulses to the brain so that you feel
pain even though your leg is no longer there.”
d. “When sensory nerves enter the spinal cord, they stimulate nerves from unaffected
organs in the same spinal cord segment as those neurons in areas where injury or
disease is located.”
ANSWER: C
A
B
C
D
Feedback
“After your amputation, pain perception increases” is a definition of pain
threshold.
“Amputating your leg caused abnormal processing of sensory input by the
peripheral nervous system” is a definition of neuropathic pain.
“Stimulation of nerves from your leg sends impulses to the brain so that you feel
pain even though your leg is no longer there” is a definition of phantom pain.
“When sensory nerves enter the spinal cord, they stimulate nerves from
unaffected organs in the same spinal cord segment as those neurons in areas
where injury or disease is located” is a definition of referred pain.
DIF: Cognitive Level: Analyze REF: 55
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
8. A patient who had extensive surgery asks the nurse for pain medication for a pain of 9 on a
scale of 0 to 10. The nurse completes an assessment of this patient’s pain and agrees to give
pain medication. When the nurse returns to the patient with the ordered intravenous pain
medication, she notices the patient’s eyes are closed and he appears to be sleeping. What is the
nurse’s appropriate action at this time?
a. Lock up the medication in a safe location until the patient awakens.
b. Arouse the patient to confirm he still wants the medication.
c. Give the medication as ordered and agreed to.
d. Consult a colleague about what action to take.
ANSWER: C
A
B
C
D
Feedback
The patient needs to receive the ordered pain medication now.
There is no reason to confirm the need for pain medication requested earlier.
Sleep is not synonymous with pain relief. When the patient reports a pain of 9 and
asks for medication for which there is an order, he needs to receive the
medication.
There is no reason to ask a colleague about giving the pain medication requested
earlier.
This study source was downloaded by 100000838401522 from CourseHero.com on 03-03-2022 08:52:20 GMT -06:00
https://www.coursehero.com/file/20909012/c6/
DIF: Cognitive Level: Apply REF: 54| 56
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Basic Care and Comfort: Assessing Pain
9. In the labor and delivery department, the nurse notices that two women who are in labor are
responding differently to their contractions. The first woman, who is having her first baby, has
rated her pain as a “7,” seems agitated, and has asked for pain medication. The second
woman, who is having her third baby, has also rated her pain as a “7,” but is calmer and says
she does not need anything for pain at this time. What explains the differences in the outward
responses to pain between these women?
a. Pain tolerance
b. Pain threshold
c. Nociception
d. Physiologic stress
ANSWER: A
A
B
C
D
Feedback
Pain tolerance is the duration or intensity of pain a person will endure before
outwardly responding. A person’s culture, pain experience, expectations, role
behaviors, and physical and emotional health influence pain tolerance. The
second woman had experienced the birth process before and had different
expectations than the first woman, who was having her first baby.
Pain threshold is the point at which a stimulus is perceived as pain. This threshold
does not vary significantly among people or in the same person over time.
Nociception is the process of pain perception and involves transduction,
transmission, perception, and modulation.
Physiologic stress stimulates the sympathetic nervous system causing
tachycardia, increased respiratory rate, and dilated pupils, but does not
necessarily affect pain response.
DIF: Cognitive Level: Analyze REF: 58
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
10. A patient admitted to the emergency department with “excruciating chest pain, above the
rating of 10,” has a heart rate of 55, rapid, irregular respirations, complains of nausea, and is
too weak to move to the stretcher without aid. The nurse recognizes that this response to
severe pain is due to the response of the nervous system.
a. Parasympathetic
b. Sympathetic
c. Central
d. Peripheral
ANSWER: A
A
Feedback
During severe or deep pain the parasympathetic nervous system may cause pallor;
rapid, irregular breathing; nausea; and vomiting.
This study source was downloaded by 100000838401522 from CourseHero.com on 03-03-2022 08:52:20 GMT -06:00
https://www.coursehero.com/file/20909012/c6/
B
C
D
The sympathetic nervous system responds to acute pain by increasing heart rate,
increasing blood pressure, causing diaphoresis, increasing respiratory rate,
increasing muscle tension, dilating pupils, and decreasing gastrointestinal
motility.
The central nervous system includes the brain and spinal cord. The manifestations
described in the case are due to parasympathetic nervous system stimulation.
The manifestations described in the case are due to parasympathetic nervous
system stimulation.
DIF: Cognitive Level: Remember REF: 59| 63
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Basic Care and Comfort: Assessing Pain
11. A patient with gout is complaining of severe, throbbing pain in the great toe. What type of
pain is this patient experiencing?
a. Neuropathic pain
b. Somatic pain
c. Referred pain
d. Visceral pain
ANSWER: B
A
B
C
D
Feedback
Neuropathic pain is caused by abnormal processing of sensory input from the
peripheral nervous system.
Somatic pain arises from bone, joint, muscle, skin, or connective tissues and is
usually aching or throbbing in quality and well located.
Referred pain is pain felt at a site different from that of an injured or diseased
organ.
Visceral pain occurs with obstruction of a hollow organ and causes intermittent
cramping pain.
DIF: Cognitive Level: Remember REF: 59
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
12. A patient with a partial small bowel obstruction describes the pain as “cramping, off-and-on
pain that spreads over my stomach.” What type of pain is this patient experiencing?
a. Referred pain
b. Phantom pain
c. Somatic pain
d. Visceral pain
ANSWER: D
A
B
C
Feedback
Referred pain is felt at a site different from that of an injured or diseased organ.
Phantom pain is associated with amputations.
Somatic pain arises from bone, joint, muscle, skin, or connective tissues and is
usually aching or throbbing in quality and well located.
This study source was downloaded by 100000838401522 from CourseHero.com on 03-03-2022 08:52:20 GMT -06:00
https://www.coursehero.com/file/20909012/c6/
D
Visceral pain occurs with obstruction of a hollow organ and causes intermittent
cramping pain.
DIF: Cognitive Level: Remember REF: 59
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
MULTIPLE RESPONSE
1. A nurse is assessing a patient who complains of “awful” abdominal pain and rates it as a 9 on
a scale of 0 to 10. Which of the following physiologic signs may accompany acute pain?
Select all that apply.
a. Tachycardia
b. Irritability
c. Increased blood pressure
d. Depression
e. Insomnia
f. Sweating
ANSWER: A, C, F
Correct: The sympathetic nervous system responds to acute pain by increasing heart rate,
increasing blood pressure, causing diaphoresis, increasing respiratory rate, increasing muscle
tension, dilating pupils, and decreasing gastrointestinal motility.
Incorrect: Irritability, depression, and insomnia are manifestations of chronic rather than
acute pain.
DIF: Cognitive Level: Apply REF: 59| 63
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
2. The nurse is performing a symptom analysis of a patient with pain. Which questions below are
appropriate for a symptom analysis? Select all that apply.
a. “Have you had any other symptoms such as nausea, vomiting, and sweating?”
b. “Where is the pain located?”
c. “Have you had a pain like this before?”
d. “What does the pain feel like?”
e. “What do you do to make your pain better?”
f. “In your culture, how are you encouraged to express your pain?”
ANSWER: A, B, D, E
Correct: “Have you had any other symptoms such as nausea, vomiting, and sweating?”
“Where is the pain located?” “What does the pain feel like?” “What do you do to make your
pain better?” These four questions are asked in a symptom analysis that includes the following
variables: onset of symptoms, location and duration of symptoms, characteristics, aggravating
factors, related symptoms, self-treatment, and severity.
Incorrect: “Have you had a pain like this before?” This question relates to the patient’s health
history. “In your culture, how are you encouraged to express your pain?” This question relates
to the patient’s culture and does not help analyze the patient’s pain experience.
This study source was downloaded by 100000838401522 from CourseHero.com on 03-03-2022 08:52:20 GMT -06:00
https://www.coursehero.com/file/20909012/c6/
DIF: Cognitive Level: Apply REF: 59-60
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
3. How do nurses assess pain of neonates or of adults with dementia or decreased level of
consciousness? Select all that apply.
a. Ask family or caregivers what indicators they think may indicate the patient’s pain.
b. Review results of blood tests for signs of pain.
c. Administer the ordered analgesic to the patient.
d. Identify any physiologic signs of pain.
e. Examine the patient for possible causes of pain.
ANSWER: A, C, D, E
Correct: These four answers are the clinical practice recommendations of Herr and
colleagues.
Incorrect: Pain cannot be detected with laboratory tests.
DIF: Cognitive Level: Understand REF: 62
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Basic Care and Comfort: Assessing Pain
This study source was downloaded by 100000838401522 from CourseHero.com on 03-03-2022 08:52:20 GMT -06:00
https://www.coursehero.com/file/20909012/c6/
Chapter 7: Mental Health and Abusive Behavior Assessment
Test Bank
MULTIPLE CHOICE
1. What function do neurotransmitters have in mental health disorders?
a. Dopamine levels are increased in schizophrenia.
b. Increased levels of gamma aminobutyric acid (GABA) contribute to anxiety.
c. Serotonin is decreased in a state of anxiety.
d. Norepinephrine is increased in depression.
ANSWER: A
A
B
C
D
Feedback
Dopamine levels are increased in schizophrenia.
Insufficient GABA may contribute to anxiety. GABA is an inhibitory
neurotransmitter.
Serotonin is increased in anxiety states.
Norepinephrine is decreased in depression.
DIF: Cognitive Level: Remember REF: 66
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Psychosocial Integrity: Mental Health Concepts
2. A male patient scores 125 on the Holmes Social Readjustment Scale. How does the nurse
interpret this score?
a. He is experiencing a great deal of stress in his life and needs hospitalization.
b. At this time he has no stress in his life and is healthy both mentally and physically.
c. He has relatively low stress in his life and use of daily relaxation can be beneficial.
d. He has a moderate chance of developing a stress-related illness and can reduce this
by practicing stress management.
ANSWER: C
A
B
C
D
Feedback
A score on the Holmes Social Readjustment Scale greater than 300 is needed for
hospitalization.
This does not apply to this person. The lowest score possible on the Holmes
Social Readjustment Scale (less than 150) indicates the amount of stress
experienced is a result of normal changes in life and is manageable.
A score on the Holmes Social Readjustment Scale of below 150 indicates the
amount of stress experienced is a result of normal changes in life and is
manageable.
A moderate chance of developing a stress-related illness and reduction through
stress management applies to a patient who scores between 150 and 300.
DIF: Cognitive Level: Apply REF: 69
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Psychosocial Integrity: Mental Health Concepts
3. A 24-year-old male patient tells the nurse he has had no energy for 2 weeks. He has no trouble
falling asleep; in fact, he sleeps deeply about 12 hours every night. He states that he has
gained 10 lb in the past 2 months and has no friends. The nurse associates these
manifestations with which mental health disorder?
a. Depression
b. Schizophrenia
c. Bipolar disorder
d. Anxiety disorder
ANSWER: A
A
B
C
D
Feedback
These are symptoms of depression.
Clinical manifestations of schizophrenia include apathy and confusion, delusions
and hallucinations, and rambling or stylized patterns of speech.
Characteristics of the manic phase are excessive emotional displays, excitement,
euphoria, and hyperactivity. In contrast, characteristics of the depressive phase are
marked apathy and feelings of profound sadness, loneliness, guilt, and lowered
self-esteem.
Anxiety is a feeling of uneasiness or discomfort experienced in varying degrees,
from mild anxiety to panic. The energy that anxiety provides may mobilize a
person to take constructive action such as solving a major problem or filling an
unmet need.
DIF: Cognitive Level: Apply REF: 68-69
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Psychosocial Integrity: Mental Health Concepts
4. A female patient states that she has had problems with depression in the past and thinks she is
depressed again. Which response by the nurse is most appropriate?
a. “What do you think is causing your depression this time?”
b. “What therapies have worked for you in the past?”
c. “Did you stop taking your medication?’”
d. “Do you think this is a situational depression?”
ANSWER: B
A
B
C
D
Feedback
This question provides information but does not direct the patient toward
identifying a treatment.
This question is a therapeutic response to determine if the same or similar therapy
can be used again for this depression. It is an open-ended question to collect more
data. Also treatment is information collected in a symptom analysis that is useful
in this situation.
This question sounds accusatory, and the nurse is guessing the cause of this
episode of depression without collecting data from the patient. This is a closedended
question asking for a “yes” or “no” response.
This is a closed-ended question and does not collect data to determine if the
patient has depression again.
DIF: Cognitive Level: Apply REF: 70
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Psychosocial Integrity: Mental Health Concepts
5. Which patient may be experiencing severe anxiety?
a. A woman who tells the nurse she is terrified of cats
b. A man who tells the nurse he feels worthless and is always tired
c. A woman who reports that she is sleeping very lightly each night because her child
has an ear infection
d. A man who phones the nurse five times asking for instructions about how to take
his new medication
ANSWER: D
A
B
C
D
Feedback
Being terrified of cats describes fear or a phobia rather than anxiety. Unlike fear,
which is a response to an actual object or event, anxiety is a response to no
specific source or actual object.
Although fatigue is a characteristic of anxiety, in this case, the patient also
verbalizes feelings of worthlessness, which suggests depression rather than
anxiety.
Although problems falling and staying asleep are characteristics of anxiety, in this
example the patient can identify the cause of the sleeplessness—her ill child—
thus anxiety is not the cause of the sleep disturbance.
A man who phones the nurse five times asking for instructions about how to take
his new medication shows characteristics of anxiety, which includes forgetfulness
and difficulty concentrating or making decisions.
DIF: Cognitive Level: Apply REF: 70
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Psychosocial Integrity: Mental Health Concepts
6. While assessing a man during a physical examination for work, the nurse suspects alcohol
use. Which assessment tool is appropriate in this situation?
a. AUDIT screening tool
b. Rapid eye test
c. Mental status examination
d. Holmes Social Readjustment Rating Scale
ANSWER: A
A
B
C
D
Feedback
AUDIT, an abbreviation for Alcohol Use Disorders Identification Test, is the
correct assessment tool in this situation.
The rapid eye test is used when there is suspicion of drug intoxication.
Mental status examination is not indicated in this case because there are no data
to suggest an alteration in mental status.
The Holmes Social Readjustment Rating Scale is used to assess stress and predict
the occurrence of a serious illness over the next 2 years based on stress alone.
DIF: Cognitive Level: Understand REF: 71-72
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Psychosocial Integrity: Mental Health Concepts
7. A nurse screens every adult and adolescent patient for alcohol consumption. Which patient
drinks more than recommended?
a. The man who reports drinking 3 beers and one shot of whiskey each day
b. The woman who reports drinking 2 glasses of wine and 2 vodka martinis each day
c. The older adult man who reports drinking one glass of sherry before going to bed
each night
d. The woman who reports drinking one glass of wine with lunch and dinner each day.
ANSWER: B
A
B
C
D
Feedback
The man who reports drinking 3 beers and one shot of whiskey each day. This
amount of alcohol is within the National Institute on Alcohol Abuse and
Alcoholism recommendations for men to drink fewer than 5 standard drinks daily.
The woman who reports drinking 2 glasses of wine and 2 vodka martinis each
day. The National Institute on Alcohol Abuse and Alcoholism recommends
women drink fewer than 4 standard drinks daily.
The older adult man who reports drinking one glass of sherry before going to bed
each night. This amount of alcohol is within the National Institute on Alcohol
Abuse and Alcoholism recommendations for men to drink fewer than 5 standard
drinks daily.
The woman who reports drinking one glass of wine with lunch and dinner each
day. This amount of alcohol is within the National Institute on Alcohol Abuse and
Alcoholism recommendations for women to drink fewer than 4 standard drinks
daily.
DIF: Cognitive Level: Apply REF: 71
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Psychosocial Integrity: Mental Health Concepts
8. During a sports physical for a 16-year-old girl, the nurse asks which question to collect data
about drug use?
a. “Many teenagers have tried street drugs. Have you tried these drugs? ”
b. “Tell me which street drugs your friends have offered to you?”
c. “Do most of your friends drink alcohol or do street drugs?”
d. “Your high school has a reputation for drug use. Do you use drugs?”
ANSWER: A
A
B
C
D
Feedback
This uses a questioning technique called “permission giving” in which the nurse
“gives permission” to the patient to discuss drug use. Questions like this help
identify a pattern of drug use and screen for drug abuse.
This is not an appropriate question because the nurse does not need this
information to assess the patient.
This is not an appropriate question because the nurse does not need this
information to assess the patient.
This is not an appropriate question because the nurse is associating the school’s
reputation with the patient’s behaviors.
DIF: Cognitive Level: Apply REF: 72
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Psychosocial Integrity: Mental Health Concepts
9. In contrasting the assessment of mental status from mental health, a nurse recognizes that data
for the mental status examination are obtained using which techniques?
a. Asking them about their relatives who have mental health disorders
b. Having them demonstrate their ability to reason and calculate
c. Asking them to recall how they have coped with daily stress
d. Having them describe their mood and emotions
ANSWER: B
A
B
C
D
Feedback
This obtains information from patients for the histories, but does not ask patients
to demonstrate mental abilities.
The mental status examination asks patients to perform calculations and other
tasks to show their abilities, rather than asking them about their abilities.
This obtains information from patients for the histories, but does not ask patients
to demonstrate mental abilities.
Having them describe their mood and emotions does not ask patients to
demonstrate mental abilities.
DIF: Cognitive Level: Analyze REF: 70
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Psychosocial Integrity: Mental Health Concepts
10. A nurse is admitting a new patient. Which statement by the patient suggests a bipolar
disorder?
a. “The last time I had blood drawn at the office, I fainted dead away.”
b. “No matter how hard I try, I just can’t get into an elevator of any kind.”
c. “Everyone knows I can control the financial health of this town with a snap of my
fingers.”
d. “I worked for Frank Sinatra’s band for several months when I lived in New Jersey
years ago.”
ANSWER: C
A
B
C
D
Feedback
This statement does not indicate bipolar disorder and may be a true statement.
This statement is an example of a phobia.
Patients in the manic phase of bipolar disorder have delusions of grandeur, which
is described in the statement.
This may be a true statement depending on the age of the patient.
DIF: Cognitive Level: Apply REF: 76
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Psychosocial Integrity: Mental Health Concepts
11. During conversation, the nurse observes that the patient is talking continuously and excitedly,
and is switching rapidly from one topic to another with seemingly no relationship between
topics. This behavior is often associated with which disorder?
a. Depression
b. Obsessive-compulsive disorder
c. Schizophrenia
d. Bipolar disorder
ANSWER: C
A
B
C
D
Feedback
This behavior is flight of ideas, which occurs in patients with schizophrenia rather
than depression.
This behavior is flight of ideas, which occurs in patients with schizophrenia rather
than obsessive-compulsive disorder.
This behavior is flight of ideas, which occurs in patients with schizophrenia.
This behavior is flight of ideas, which occurs in patients with schizophrenia rather
than bipolar disorder.
DIF: Cognitive Level: Understand REF: 76
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Psychosocial Integrity: Mental Health Concepts
12. During a visit to the clinic for an annual gynecologic examination, a patient tells the nurse that
she had a bad experience on an airplane, saying, “When I sat down, my heart started racing, I
was short of breath and sweaty, and I felt as if I was going to die.” She stated that her husband
helped her to calm down after a few minutes. The nurse recognizes that the patient was
describing which problem?
a. Bipolar disorder, manic phase
b. Moderate anxiety
c. Panic
d. Delusions
ANSWER: C
A
B
C
D
Feedback
Characteristics of the manic phase are excessive emotional displays, excitement,
euphoria, hyperactivity accompanied by elation, boisterousness, impaired ability
to concentrate, decreased need for sleep, and limitless energy, often accompanied
by delusions of grandeur.
The moderately anxious person has a narrower field of perception and uses
selective inattention to ignore stimuli in the environment to focus on a specific
concern.
Physical manifestations of a panic attack represent sympathetic nervous system
stimulation. The person experiences muscle tension, tachycardia, dyspnea,
hypertension, increased respiration, and profuse perspiration.
Delusions are persistent abnormal beliefs or perceptions held by a person despite
the evidence that refutes it.
DIF: Cognitive Level: Apply REF: 77
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Psychosocial Integrity: Mental Health Concepts
13. A patient in the waiting room appears anxious and moves around the room cleaning surfaces
with a disinfectant cloth. This behavior is consistent with which disorder?
a. Bipolar disorder
b. Delirium
c. Schizophrenia
d. Obsessive-compulsive disorder
ANSWER: D
A
B
C
D
Feedback
Bipolar disorder is a type of depression characterized by episodes of mania,
depression, or mixed moods.
Delirium has manifestations that include attention deficits, disorganized thinking,
confusion, disorientation, restlessness, incoherence, anxiety, and excitement.
Schizophrenia is characterized by gross distortion of reality, disturbances of
language and communication, withdrawal from social interaction, and the
disorganization and fragmentation of thought perception and emotional reaction.
This patient was concerned about contamination. Compulsions are unwanted,
repetitive behavior patterns or mental acts that are intended to reduce anxiety. The
person recognizes that the behaviors are excessive or unreasonable but continues
them because of the relief from the discomfort of anxiety that they provide.
DIF: Cognitive Level: Understand REF: 77
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Psychosocial Integrity: Mental Health Concepts
14. An elderly patient was admitted with pneumonia and a fever of 104.5° F. At the time of
admission he was confused, disoriented, restless, and tried to slap the nurse who started an
intravenous line. His daughter stated, “Just yesterday he was perfectly fine, except for a cold. I
can’t believe he is acting this way now.” Within a few days, his erratic behavior subsided and
his daughter was relieved that he was “back to normal.” The nurse recognizes that this patient
was exhibiting signs of which disorder?
a. Dementia
b. Delirium
c. Panic attack
d. Alcohol withdrawal
ANSWER: B
A
B
C
Feedback
Dementia is a syndrome of acquired, progressive, intellectual impairment that
compromises function, such as memory, language, visual-spatial skills, emotion,
personality, and cognition.
Delirium is characterized by a disturbance of consciousness and a change in
cognition that develops rapidly over a short period of time.
A panic attack is characterized by complete disruption of the perceptual field. The
person experiences intense terror and is unable to think logically or make
decisions. The person experiences muscle tension, tachycardia, dyspnea,
hypertension, increased respiration, and profuse perspiration.
D
Early manifestations of alcohol withdrawal include hand tremors, sweating,
nausea and vomiting, anxiety, and agitation.
DIF: Cognitive Level: Understand REF: 77
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Psychosocial Integrity: Mental Health Concepts
15. During a report, a nurse hears about a patient who was admitted at 8 PM after an automobile
accident. He had a blood alcohol level of 100 mg/dl at the time of admission. During the 8 AM
assessment, the nurse notes that the patient is having hand tremors, is sweaty, is slightly
agitated, and complains of nausea. The nurse recognizes that the patient may be exhibiting
signs of which disorder?
a. Alcohol withdrawal syndrome
b. Delirium tremens
c. Panic
d. Delirium
ANSWER: A
A
B
C
D
Feedback
The history and laboratory data reflect alcohol withdrawal syndrome. Early
manifestations of alcohol withdrawal include hand tremors, sweating, nausea and
vomiting, anxiety, and agitation. These manifestations begin 6 to 24 hours after
the patient’s last drink, peak in 24 to 36 hours, and end after 48 hours of
abstinence.
The time sequence is not consistent with delirium tremens. During delirium
tremens, a patient experiences cardiac dysrhythmias, hypertension, increased
respirations, profuse sweating, delusion, and hallucinations.
The history is not consistent with panic disorder. In the panic level of anxiety, a
person experiences manifestations of anxiety that represent sympathetic nervous
system stimulation, as well as muscle tension, tachycardia, dyspnea,
hypertension, increased respiration, and profuse perspiration.
Manifestations of delirium include attention deficits, disorganized thinking,
confusion, disorientation, restlessness, incoherence, anxiety, excitement, and, at
times, illusions.
DIF: Cognitive Level: Understand REF: 77
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Psychosocial Integrity: Mental Health Concepts
MULTIPLE RESPONSE
1. Which neurotransmitters are decreased in patients with depression? Select all that apply.
a. Acetylcholine (Ach)
b. Histamine
c. Norepinephrine (NE)
d. Dopamine (DA)
e. Gamma aminobutyric acid (GABA)\
f. Serotonin (5 HT)
ANSWER: B, C, D, F
Correct: Histamine, norepinephrine (NE), dopamine (DA), and serotonin (5 HT) are
neurotransmitters that are decreased in depression. Drugs prescribed for people with
depression may provide therapy by increasing these neurotransmitters.
Incorrect: Acetylcholine (Ach) is increased in depression. Gamma aminobutyric acid
(GABA) is decreased in schizophrenia and anxiety states.
DIF: Cognitive Level: Understand REF: 66
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Psychosocial Integrity: Mental Health Concepts
2. During a mental health history, the nurse suspects altered mental status for a patient. Which
questions are appropriate to ask when assessing mental status? Select all that apply.
a. “Do you have difficulty making decisions?”
b. “Do you know where you are?”
c. “Are there times when you wanted to escape?”
d. “If you bought a hat for $5.75 and gave the sales person $10.00, how much change
do you expect back?”
e. “What would you do if a fire started in your home?”
f. “What does this phrase ‘A rolling stone gathers no moss’ mean?”
ANSWER: B, D, E, F
Correct: “Do you know where you are?” assesses orientation. “If you bought a hat for $5.75
and gave the sales person $10.00, how much change do you expect back?” assesses
calculation ability. “What would you do if a fire started in your home?” assesses judgment.
“What does this phrase ‘A rolling stone gathers no moss’ mean?” assesses abstract reasoning.
Incorrect: For the nurse to assess mental status, the patient needs to demonstrate abilities
such as calculation, judgment, and abstract reasoning.
DIF: Cognitive Level: Apply REF: 70-71
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Psychosocial Integrity: Mental Health Concepts
3. While conducting a health history, the nurse asks which questions to assess for risk factors
associated with depression? Select all that apply.
a. “Has anyone in your family ever been diagnosed with depression?”
b. “Have you noticed a change in how much energy you have?”
c. “Do you have crying spells?”
d. “Do your muscles seem tense?”
e. “Do you feel that something bad is about to happen to you?”
f. “Do you have difficulty making decisions?”
ANSWER: A, B, C, F
Correct: These questions are related to risk factors for depression.
Incorrect: Tense muscles are associated with stress and anxiety rather than depression.
Feeling that something bad is about to happen relates to paranoia rather than depression.
DIF: Cognitive Level: Apply REF: 68-70| 76
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Psychosocial Integrity: Mental Health Concepts
COMPLETION
1. Researchers have found that it is the of a recent life event that determines a person’s
emotional or psychological reaction to it.
ANSWER:
Perceptions
Each culture influences how a stressful event is perceived and the acceptable ways that people
of that culture are expected to respond.
DIF: Cognitive Level: Remember REF: 67
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Psychosocial Integrity: Mental Health Concepts
Chapter 8: Nutritional Assessment
Test Bank
MULTIPLE CHOICE
1. A patient with mild renal disease has been put on a 2200-calorie per day diet plan with the
lowest recommended amount of protein. During discharge teaching, the nurse explains to this
patient how to use nutrition labels to determine the amount of protein in the product. The
nurse explains, however, that the label is based on 2000 calories. Which is the appropriate
formula to teach this patient the least amount of protein he can eat on his prescribed diet?
a. 2200 calories 0.15 = 330/9 calories/gram = 36.6 g
b. 2200 calories 0.10 = 220/4 calories/gram = 55 g
c. 2200 calories 0.20 = 440/9 calories/gram = 48.8 g
d. 2200 calories 0.12 = 264/4 calories/gram = 66 g
ANSWER: D
Feedback
A Each gram of protein yields 4 calories rather than 9.
B Twelve percent is the least recommended percentage for proteins, rather than
10%.
C Twelve percent is the least recommended percentage for proteins. Each gram of
protein yields 4 calories rather than 9.
D Proteins should account for 12% to 20% of total calories. Each gram of protein
yields 4 calories.
DIF: Cognitive Level: Apply REF: 81
TOP: Nursing Process: Implementation
MSC: NCLEX Patient Needs: Physiologic Integrity: Basic Care and Comfort: Nutrition and
Hydration
2. A patient is put on an 1800-calorie a day diet plan. During discharge teaching, the nurse
explains to this patient how to use nutrition labels to determine the amount of carbohydrates in
the product. The nurse explains, however, that the label is based on 2000 calories. Which is
the appropriate formula to teach this patient of the maximum grams of carbohydrates she can
eat on her prescribed diet?
a. 1800 calories 0.45 = 810/4 calories/gram = 202.5 g
b. 1800 calories 0.60 = 1080/4 calories/gram = 270 g
c. 1800 calories 0.55 = 990/9 calories/gram = 110 g
d. 1800 calories 0.50 = 900/9 calories/gram = 100 g
ANSWER: B
Feedback
A Carbohydrates should account for a maximum of 60% of total calories rather than
45%.
B Carbohydrates should account for 55% to 60% of total calories. Each gram of
carbohydrates yields 4 calories.
C Each gram of carbohydrates yields 4 calories rather than 9.
D
Carbohydrates should account for a maximum of 60% of total calories, rather
than 50%. Each gram of carbohydrates yields 4 calories rather than 9.
DIF: Cognitive Level: Apply REF: 81
TOP: Nursing Process: Implementation
MSC: NCLEX Patient Needs: Physiologic Integrity: Basic Care and Comfort: Nutrition and
Hydration
3. A patient tells the nurse that she tries to keep her fat intake at less than 15% of her total caloric
intake per day. What is the nurse’s most appropriate response to this patient’s comment?
a. “That is admirable; how do you accomplish fat intake that low on a daily basis?”
b. “Eating fat is essential for good health, and you should consume about 40% of your
fats as monounsaturated fat.”
c. “Limiting fat prevents some diseases, but your fat intake is much lower than the
25% recommended.”
d. “If you want to bring your fat intake down further, you might want to eliminate
eating fast foods.”
ANSWER: C
A
B
C
D
Feedback
The patient’s fat intake is too low. The recommended amount of fat is 25% to
30% of total calories.
The recommended amount of fat is 25% to 30% of total calories.
The recommended amount of fat is 25% to 30% of total calories.
The patient’s fat intake is already too low. The recommended amount of fat is
25% to 30% of total calories.
DIF: Cognitive Level: Apply REF: 81
TOP: Nursing Process: Implementation
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Lifestyle Choices
4. A patient who keeps his fat consumption at 10% of his total caloric intake is at risk for
deficiency of which nutrient(s)?
a. Iron
b. Vitamins A, D, and K
c. Zinc
d. B and C vitamins
ANSWER: B
A
B
C
D
Feedback
Iron absorption is not affected by low fat intake.
Vitamins A, D, and K are fat soluble vitamins. If the patient does not have enough
fat intake, adequate amounts of these vitamins cannot be absorbed. Fat soluble
vitamins should be linked to a lack of body fat.
Zinc absorption is not affected by low fat intake.
Vitamins B and C are water soluble vitamins and their absorption is not affected
by low fat intake.
DIF: Cognitive Level: Apply REF: 81
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Basic Care and Comfort: Nutrition and
Hydration
5. A nurse is asking questions about the present health status of a young woman who has lost
weight recently. Which question is most appropriate when inquiring about present health
status?
a. “What concerns have you had in the past regarding your weight?”
b. “Do you have anorexia?”
c. “Describe the recent changes in your weight.”
d. “Do you have a family history of eating disorders?”
ANSWER: C
A
B
C
D
Feedback
This question implies the patient has or should have concerns about weight loss
and is not focused on the present health status.
This is not an appropriate question. More data are needed about this patient
before anorexia can be suspected or determined.
Asking the patient to describe recent changes in weight is an appropriate, openended
question to begin data collection so that the patient can report her current
health status related to weight.
This question is asked in the history rather than in the present health status part of
the health history.
DIF: Cognitive Level: Apply REF: 83
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Basic Care and Comfort: Nutrition and
Hydration
6. While assessing a patient’s ability to consume food, the nurse recalls which types of foods are
the easiest to chew and swallow?
a. Thin liquids
b. Soft foods
c. Dry foods
d. Chewy foods
ANSWER: B
A
B
C
D
Feedback
Thin liquids and foods requiring forceful chewing (such as meat) may not be
tolerated well.
Foods that are soft and highly viscous are most easily chewed and swallowed.
Foods that are soft and highly viscous are most easily chewed and swallowed.
Thin liquids and foods requiring forceful chewing (such as meat) may not be
tolerated well.
DIF: Cognitive Level: Understand REF: 84
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Basic Care and Comfort: Nutrition and
Hydration
7. Which tool is the best choice for a nurse to use as a quick screening tool to assess a patient’s
dietary intake?
a. Food diary
b. Calorie count
c. Comprehensive diet history
d. 24-hour recall
ANSWER: D
A
B
C
D
Feedback
A food diary provides detailed information, but is not convenient and requires a
follow-up visit.
A calorie count requires several days to collect data and requires a trained
dietitian to analyze the results.
A comprehensive diet history may provide more accurate reflection of nutrient
intake, but is time-consuming to acquire and requires a trained/skilled dietary
interviewer.
Twenty-four-hour recall is useful as a quick screening tool to assess dietary
intake.
DIF: Cognitive Level: Understand REF: 84
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Basic Care and Comfort: Nutrition and
Hydration
8. A nurse calculates a patient’s body mass index (BMI) as 33. This measurement indicates
which class of weight?
a. Overweight
b. Obesity class I
c. Obesity class II
d. Obesity class III
ANSWER: B
Feedback
A Overweight is a BMI of 25 to 29.9.
B Obesity class I is a BMI of 30 to 34.9.
C Obesity class II is a BMI of 35 to 39.9.
D Obesity class III is a BMI greater than 40.
DIF: Cognitive Level: Understand REF: 86-87
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Basic Care and Comfort: Nutrition and
Hydration
9. Nurses use which measurement as the most highly correlated with risk of morbidity and
mortality?
a. Waist-to-hip ratio
b. Triceps skinfold measure
c. Desirable body weight
d. Body mass index (BMI)
ANSWER: D
A
B
C
D
Feedback
The waist-to-hip ratio is an indication of the risk of unhealthy fat distribution. A
ratio that exceeds the desired ratio is indicative of upper body obesity. This
increases the risk of developing health problems related to obesity (e.g., diabetes,
hypertension, coronary artery disease, gallbladder disease, osteoarthritis, and
sleep apnea).
Triceps skinfold measurement provides an estimate of total body fat, which is
only one measure of risk for obesity, and not, by itself, the most reliable and valid
measurement to determine risk.
Calculating desirable body weight and comparing it to actual body weight does
not consider height in the assessment of obesity.
The BMI considers both weight and height in the calculation. The U.S. Preventive
Services Task Force advocates the BMI assessment as reliable and valid for
identifying adults at risk of morbidity and mortality because of being overweight
or obese. For this reason, calculating BMI is recommended for all individuals on
a periodic basis.
DIF: Cognitive Level: Understand REF: 86-87
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Basic Care and Comfort: Nutrition and
Hydration
10. What is the desired body weight for a male who is 7 feet tall?
a. 178 lb
b. 225 lb
c. 250 lb
d. 275 lb
ANSWER: C
A
B
C
D
Feedback
This incorrect result is obtained when 106 lb is used for the first 6 feet rather than
5 feet (84 inches – 72 inches = 12); thus, 106 + (12 6) = 178 lb.
This incorrect result is obtained when the scale for women is used rather than the
scale for men (84 inches – 60 inches = 24); thus, 105 + (24 5) = 225.
The patient is 84 inches tall. Use 106 lb for the first 5 feet (60 inches) and 6 lb/
inch for the remaining 24 inches (84 inches – 60 inches = 24); thus, 106 + (24
6) = 250 lb. Students must perform a calculation to find the answer.
A result of 275 lb uses an incorrect calculation.
DIF: Cognitive Level: Apply REF: 90
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Lifestyle Choices
11. During a physical examination, the nurse notes that the patient’s skin is dry and flaking, with
patches of eczema. Which nutritional deficiency might be present?
a. Vitamin C
b. Vitamin B
c. Essential fatty acid
d. Protein
ANSWER: C
A
B
C
D
Feedback
Vitamin C deficiency causes bleeding gums, arthralgia, and petechiae.
Vitamin B deficiency is too large a category to consider. Specific categories of
vitamin B deficiency have been identified, such as pyridoxine and thiamine.
Dry and scaly skin is a manifestation of essential fatty acid deficiency.
Protein deficiency causes decreased pigmentation and lackluster hair.
DIF: Cognitive Level: Understand REF: 86
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Basic Care and Comfort: Nutrition and
Hydration
12. Which patient needs to be taught about how diet and exercise can lower lipids to reduce the
risk for coronary artery disease?
a. A woman with a high-density lipoprotein (HDL) level of 53 mg/dl
b. A man with an HDL level of 43 mg/dl
c. A woman with a low-density lipoprotein (LDL) level of 125 mg/dl
d. A man with an LDL level of 200 mg/dl
ANSWER: D
A
B
C
D
Feedback
This patient’s HDL level is in the expected range.
This patient’s HDL level is in the expected range.
This patient’s LDL level is in the expected range.
The healthy range of LDL for men and women is <130 mg/dl.
DIF: Cognitive Level: Apply REF: 91| 93
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Lifestyle Choices
13. Which patient may require additional nutritional assessment?
a. A male patient with a blood glucose level of 100 mg/dl
b. A pregnant patient with a hemoglobin level of 10.5 g/dl
c. A female patient with a prealbumin level of 25 mg/dl
d. A male patient with a serum triglyceride level of 100 mg/dl
ANSWER: B
A
B
C
D
Feedback
This patient’s glucose level is within normal limits.
The expected hemoglobin level for a pregnant patient is 12 to 16 g/dl.
This patient’s prealbumin level is within normal limits.
This patient’s triglyceride level is within normal limits.
DIF: Cognitive Level: Analyze REF: 91| 93
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Basic Care and Comfort: Nutrition and
Hydration
14. During a physical examination, the nurse notes that the patient’s skin is dry and flaking, with
patches of eczema, and suspects a nutritional deficiency. What additional data should the
nurse expect to find to confirm the suspicion?
a. Hair loss and hair that is easily removed from the scalp
b. Inflammation of the tongue and fissured tongue
c. Inflammation of peripheral nerves, and numbness and tingling in extremities
d. Fissures and inflammation of the mouth
ANSWER: A
A
B
C
D
Feedback
Hair loss (alopecia) and hair that is easily removed from the scalp (easy pluck
ability), such as dry, flaking skin, is caused by essential fatty acid deficiency.
Inflammation of the tongue (glossitis) and fissured tongue are manifestations of a
niacin deficiency.
Inflammation of peripheral nerves (neuropathy) and numbness and tingling in
extremities (paresthesia) are manifestations of a thiamine deficiency.
Fissures of the mouth (cheilosis) and inflammation of the mouth (stomatitis) are
manifestations of a pyridoxine deficiency.
DIF: Cognitive Level: Analyze REF: 88
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Basic Care and Comfort: Nutrition and
Hydration
15. A male patient weighs 205 lb and his desired body weight (DBW) is 190 lb. How should the
nurse counsel this patient about his weight?
a. He has mild obesity and needs to increase exercise and assess his diet for nutrients
and calories.
b. He has moderate obesity and needs to consult a health care provider about weight
loss therapy.
c. He is within normal limits and need not be concerned at this time.
d. Further data are needed before an interpretation can be determined.
ANSWER: C
Feedback
A Using the DBW scale, mild obesity is 20% to 40% above DBW. This patient is
9% above his DBW.
B Using the DBW scale, moderate obesity is 40% to 100% greater than DBW. This
patient is 9% above his DBW.
C Ideally, the patient will fall between 90% and 110% of DBW, which for this
patient is between 171 lb and 209 lb. A calculation is required to answer the
question.
D According to the DBW scale, the patient will ideally be between 90% and 110%
of DBW; therefore, the nurse has enough information to make an interpretation.
DIF: Cognitive Level: Apply REF: 90
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Lifestyle Choices
16. A patient’s current body weight (304 lb) and his desirable body weight of 190 lb. How does
the nurse classify this patient’s weight?
a. Within expected range
b. Mildly obesity
c. Moderate obesity
d. Morbid obesity
ANSWER: C
Feedback
A A range of 90% to 110% of DBW is considered normal. This patient’s weight of
304 is 60% above his DBW.
B Mildly obesity is 20% to 40% above DBW. This patient’s weight of 304 is 60%
above his DBW.
C Moderate obesity is 40% to 100% above the DBW. This patient’s weight of 304 is
60% above his DBW.
D Morbid obesity is 100% greater than DBW. This patient’s weight of 304 is 60%
above his DBW.
DIF: Cognitive Level: Apply REF: 90
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Lifestyle Choices
17. Which patient has the least risk for unhealthy fat distribution?
a. The man whose triceps skinfold is at the 25th percentile
b. The woman whose triceps skinfold is at the 72nd percentile
c. The man whose waist circumference is 46 inches and hip circumference is 40
inches
d. The woman whose waist circumference is 30 inches and hip circumference is 38
inches
ANSWER: D
A
B
C
D
Feedback
Triceps skinfold is an estimate for total body fat, rather than risk. The expected
value is near the 50th percentile.
Triceps skinfold is an estimate for total body fat, rather than risk. The expected
value is near the 50th percentile.
This man’s waist-to-hip ratio is 1.15, which is higher than the 1.0 or less expected
value for a man.
This woman’s waist-to-hip ratio is 0.789, which is below 0.8, the expected value
for women.
DIF: Cognitive Level: Apply REF: 91
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Lifestyle Choices
18. A patient who has anorexia nervosa reports a healthy diet and no protein calorie malnutrition.
Which lab value best confirms this patient’s report?
a. Prealbumin
b. Serum albumin
c. Blood glucose
d. Serum cholesterol
ANSWER: A
Feedback
A Prealbumin is a reflection of protein and calorie intake for the previous 2 to 3
days.
B Serum albumin measures circulating protein. Albumin can be affected by a
number of factors, including fluid status, blood loss, liver function, and stress.
Fluctuation of albumin levels occurs over 3 to 4 weeks.
C Blood glucose measures can be affected by many factors such as stress, which
raises blood glucose levels, and is not a measure of protein calorie malnutrition.
D Serum cholesterol is part of the lipid profile, which provides data on fat
metabolism only, and is not a measure of protein calorie malnutrition.
DIF: Cognitive Level: Understand REF: 93
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Basic Care and Comfort: Nutrition and
Hydration
MULTIPLE RESPONSE
1. A nurse is assessing an 80-year-old patient who is cared for at home by his 79-year-old wife.
Which data indicate this patient has malnutrition? Select all that apply.
a. Body mass index (BMI) of 17
b. Waist-to-hip ratio of 1.0
c. Weight loss of 6% since last month’s visit
d. Prealbumin level of 16 mg/dl
e. Hematocrit level of 50%
f. Hemoglobin level of 20 g/dl
ANSWER: A, C, F
Correct: A BMI of 18.5 to 24.9 is the normal range, and this patient is below normal. Severe
weight loss is a more than 2% weight change over 1 week. The expected hemoglobin for a
man is 14 to 18 g/dl. These values may also indicate dehydration.
Incorrect: Waist-to-hip ratio of 1.0 is an expected value for men. The expected level for
prealbumin is 15 to 36 mg/dl. This hematocrit level is within normal limits.
DIF: Cognitive Level: Analyze REF: 86-87| 90| 93
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Basic Care and Comfort: Nutrition and
Hydration
COMPLETION
1. A man who is 6 feet 9 inches tall is told by his provider to lose weight so that he is closer to
his desired body weight. He asks the nurse, “How can I find out what my desired body weight
should be?” The nurse responds, “Let me show you how to calculate it. Your desired body
weight (DBW) should be lb.”
ANSWER:
232
6 feet 9 inches = 81 inches. DBW = 106 lb for the first 60 inches + 6 lb for every other inch,
which for this man equals 21 inches (81” – 60” = 21”). 21 6 = 126 +106 = 232 lb.
DIF: Cognitive Level: Apply REF: 90
TOP: Nursing Process: Implementation
MSC: NCLEX Patient Needs: Physiologic Integrity: Basic Care and Comfort: Nutrition and
Hydration
2. A woman who is 4 feet 11 inches tall is told by her provider to lose weight so that she is closer
to her desired body weight. She asks the nurse, “How can I find out what my desired body
weight should be?” The nurse responds, “Let me show you how to calculate it. Your desired
body weight (DBW) should be lb.”
ANSWER:
103.25
4 feet 11 inches = 59 inches. DBW = 105 lb for the 60 inches + 5 lb for every other inch.
However this woman is under 5 feet in height. Thus 105 lb/60 inches = 1.75 lb/inch. 1.75 59
inches = 103.25 lb.
DIF: Cognitive Level: Apply REF: 90
TOP: Nursing Process: Implementation
MSC: NCLEX Patient Needs: Physiologic Integrity: Basic Care and Comfort: Nutrition and
Hydration
3. A woman’s waist circumference is 32 inches and her hip circumference is 29 inches. Her
waist-to-hip ratio is .
ANSWER:
1.10
Calculate waist-to-hip by dividing waist measurement by the hip measurement, 32 inches/29 =
1.10.
DIF: Cognitive Level: Apply REF: 91
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Basic Care and Comfort: Nutrition and
Hydration
Chapter 9: Skin, Hair, and Nails
Test Bank
MULTIPLE CHOICE
1. A patient asks the nurse if it is possible to grow new skin. What is the nurse’s most
appropriate response?
a. “Even if new skin growth is required, the melanocytes do not regenerate.”
b. “The avascular epidermis sheds slowly and is replaced completely every 4 weeks.”
c. “The outer layer of skin remains the same over the lifetime except for repairing
injuries.”
d. “Epidermal regeneration is impossible because it is avascular.”
ANSWER: B
A
B
C
D
Feedback
Melanocytes are not involved in regeneration. They secrete melanin, which
provides pigment for the skin and hair and serves as a shield against ultraviolet
radiation.
Within this deepest layer of epidermis, active cell generation takes place. As cells
are produced, they push up the older cells toward the skin surface. The entire
process takes about 30 days.
The dead cells are continuously sloughed off and replaced by new cells moving
up from the underlying epidermal layers.
Within this deepest layer of epidermis, active cell generation takes place.
DIF: Cognitive Level: Understand REF: 98
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific
Assessments
2. A nurse assessing a patient with liver disease expects to find which manifestation during the
examination?
a. Yellowish color in the axilla and groin
b. Yellow pigmentation in the sclera
c. Very pale skin on the palms
d. Ashen-gray color in the oral mucous membranes
ANSWER: B
A
B
C
D
Feedback
Instead of the axilla and groin, assess the sclera of the eyes, fingernails, palms of
hands, and oral mucosa.
Jaundice is manifested by a yellowish color in the sclera of the eyes and palms of
the hands in both light- and dark-skinned patients.
Pale skin may indicate anemia, but not jaundice. Yellow color of the palms
indicates jaundice.
Ashen-gray color may be seen in dark-skinned patients who are cyanotic.
DIF: Cognitive Level: Apply REF: 98| 101
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body
Systems
3. How does the nurse recognize jaundice in a dark-skinned patient?
a. Inspect the conjunctiva for ashen-gray color.
b. Inspect the nail beds for a deeper brown or purple skin tone.
c. Inspect the palms and soles for yellowish-green color.
d. Inspect the oral mucous membrane for yellow color.
ANSWER: C
A
B
C
D
Feedback
Ashen-gray color may be seen in dark-skinned patients who are cyanotic.
Brown or purple tone is seen in dark-skinned patients with erythema.
In dark-skinned patients, jaundice manifests as a yellowish-green color that can
be seen most obviously in the sclera, palms of hands, and soles of feet.
Mucous membranes do not change color from jaundice.
DIF: Cognitive Level: Understand REF: 103, Table 9-1
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body
Systems
4. What signs of cyanosis does a nurse inspect for in a dark-skinned patient?
a. Ashen-gray color of the oral mucous membranes
b. Blue color in the nail beds
c. Ashen-blue color in the palms and soles
d. Blue-gray color in the ear lobes and lips
ANSWER: A
A
B
C
D
Feedback
Cyanosis is manifested by ashen-gray color of the oral mucous membranes and
nail beds in a dark-skinned patient.
An ashen-gray color of the nail beds is expected in a dark-skinned patient, rather
than blue.
An ashen-gray color of the oral mucous membranes and nail beds are expected in
a dark-skinned patient.
An ashen-gray color of the oral mucous membranes and nail beds are expected in
a dark-skinned patient.
DIF: Cognitive Level: Apply REF: 103, Table 9-1
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body
Systems
5. When the patient’s chart includes a notation that petechiae are present, what finding does a
nurse expect during inspection?
a. Purplish-red pinpoint lesions
b. Deep purplish or red patches of skin
c. Small raised fluid-filled pinkish nodules
d. Generalized reddish discoloration of an area of skin
ANSWER: A
A
B
C
D
Feedback
Purplish-red pinpoint lesions describes the appearance of petechiae.
Petechiae are pinpoints, not as large as a patch.
Petechiae are pinpoints, not raised as a nodule.
Petechiae are pinpoints, not generalized.
DIF: Cognitive Level: Understand REF: 103, Table 9-1| 117
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body
Systems
6. When performing a skin assessment of an adult patient, the nurse expects what finding?
a. Reddened area does not blanch when gentle pressure is applied
b. Indentation of the finger remains in the skin after palpation
c. Flaking or scaling of the skin
d. Return of skin to its original position when pinched up slightly
ANSWER: D
A
B
C
D
Feedback
This is an indication of a stage I pressure ulcer.
This is a description of edema.
This may be an indication of dry skin, systemic disease, or nutritional deficiency.
This is an assessment of skin turgor; skin should return to its original position.
DIF: Cognitive Level: Apply REF: 106
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Reduction of Risk Potential: System Specific Assessments
7. A nurse notices a patient’s nails are thin and depressed with the edges turned up. What
additional abnormal data should the nurse expect to find on this patient?
a. Pale conjunctiva
b. Jaundice
c. Ecchymosis
d. Rashes
ANSWER: A
A
B
C
D
Feedback
The abnormal nail finding was koilonychia, which occurs in patients with anemia
who frequently have pale conjunctiva.
Jaundice is due to increased serum bilirubin, indicating liver or gallbladder
disease, and does not create changes in nail structure.
Ecchymosis occurs after trauma to the blood vessel resulting in bleeding under
the tissue and does not cause changes in nail structure.
Rashes indicate an inflammation or allergic reaction that does cause changes in
the nails.
DIF: Cognitive Level: Analyze REF: 108
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body
Systems
8. A 45-year-old woman tells the nurse she is distressed by the presence of dark, coarse hair on
her face that has recently developed. What is the nurse’s most appropriate response to this
patient?
a. “This is simple vellus hair and it will decrease in amount over time.”
b. “Some women in your cultural group normally have dark hair on their faces.”
c. “This is unusual; female hair distribution should be limited to arms, legs, and
pubis.”
d. “Coarse dark hair could result from hormonal changes such as from menopause.”
ANSWER: D
A
B
C
D
Feedback
This response is not true. This example describes hirsutism, a condition
associated with an increase in the growth of facial, body, or pubic hair in women.
It does not decrease over time and the hair is not vellus.
Although it is true that women of some cultural groups normally have dark hair
on the face, women in these cultural groups have darker facial hair most of their
adult lives; the patient in this item has a new onset of hirsutism.
It is not true that female hair distribution should normally be limited to arms, legs,
and pubis. Women do have hair on their faces and other areas.
Coarse, dark hair on the face describes hirsutism, an increase in the growth of
facial, body, or pubic hair in women that can be associated with menopause or an
endocrine disorder.
DIF: Cognitive Level: Apply REF: 107
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body
Systems
9. What findings does a nurse expect when inspecting and palpating a patient’s nails?
a. A nail base angle of not more than 90 degrees
b. Whitish to clear nails in darker-skinned patients
c. Nail surface is smooth and rounded
d. Transverse depression running across the nails
ANSWER: C
A
B
C
D
Feedback
The expected angle of the nail base is 160 degrees.
Patients with darker-pigmented skin typically have nails that are yellow or brown,
and vertical banded lines may appear.
Nail surface that is smooth and rounded is an expected finding.
This is a description of Beau lines.
DIF: Cognitive Level: Apply REF: 107
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific
Assessments
10. A nurse notices that the angle of the patient’s proximal nail fold and the nail plate are almost a
flat line; about 160 degrees. How does the nurse interpret this finding?
a. This patient has chronic pulmonary disease.
b. This is an expected finding.
c. This is due to stress to the nails.
d. This is associated with anemia.
ANSWER: B
A
B
C
D
Feedback
This patient has chronic pulmonary disease, which causes clubbing (when the
angle of the nail base exceeds 180 degrees).
The expected angle of the nail base is 160 degrees.
This answer describes Beau lines, which appear as a groove or transverse
depression running across the nail. It results from a stressor that temporarily
impairs nail formation.
This is associated with anemia, which causes koilonychia, a thin, depressed nail
with the lateral edges turned upward.
DIF: Cognitive Level: Understand REF: 108-109
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific
Assessments
11. As a nurse is inspecting the nails of a patient with chronic hypoxemia and notices
enlargements of the ends of the fingers and angles of the nail base greater than a straight line
(exceeding 180 degrees). How does the nurse document these findings?
a. An expected finding
b. Koilonychia (spoon nail)
c. Clubbing
d. Leukonychia
ANSWER: C
A
B
C
D
Feedback
This is clubbing, which is not an expected finding.
Koilonychia is a thin, depressed nail with the lateral edges turned upward and is
associated with anemia.
Clubbing is present when the angle of the nail base exceeds 180 degrees. It is
caused by proliferation of the connective tissue resulting in an enlargement of the
distal fingers and is most commonly associated with chronic respiratory or
cardiovascular disease.
Leukonychia appears as white spots on the nail plate, usually caused by minor
trauma or manipulation of the cuticle.
DIF: Cognitive Level: Apply REF: 108-109
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body
Systems
12. While giving a history, a patient reports itching arms, legs, and chest after using a new soap.
What manifestations does the nurse expect to find on the arms, legs, and chest when
inspecting this patient’s skin?
a. Elevated irregularly shaped areas of edema of variable diameter
b. Elevated, firm, and rough lesions with flat surface greater than 1 cm in diameter
c. Elevated circumscribed superficial lesions less than 1 cm in diameter filled with
serous fluid
d. Elevated, firm circumscribed areas less than 1 cm in diameter
ANSWER: A
A
B
C
D
Feedback
This is a description of wheals, which occur as a result of allergic reactions.
This is a description of plaque.
This is a description of a vesicle.
This is a description of a papule.
DIF: Cognitive Level: Analyze REF: 112| 123-124
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body
Systems
13. While inspecting the skin, a nurse notices a lesion on the patient’s upper right arm. What is the
best way to document the size of this lesion?
a. Compare its size to the size of a coin.
b. Estimate its size to the nearest inch.
c. Use a centimeter ruler to measure the lesion.
d. Trace the lesion onto a piece of paper.
ANSWER: C
A
B
C
D
Feedback
Comparing its size to the size of a coin can be done if no measurement tool is
available, but the best way is to measure the lesion.
Estimating size to the nearest inch is not recommended due to inaccuracy.
A centimeter ruler to measure the size of lesions may be helpful. The lesion is
documented based on its characteristics, including location, distribution, color,
pattern, edges, flat or raised, and size.
Tracing the lesion onto a piece of paper can be done if no measurement tool is
available, but the best way is to measure the lesion.
DIF: Cognitive Level: Apply REF: 110-111, Box 9-2
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body
Systems
14. During shift report, a nurse learns that a patient has a macular rash. As the nurse inspects the
patient’s skin, what finding will confirm the rash?
a. Elevated, firm, well-defined lesions less than 1 cm in diameter
b. Depressed, firm, or scaly, rough lesions greater than 1 cm in diameter
c. Elevated, fluid-filled lesions less than 1 cm in diameter
d. Flat, well-defined, small lesions less than 1 cm in diameter
ANSWER: D
A
B
C
D
Feedback
Elevated, firm, well-defined lesions less than 1 cm in diameter is a description of
a papule.
Depressed, firm, or scaly, rough lesions greater than 1 cm in circumference is an
incorrect description.
Elevated, fluid-filled lesions less than 1 cm in diameter is a description of a
vesicle.
Flat, well-defined, small lesions less than 1 cm in diameter is a description of a
macule.
DIF: Cognitive Level: Apply REF: 111
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body
Systems
15. During inspection of a patient’s upper back, the nurse notices three small, elevated superficial
lesions filled with purulent fluid. How does the nurse document this finding?
a. As three cysts on the upper back
b. As several bullae on the back
c. As three pustules on the upper back
d. As three wheals on the upper back
ANSWER: C
A
B
C
D
Feedback
Cysts are elevated, circumscribed, encapsulated lesions.
Bullae are vesicles greater than 1 cm in diameter. This documentation is not
specific to the number or exact location.
Pustules are elevated, superficial lesions similar to vesicles but filled with
purulent fluid. This is a specific documentation of what the nurse saw (three
pustules) and their location (upper back).
Wheals are elevated irregular-shaped areas of cutaneous edema that are solid,
transient, and of variable diameter.
DIF: Cognitive Level: Understand REF: 113
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body
Systems
16. A nurse notices multiple lesions on a patient’s left hand that are 0.5 cm in width, elevated,
circumscribed, and filled with serous fluid. What kind of primary lesions are these?
a. Macules
b. Patches
c. Vesicles
d. Bullae
ANSWER: C
A
B
C
D
Feedback
Macules are flat, circumscribed areas that are a change in the color of the skin and
are less than 1 cm in diameter.
Patches are flat, nonpalpable, irregular-shaped macules greater than 1 cm in
diameter.
Vesicles are elevated, circumscribed, superficial (do not extend into dermis),
filled with serous fluid, and less than 1 cm in diameter. This documentation tells
the number and location of the lesions.
Bullae are large vesicles greater than 1 cm in diameter.
DIF: Cognitive Level: Understand REF: 113
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body
Systems
17. A nurse notices multiple lesions on the back of a patient’s left hand that are 0.5 cm in width,
elevated, circumscribed, and filled with serous fluid. How does the nurse document these
lesions?
a. As multiple macules on the dorsum of the left hand
b. As multiple vesicles on the dorsum of the left hand
c. As several patches on the left hand
d. As several bullae on the dorsum of the left hand
ANSWER: B
A
B
C
D
Feedback
Macules are flat, circumscribed areas that are a change in the color of the skin and
are less than 1 cm in diameter.
Vesicles are elevated, circumscribed, superficial (do not extend into dermis),
filled with serous fluid, and less than 1 cm in diameter. This documentation tells
the number and location of the lesions.
Patches are flat, nonpalpable, irregular-shaped macules greater than 1 cm in
diameter. This documentation does not include location of lesions.
Bullae are large vesicles greater than 1 cm in diameter.
DIF: Cognitive Level: Understand REF: 113
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body
Systems
18. A patient has come to the clinic complaining of a “bump” behind his right ear. Upon
inspection, the nurse notes a lesion that is elevated, solid, and 4 cm in diameter. What does the
nurse call this lesion when she reports her findings to the health care provider?
a. Tumor
b. Nodule
c. Keloid
d. Papule
ANSWER: A
A
B
C
D
Feedback
A tumor is an elevated and solid lesion, may or may not be clearly demarcated,
extends deeper in the dermis, and greater than 2 cm in diameter.
A nodule is an elevated, firm, circumscribed lesion that extends deeper into the
dermis than a papule and is 1 to 2 cm in diameter.
A keloid is an irregularly-shaped, elevated, progressively-enlarging scar that
grows beyond the boundaries of the wound.
A papule is an elevated, firm, circumscribed area less than 1 cm in diameter.
DIF: Cognitive Level: Understand REF: 112
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body
Systems
19. A nurse is inspecting the skin of a patient who has had skin problems after multiple piercings.
How will the nurse recognize the characteristics of keloids?
a. Roughened and thickened scales involving flexor surfaces
b. Hypertrophic scarring extending beyond the original wound edges
c. Thin, fibrous tissue replacing normal skin following injury
d. Loss of the epidermal layer, creating a hollowed-out or crusted area
ANSWER: B
A
B
C
D
Feedback
Roughened and thickened scales involving flexor surfaces is a description of
lichenification.
Hypertrophic scarring extending beyond the original wound edges is a description
of a keloid.
Thin, fibrous tissue replacing normal skin following injury is a description of a
scar.
Loss of the epidermal layer, creating a hollowed-out or crusted area is a
description of excoriation.
DIF: Cognitive Level: Understand REF: 114
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body
Systems
20. A patient reports the mole on the scalp has started itching and it bleeds when scratching it.
What other finding is a danger sign for pigmented skin lesions?
a. Symmetry of the lesion
b. Rounded border
c. Color variation
d. Size less than 6 mm wide
ANSWER: C
A
B
C
D
Feedback
Symmetry is an expected finding for moles. Asymmetric lesions are an early sign
of malignant melanoma.
A rounded border is an expected finding. A border that is poorly defined or
irregular is an early sign of malignant melanoma.
Uneven, variegated color is an early sign of malignant melanoma.
A size of less than 6 mm wide is an expected finding. A lesion greater than 6 mm
is an early sign of malignant melanoma.
DIF: Cognitive Level: Analyze REF: 111| 130
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body
Systems
21. A toddler patient has a small, slightly raised bright red area on the trunk. The child’s mother
reports that the lesion has been present since birth and has become a little larger. What type of
lesion does the nurse suspect?
a. Vascular nevi
b. Purpura
c. Ecchymosis
d. Cherry hemangioma is a benign tumor consisting of a mass of small blood vessels and can
vary in size. These are typically small, slightly raised lesions that are bright red in color
appearing on the face, neck and trunk of the body. These lesions increase in size with age.
ANSWER: D
A
B
C
D
Feedback
Vascular nevi is a type of angioma that involves the capillaries within the skin
producing an irregular macular patch that can vary from light red to dark red to
purple in color.
Purpura is a flat, reddish purple, nonblanchable discoloration in the skin greater
than 0.5 cm in diameter.
Ecchymosis is a reddish purple, nonblanchable spot of variable size.
Cherry hemangioma is a benign tumor consisting of a mass of small blood vessels
and can vary in size. These are typically small, slightly raised lesions that are
bright red in color appearing on the face, neck and trunk of the body. These
lesions increase in size with age.
DIF: Cognitive Level: Understand REF: 117-118
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body
Systems
22. A nurse notices several reddish purple, nonblanchable spots of different sizes on the arms and
legs of a patient with a low platelet count. How does the nurse distinguish ecchymosis from
purpura?
a. Ecchymosis is variable in size and a purpura is greater than 0.5 cm in diameter.
b. Ecchymosis does not blanch and purpura does blanch.
c. Ecchymosis has raised lesions and purpura has flat lesions.
d. Ecchymosis is irregularly shaped and purpura is round.
ANSWER: A
A
B
C
D
Feedback
Ecchymosis is variable in size and a purpura is greater than 0.5 cm in diameter.
This is an accurate statement.
Ecchymosis does not blanch and purpura does blanch. Both of these lesions are
nonblanchable.
Ecchymosis has raised lesions and purpura has flat lesions. Both of these lesions
are flat.
Ecchymosis is irregularly shaped and purpura is round. There is no specified
shape for either type of lesion.
DIF: Cognitive Level: Apply REF: 118, Table 9-4
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body
Systems
23. A patient is visiting an urgent care center after being hit in the back with a baseball. Upon
examination, the nurse notes a flat, nonblanchable spot 2.25 cm wide that is reddish-purple in
color. How does the nurse document this lesion?
a. As an angioma
b. As purpura
c. As petechiae
d. As ecchymosis
ANSWER: D
A
B
C
D
Feedback
An angioma is characterized by a small central red area with radiating spider-like
legs that blanches with pressure. The lesion of this patient does not blanch.
Purpura is flat, reddish purple, non-blanchable, and greater than 0.5 cm in size. It
is caused by infection or a bleeding disorder, not trauma.
Petechiae are tiny, flat, reddish-purple, non-blanchable spots in the skin less than
0.5 cm in diameter and appear as tiny red spots that are pinpoint to pinhead in
size.
Ecchymosis is reddish purple in color, nonblanchable and is caused by trauma
(being hit with a baseball) to the blood vessel which results in bleeding
underneath the skin. The size of the ecchymotic area varies depending on the
level of trauma.
DIF: Cognitive Level: Understand REF: 118
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body
Systems
24. A nurse is performing an admission physical examination on a patient who has been
bedridden for a month. The nurse notices a pressure ulcer on the patient’s left trochanter area
that involves partial-thickness skin loss with damage to the subcutaneous tissue. The nurse
reports this ulcer at what stage?
a. Stage I
b. Stage II
c. Stage III
d. Stage IV
ANSWER: B
A
B
C
D
Feedback
Stage I ulcers have persistent redness, but the epidermis is intact.
Stage II ulcers have partial-thickness skin loss of dermis. It appears as a shiny or
dry shallow open ulcer with pink wound bed without slough or bruising.
Stage III ulcers have full-thickness skin loss involving damage to or necrosis of
subcutaneous tissue that may extend to, but not through, underlying fascia.
Stage IV ulcers have full-thickness tissue loss with exposed bone, tendon, or
muscle. Slough or eschar may be within the wound bed.
DIF: Cognitive Level: Understand REF: 121-122
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body
Systems
25. A patient complains of itching on her feet. On inspection the nurse observes weeping vesicles
and skin that is softened and broken down between the toes? What explanation does the nurse
give the patient about the cause of this skin disorder?
a. “Your itching is caused by a bacterial infection.”
b. “Your itching is caused by an allergic reaction.”
c. “Your itching is caused by a viral infection.”
d. “Your itching is caused by a fungal infection.”
ANSWER: D
A
B
C
D
Feedback
Bacterial infections such as cellulitis cause redness, warmth, and tenderness,
rather than itching.
Allergic reactions such as contact dermatitis cause itching, but they appear as
localized erythema, and may also form edema, wheals, scales, or vesicles.
Viral infection such as herpes form grouped vesicles that are painful, rather than
itching.
This is a description of tinea pedia, which is caused by a number of dermophyte
fungal infections.
DIF: Cognitive Level: Analyze REF: 127
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body
Systems
26. A patient expresses concern that a new lesion may be melanoma. Which finding suggests a
malignant melanoma?
a. Nonblanching lesion
b. Irregular border
c. Diameter less than 5 mm
d. Black color of the lesion
ANSWER: B
A
B
C
D
Feedback
Blanching is not assessed in malignant skin lesions.
Irregular border or poorly defined border is an indication of a malignancy.
Diameter of a malignant skin lesion is usually greater than 6 mm.
Melanoma is a variety of colors.
DIF: Cognitive Level: Apply REF: 102| 129-130
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body
Systems
27. During a health fair, which recommendation is appropriate as a primary prevention measure to
reduce the risk for skin cancer?
a. Use a tanning booth instead of sunning outside if a tan is desired.
b. Wear protective clothing while in the sun.
c. Perform self-examination of skin monthly.
d. Use sunscreen with a sun protection except on overcast days.
ANSWER: B
A
B
C
D
Feedback
Avoiding tanning and sunning are part of primary prevention.
Wearing protective clothing while in the sun provides primary prevention for skin
cancer.
Performing self-examination of skin monthly is secondary prevention.
Sunscreen also needs to be used on overcast days.
DIF: Cognitive Level: Understand REF: 102
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Self-Care
28. A nurse notes that a 2-year-old child has multiple bruises over his body at different stages of
healing. What is the most appropriate action for the nurse at this time?
a. Obtain further data now to rule out abuse.
b. Remind parents that toddlers are clumsy and may fall, causing bruising.
c. Determine if this toddler has a coagulation disorder.
d. Recommend further observation at future visits.
ANSWER: A
A
B
C
D
Feedback
Further investigation is needed to rule out abuse. The important clue is bruises in
different stages in healing. Injuries to the skin are generally recognized in three
forms: bruises, bites, and burns.
Remind parents that toddlers are clumsy and may fall, causing bruising. The
important clue is bruises in different stages of healing.
A coagulation disorder can be ruled out by a laboratory test for platelets.
Recommend further observation at future visits. Action must be taken during this
visit if abuse is suspected.
DIF: Cognitive Level: Apply REF: 101| 118| 130-131
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body
Systems
MULTIPLE RESPONSE
1. What findings does the nurse expect when assessing skin, hair, and nails of a healthy male
adult? Select all that apply.
a. Transverse depression noticed across nails
b. Scalp is bald
c. Elevated, firm, circumscribed area less than 1 cm wide found on the fingers
d. Purpura and ecchymosis are noticed on arms and legs
e. Freckles are noted on face, back, arms, and legs
f. Skin turgor is elastic
ANSWER: B, E, F
Correct:Scalp is bald; freckles are noted on face, back, arms and legs; and skin turgor is
elastic . These are expected findings for a healthy adult male.
Incorrect: Transverse depression across the nails describes Beau lines. It results from a
stressor that temporarily impairs nail formation. An elevated, firm, circumscribed area, less
than 1 cm wide on the fingers describes a papule, such as a wart. Purpura and ecchymosis on
arms and legs are indications of bleeding.
DIF: Cognitive Level: Analyze REF: 106-107| 119
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific
Assessments
2. Which questions are appropriate to ask a patient when performing a symptom analysis for a
rash? Select all that apply.
a. “When did the rash first start?”
b. “Do you have a family history of rashes?”
c. “What makes the rash worse?”
d. “What do you do to make your rash better?”
e. “Describe the sensation from the rash, does it burn or itch?”
f. “Describe what the rash looked like initially.”
ANSWER: A, C, D, E, F
Correct: These are questions asked in a symptom analysis that includes the following
variables: onset of symptoms, location and duration of symptoms, characteristics, severity of
symptoms, related symptoms, alleviating factors, aggravating factors, and attempts at selftreatment.
Incorrect: This question relates to the patient’s history.
DIF: Cognitive Level: Analyze REF: 100
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body
Systems
Chapter 10: Head, Eyes, Ears, Nose, and Throat
Test Bank
MULTIPLE CHOICE
1. A patient is admitted with edema of the occipital lobe following a head injury. The nurse
correlates which finding with damage to this area?
a. Ipsilateral ptosis
b. Impaired vision
c. Pupillary constriction
d. Increased intraocular pressure
ANSWER: B
A
B
C
D
Feedback
Ipsilateral ptosis (drooping of the eye lid) is controlled by the oculomotor cranial
nerve (CN III) that is located in the midbrain. The nurse must correlate anatomy
with function and assessment.
The occipital lobe contains the visual context.
Pupillary constriction is controlled by the oculomotor cranial nerve (CN III) that
is located in the midbrain.
This abnormality is associated with glaucoma rather than injury to the occipital
lobe.
DIF: Cognitive Level: Analyze REF: 138
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
2. The nurse is taking a health history on a patient who reports frequent stabbing headaches
occurring once a day lasting about an hour. Which statement by the patient is most indicative
of cluster headaches?
a. “I usually have nausea and vomiting with my headaches.”
b. “My whole head is constantly throbbing.”
c. “It feels like my head is in a vice.”
d. “The pain is on the left side over my eye, forehead, and cheek.”
ANSWER: D
A
B
C
D
Feedback
This is descriptive of migraines rather than cluster headaches.
This is descriptive of migraines rather than cluster headaches.
This is descriptive of tension rather than cluster headaches.
This description is consistent with cluster headaches.
DIF: Cognitive Level: Apply REF: 144
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
3. A patient reports having migraine headaches on one side of the head that often start with an
aura and last 1 to 3 days. As a part of the symptom analysis, the patient reports which
associated symptoms of migraine headaches?
a. Nausea, vomiting, or visual disturbances
b. Nasal stuffiness or discharge
c. Ringing in the ears or dizziness
d. Red, watery eyes or drooping eyelids
ANSWER: A
A
B
C
D
Feedback
These are symptoms associated with migraine headaches.
This is a symptom associated with cluster headaches rather than migraine
headaches.
These symptoms are not associated with migraine headaches.
These are symptoms associated with cluster headaches rather than migraine
headaches.
DIF: Cognitive Level: Analyze REF: 144
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
4. The nurse is taking a health history on a patient who reports frequent headaches with pain in
the front of the head, but sometimes felt in the back of the head. Which statement by the
patient is most indicative of tension headaches?
a. “I usually have nausea and vomiting with my headaches.”
b. “My whole head is constantly throbbing.”
c. “It feels like my head is in a vice.”
d. “The pain is on the left side over my eye, forehead, and cheek.”
ANSWER: C
A
B
C
D
Feedback
This is descriptive of migraines rather than tension headaches.
This is descriptive of migraines rather than tension headaches.
This is descriptive of tension headaches, which is consistent with the rest of the
data reported by the patient.
This is consistent with cluster headaches rather than tension headaches.
DIF: Cognitive Level: Apply REF: 144
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
5. During symptom analysis, the nurse helps the patient distinguish between dizziness and
vertigo. Which description by the patient indicates vertigo?
a. “I felt faint, like I was going to pass out.”
b. “I just could not keep my balance when I sat up.”
c. “It seemed that the room was spinning around.”
d. “I was afraid that I was going to lose consciousness.”
ANSWER: C
A
B
C
D
Feedback
This is a description of lightheadedness, a form of dizziness.
This is a description of disequilibrium, a form of dizziness.
This is consistent with vertigo because it includes a sensation of motion.
This is a description of syncope, a form of dizziness.
DIF: Cognitive Level: Analyze REF: 144
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
6. During symptom analysis, the nurse helps the patient distinguish between dizziness and
vertigo. Which description by the patient indicates dizziness?
a. “I felt faint, like I was going to pass out.”
b. “It felt like I was on a merry-go-round.”
c. “The room seemed to be spinning around.”
d. “My body felt like it was revolving and could not stop.”
ANSWER: A
A
B
C
D
Feedback
This is a description of lightheadedness, a form of dizziness.
This is consistent with objective vertigo because it includes a sensation of motion.
This is consistent with objective vertigo because it includes a sensation of motion.
This is consistent with subjective vertigo because it includes a sensation of one’s
body rotating in space.
DIF: Cognitive Level: Analyze REF: 144-145
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
7. Which patient in the eye clinic should the nurse assess first?
a. The patient who reports a gradual clouding of vision
b. The patient who complains of sudden loss of vision
c. The patient who complains of double vision
d. The patient who complains of poor night vision
ANSWER: B
A
B
C
D
Feedback
A gradual clouding of vision is a symptom of cataracts that develop slowly and do
not require immediate assessment.
Sudden vision loss may indicate a detached retina and requires immediate
referral.
Double vision is a symptom of cataracts that develop slowly and do not require
immediate assessment.
Poor night vision is a symptom of cataracts that develop slowly and do not
require immediate assessment.
DIF: Cognitive Level: Apply REF: 144-145
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
8. A patient complains of right ear pain. What findings does the nurse anticipate on inspecting
the patient’s ears?
a. Redness and edema of the pinna of the right ear
b. Report of pain when the nurse manipulates the right ear
c. Bulging and red tympanic membrane in the right ear
d. Increased cerumen in the right ear canal
ANSWER: C
A
B
C
D
Feedback
Redness and edema of the pinna of the right ear is consistent with external ear
pain that may be associated with otitis externa or swimmer’s ear.
Report of pain when the nurse manipulates the right ear is consistent with
external ear pain that may be associated with otitis externa or swimmer’s ear.
Bulging and red tympanic membrane in the right ear is consistent with internal
ear pain that may be associated with otitis media.
Increased cerumen in the right ear canal is not consistent with internal ear pain.
DIF: Cognitive Level: Apply REF: 145| 165
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
9. During the history, a patient reports watery nasal drainage from allergies. Based on this
information, what does the nurse expect to find on inspection of the nares?
a. Enlarged and pale turbinates
b. Polyps within the nares
c. High vascularity of the turbinates
d. Dry and dull turbinates
ANSWER: A
A
B
C
D
Feedback
Enlarged and pale turbinates are expected findings for allergic rhinitis.
Polyps within the nares is not an expected finding.
High vascularity of the turbinates is not an expected finding.
Dry and dull turbinates is not an expected finding.
DIF: Cognitive Level: Apply REF: 145-146| 186
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
10. A patient complains of nasal drainage and sinus headache. The nurse suspects a nasal
infection and anticipates observing which finding during examination?
a. Foul-smelling drainage
b. Purulent green-yellow drainage
c. Bloody drainage
d. Watery drainage
ANSWER: B
A
B
C
D
Feedback
Foul-smelling drainage is consistent with a foreign object in the nose.
Purulent green-yellow drainage is consistent with a nasal or sinus infection.
Bloody drainage is consistent with trauma to the nose.
Watery drainage is consistent with a nasal allergy.
DIF: Cognitive Level: Apply REF: 145
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
11. A patient complains of itching, swelling, and drainage from the eyes with a postnasal drip and
sneezing. What type of nasal drainage does the nurse anticipate seeing during inspection of
this patient’s nares?
a. Clear
b. Malodorous
c. Yellow
d. Green
ANSWER: A
A
B
C
D
Feedback
The patient has allergic rhinitis, which produces clear drainage.
Malodorous drainage is associated with bacterial infection, which is not
consistent with the history given by this patient.
Yellow drainage is associated with bacterial infection, which is not consistent
with the history given by this patient.
Green drainage is associated with bacterial infection, which is not consistent with
the history given by this patient.
DIF: Cognitive Level: Apply REF: 145
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
12. A patient reports a history of snorting cocaine and is concerned about his bloody nasal
drainage. What does the nurse expect to see on inspection of his nose?
a. Deviated septum
b. Pale turbinates
c. Perforated nasal septum
d. Localized erythema and edema
ANSWER: C
A
B
C
D
Feedback
Deviated septum may be from birth or trauma to the nose, but not from cocaine
use.
Pale turbinates are an indication of allergies.
Perforated nasal septum develops from cocaine use.
Localized erythema and edema are nonspecific and indicate inflammation
somewhere in the nose.
DIF: Cognitive Level: Apply REF: 170
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
13. While taking a history, the nurse observes that the patient’s facial cranial nerves (CN VII) are
intact based on which behaviors of the patient?
a. The patient’s eyes move to the left, right, up, down, and obliquely during
conversation.
b. The patient moistens the lips with the tongue.
c. The sides of the mouth are symmetric when the patient smiles.
d. The patient’s eyelids blink periodically.
ANSWER: C
A
B
C
D
Feedback
This represents movement of the extraocular muscles, which are controlled by the
oculomotor, trochlear, and abducens cranial nerves (CN III, IV, and VI,
respectively).
This represents movement of the tongue, which is controlled by the hypoglossal
cranial nerve (CN XII).
This represents facial symmetry, which is controlled by the facial cranial nerve
(CN VII).
This represents function of the oculomotor cranial nerve (CN III).
DIF: Cognitive Level: Apply REF: 137| 171
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific
Assessments
14. To assess jaw movement of an adult patient, the nurse uses which technique?
a. Asking the patient to open the mouth and then passively moving the patient’s open
jaw from side to side
b. Placing two fingers in front of each ear and asking the patient to slowly open and
close the mouth
c. Asking the patient to open the mouth and to resist the nurse’s attempt to close the
mouth
d. Using the pads of all fingers to feel along the mandible for tenderness and nodules
ANSWER: B
A
B
C
D
Feedback
The patient’s jaw movement should be active, not passive.
This is the correct technique for palpating the jaw.
This technique assesses strength of the jaw, which is not typically evaluated.
Palpating under the middle of the mandible may reveal the submental lymph
node.
DIF: Cognitive Level: Apply REF: 149
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
15. The nurse palpates the patient’s jaw movement, placing two fingers in front of each ear and
asking the patient to slowly open and close the mouth. What additional request does the nurse
ask the patient to do to assess the jaw?
a. Clinch the jaws together as tightly as possible.
b. Move the lower jaw from side to side.
c. Open the mouth as wide as possible, like a yawn.
d. Move the lower jaw forward and backward several times.
ANSWER: B
A
B
C
D
Feedback
This is not an assessment technique for the jaw.
This is the technique to complete assessment of the motion of the jaw.
This was completed when the nurse asked the patient to open and close the
mouth.
This is not an assessment technique for the jaw.
DIF: Cognitive Level: Apply REF: 149
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
16. A patient is in a sitting position as the nurse palpates the temporal arteries and feels smooth,
bilateral pulsations. What is the appropriate action for the nurse at this time?
a. Auscultate the temporal arteries for bruits.
b. Palpate the arteries with the patient in supine position.
c. Document this as an expected finding.
d. Measure the patient’s blood pressure.
ANSWER: C
A
B
C
D
Feedback
This is not necessary for this patient at this time.
This is not necessary for this patient at this time.
These are consistent with expected assessment.
This will be done as a part of the assessment, but does not relate to the expected
palpation of this patient’s temporal arteries.
DIF: Cognitive Level: Apply REF: 149
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific
Assessments
17. What instructions does the nurse give the patient before using the Snellen visual acuity chart?
a. “Remove your eyeglasses before attempting to read the lowest line.”
b. “Stand 10 feet from the chart and read the first line aloud.”
c. “Hold a white card over one eye and read the smallest possible line.”
d. “Squint if necessary to improve the ability to read the largest letters.”
ANSWER: C
A
B
C
D
Feedback
Patients should wear their glasses when visual acuity is tested.
The patient should stand 20 feet from the Snellen chart.
This is the appropriate technique for using the Snellen chart.
The patient should not squint to see the chart.
DIF: Cognitive Level: Understand REF: 149
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
18. Which cranial nerve is assessed by using the Snellen visual acuity chart?
a. Optic cranial nerve (CN II)
b. Oculomotor cranial nerve (CN III)
c. Abducens cranial nerve (CN IV)
d. Trochlear cranial nerve (CN VI)
ANSWER: A
A
B
C
D
Feedback
The optic cranial nerve (CN II) provides vision tested by the Snellen visual acuity
chart.
CN III controls pupillary constriction, eyelid movement, and eyeball movement.
CN IV controls eyeball movement.
CN VI controls eyeball movement.
DIF: Cognitive Level: Apply REF: 138| 150
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific
Assessments
19. Which finding on assessment of a patient’s eyes should the nurse document as abnormal?
a. An Asian American patient with an upward slant to the palpebral fissure
b. A Caucasian American patient whose sclerae are visible between the upper and
lower lids and the iris
c. An African American patient who has off-white sclerae with tiny black dots of
pigmentation near the limbus
d. An American Indian patient whose pupillary diameters are 5 mm bilaterally
ANSWER: B
A
B
C
D
Feedback
An Asian American patient with an upward slant to the palpebral fissure has an
expected racial variation.
A Caucasian American patient whose sclerae are visible between the upper and
lower lids and the iris has eyeball protrusion beyond the supraorbital ridge, which
indicates exophthalmos caused by hyperthyroidism.
An African American patient who has off-white sclerae with tiny black dots of
pigmentation near the limbus has an expected racial variation.
An American Indian whose pupils are 5 mm bilaterally is an expected finding.
DIF: Cognitive Level: Understand REF: 151
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
20. A nurse shines a light toward the bridge of the patient’s nose and notices that the light
reflection in the right cornea is at the 9 o’clock position and in the left cornea at the 9 o’clock
position. What is the interpretation of this finding?
a. The extraocular muscles of both eyes are intact.
b. The cornea of each eye is transparent.
c. The sclera of each eye is clear.
d. The consensual reaction of both eyes is intact.
ANSWER: A
A
B
C
D
Feedback
The reflection of the light in both eyes in the same location indicates muscles
holding the eyes are symmetric.
The reflection of the light in both eyes in the same location indicates muscles
holding the eyes are symmetric.
The reflection of the light in both eyes in the same location indicates muscles
holding the eyes are symmetric.
Consensual reaction involves constriction of pupils.
DIF: Cognitive Level: Apply REF: 153
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
21. How does a nurse assess movements of the eyes?
a. By assessing peripheral vision
b. By noting the symmetry of the corneal light reflex
c. By assessing the cardinal fields of gaze
d. By performing the cover-uncover test
ANSWER: C
A
B
Feedback
This tests the function of cranial nerve I (optic).
This indicates symmetry of eye muscles.
C
D
This tests the movement of the eye in all directions, which assesses the functions
of the cranial nerves III (oculomotor), IV (abducens), and VI (trochlear).
This is performed after the corneal light reflex is abnormal, indicating asymmetric
eye muscles.
DIF: Cognitive Level: Understand REF: 154-156
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
22. On inspection of the external eye structures of an African American patient, the nurse notices
the sclerae are not white, but appear a darker shade with tiny black dots of pigmentation near
the limbus. How does the nurse document this finding?
a. As an indication of a type of anemia
b. As a hordeolum or sty
c. As jaundice
d. As an expected racial variation
ANSWER: D
A
B
C
D
Feedback
This may cause a pale conjunctiva.
This is an acute infection originating in the sebaceous gland of the eyelid.
Jaundice is a yellow color of the sclera associated with liver or gallbladder
disease.
This as an expected racial variation.
DIF: Cognitive Level: Remember REF: 153
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific
Assessments
23. A nurse shines a light in the right pupil to test constriction and notices that the left pupil
constricts as well. Based on these data, the nurse should take what action?
a. Document this finding as an abnormal finding.
b. Assess the patient for accommodation.
c. Document this finding as a consensual reaction.
d. Assess the patient’s corneal light reflex.
ANSWER: C
A
B
C
D
Feedback
This is a description of an expected finding—consensual reaction.
Accommodation is not assessed in response to consensual reaction; it tests the
function of the oculomotor cranial nerve (CN III).
This is a description of expected consensual reaction.
This item describes a consensual reaction rather than a corneal light reflex.
DIF: Cognitive Level: Apply REF: 154
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific
Assessments
24. When inspecting a patient’s eyes, the nurse assesses the presence of cranial nerve III
(oculomotor nerve) by observing the eyelids open and close bilaterally. What other technique
does a nurse use to test the function of this cranial nerve?
a. Pupillary constriction to light
b. Visual acuity
c. Peripheral vision
d. Presence of the red reflex
ANSWER: A
A
B
C
D
Feedback
Cranial nerve III (oculomotor) controls pupillary dilation and constriction, as well
as eyelid movement. Pupil dilation and ptosis may occur when CN III is
impaired.
Cranial nerve II (optic) provides vision.
Cranial nerve II (optic) provides peripheral vision.
The red reflex is not controlled by cranial nerve III, but is created by a light
illuminating the retina.
DIF: Cognitive Level: Apply REF: 154
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific
Assessments
25. How does a nurse recognize normal accommodation?
a. The patient has peripheral vision of 90 degrees left and right.
b. The patient’s eyes move up and down, side to side, and obliquely.
c. The right pupil constricts when a light is shown in the left pupil.
d. The patient’s pupils dilate when looking toward a distant object.
ANSWER: D
Feedback
A Normally a patient has 90 degrees peripheral vision temporally, but only 60
degrees nasally.
B This is an expected finding, but is not a test for accommodation. It is a test of
extraocular muscle function in the six cardinal fields of gaze.
C This is an expected finding for consensual reaction, rather than accommodation.
D This is an indication of accommodation.
DIF: Cognitive Level: Understand REF: 154
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific
Assessments
26. How does a nurse recognize a patient’s mydriasis?
a. The lens of each of the patient’s eyes is opaque.
b. There is involuntary rhythmical, horizontal movement of the patient’s eyes.
c. There is a white opaque ring encircling the patient’s limbus.
d. The patient’s pupils are 7 mm and do not constrict.
ANSWER: D
A
B
C
D
Feedback
An opaque lens is an abnormality that occurs when cataracts are present.
An involuntary rhythmical, horizontal movement of the patient’s eyes is a
description of nystagmus.
A white opaque ring encircling the patient’s limbus is a description of corneal
arcus seen in patients older than 60 years of age.
Mydriasis is pupil size greater than 6 mm and the pupil fails to constrict.
DIF: Cognitive Level: Understand REF: 154
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
27. A nurse uses which technique to assess a patient’s peripheral vision?
a. The nurse asks the patient to keep the head still and by moving the eyes only,
follow the nurse’s finger as it moves side to side, up and down, and obliquely.
b. The nurse covers one of the patient’s eyes with a card and observes the uncovered
eye for movement, then removes the card and observes the just uncovered eye for
movement.
c. With the patient and nurse facing each other and a card covering their
corresponding eyes, the nurse moves an object into the visual field and the patient
reports when the object is seen.
d. The nurse shines a light on both corneas at the same time and notes the location of
the reflection in each eye.
ANSWER: C
A
B
C
D
Feedback
This technique tests extraocular muscle symmetry.
This cover-uncover technique is performed when the corneal light reflex is
asymmetric.
This is the confrontation test that tests peripheral vision.
This describes the corneal light reflex that tests the symmetry of the eye muscles.
DIF: Cognitive Level: Apply REF: 150
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
28. During an eye assessment, a nurse asks the patient to cover one eye with a card as the nurse
covers his or her eye directly opposite the patient’s covered eye. The nurse moves an object
into the field of vision and asks the patient to tell when the object can be seen. This
assessment technique collects what data about the patient’s eyes?
a. Symmetry of extraocular muscles
b. Visual acuity in the uncovered eye
c. Peripheral vision of the uncovered eye
d. Consensual reaction of the uncovered eye
ANSWER: C
A
B
C
D
Feedback
Symmetry is tested by the corneal light reflex.
Visual acuity is tested using the Snellen chart.
This describes the confrontation test, which assesses peripheral vision.
Consensual reaction is tested by noticing the pupillary constriction of one eye
when a light is being shown into the other eye.
DIF: Cognitive Level: Apply REF: 156
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
29. During an eye examination of an Asian patient, a nurse notices an involuntary rhythmical,
horizontal movement of the patient’s eyes. How does a nurse document this finding?
a. An expected racial variation
b. Nystagmus
c. Exophthalmus
d. Myopia
ANSWER: B
A
B
C
D
Feedback
This is not a racial variation.
An involuntary rhythmical, horizontal movement of the patient’s eyes is a
description of nystagmus.
Exophthalmus is the bulging of the eyeball forward, seen in patients with
hyperthyroidism.
Myopia is an elongated eyeball found in patients who are nearsighted.
DIF: Cognitive Level: Understand REF: 156
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
30. A nurse shines a light toward the bridge of the patient’s nose and notices that the light
reflection in the right cornea is at the 2 o’clock position and in the left cornea at the 10 o’clock
position. Based on these data, the nurse should take what action?
a. Document these findings as normal.
b. Perform the cover-uncover test.
c. Perform the confrontation test.
d. Document these findings as abnormal.
ANSWER: B
A
B
Feedback
The findings are abnormal. The light should appear in the same location in each
cornea.
The nurse is performing the corneal light reflex test and the findings are
abnormal. Thus, when the corneal light reflex is asymmetric, the cover-uncover
C
D
test is performed to determine which eye has the weak extraocular muscle(s).
The confrontation test is used to assess peripheral visual fields and is not
appropriate to perform when the corneal light reflex is asymmetric.
The asymmetric corneal light reflex is abnormal, but the cover-uncover test
should follow the abnormal finding to determine which eye has the weak
extraocular muscle(s).
DIF: Cognitive Level: Analyze REF: 153
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
31. During the history, a patient reports blurred vision, seeing double at times, and a glare from
headlights from oncoming cars at night. Based on this information, what finding does the
nurse expect to find on assessment of this patient’s eyes?
a. Anterior chamber depth is shallow.
b. Red reflex is absent.
c. Extraocular muscle movement is asymmetric.
d. Retinal arteries are wider than retinal veins.
ANSWER: B
A
B
C
D
Feedback
Shallow anterior chamber depth occurs in glaucoma.
The symptoms suggest cataracts. The red reflex cannot be seen because the light
cannot penetrate the opacity of the lens.
Extraocular muscle movement is asymmetric. Cataracts affect the lens rather than
the eye muscles.
Retinal arteries are wider than retinal veins. Cataracts affect the lens rather than
the retinal vessels.
DIF: Cognitive Level: Analyze REF: 158| 184
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
32. What changes in using the ophthalmoscope should the nurse need to make when inspecting
the eye of a patient who is nearsighted?
a. Holding the ophthalmoscope in the right hand when inspecting the patient’s right
eye
b. Using the grid light of the lens aperture to visualize the internal structures of the
eye
c. Rotating the diopter to the red (minus) numbers
d. Asking the patient to look directly into the ophthalmoscope light
ANSWER: C
A
B
C
Feedback
This procedure is performed with all patients having an internal eye examination.
The grid is used to estimate the size of lesions.
This compensates for the longer eyeball of a myopic patient.
D
This is an instruction given to the patient to visualize the macula.
DIF: Cognitive Level: Apply REF: 158
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
33. After seeing the red reflex and retinal vessels through the ophthalmoscope, how does the
nurse locate the optic disc?
a. By rotating the diopter to the block (positive) numbers until the optic disc comes
into focus
b. By following the retinal vessels inward toward the nose until optic disc is seen
c. By using the green beam light while looking outward toward the ear until the disc
is seen
d. By locating the macula and then looking temporally (toward the ear) until the disc
is seen
ANSWER: B
A
B
C
D
Feedback
This procedure is used for patients who are myopic.
This procedure locates the optic disc.
The green beam is used to identify retinal hemorrhages.
The macula lies temporal to the optic disc; thus the optic disc is in the opposite
direction.
DIF: Cognitive Level: Apply REF: 158-159
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
34. When using an ophthalmoscope to examine the internal eye, how does the nurse distinguish
the retinal arteries from the retinal veins?
a. The arteries are narrower than veins.
b. The arteries are a darker red than veins.
c. The arteries have no light reflex and the veins have a narrow band of light in the
center.
d. The arteries have prominent pulsations and veins have no pulsations.
ANSWER: A
Feedback
A The artery-to-vein width should be 2:3 to 4:5.
B Arteries are lighter red than veins.
C Arteries have a narrow band of light in the center and veins have no light reflex.
D Arteries show little to no pulsations and venous pulsations may be visible.
DIF: Cognitive Level: Understand REF: 159
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
35. Which finding warrants a referral for additional evaluation?
a. Earlobes hanging freely from the base of the pinna
b. Ears having painless nodules less than 1 cm in diameter at the helix
c. Ears measuring 8 cm in length
d. Pinna is 20 degrees lower than the outer canthus of the eye
ANSWER: D
A
B
C
D
Feedback
Earlobes hanging freely from the base of the pinna is an expected finding.
This is called a Darwin tubercle. It is a normal deviation and may be noted at the
helix of the ear.
A length of 8 cm is an expected finding.
The pinna of the ear should align directly with the outer canthus of the eye and be
angled no more than 10 degrees from a vertical position.
DIF: Cognitive Level: Apply REF: 160
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
36. A nurse is assessing a patient who was hit at the base of the skull with a blunt instrument
causing a skull fracture. What assessment finding does this nurse anticipate during the
inspection?
a. Tinnitus, vertigo, and dizziness
b. Clear drainage from the ear and nose
c. Loss of hearing and smell
d. Purulent drainage from the ear and bloody drainage from the nose
ANSWER: B
A
B
C
D
Feedback
These are subjective and gathered during the history rather than inspection.
Although the patient may report having dizziness or vertigo, the finding of
tinnitus is inconsistent with a basilar skull fracture.
This may occur after a basilar skull fracture. The clear drainage may be
cerebrospinal fluid.
This is inconsistent with a basilar skull fracture.
Purulent drainage is inconsistent with a basilar skull fracture, and bloody drainage
usually does not come from the nose, but may be seen from the ear.
DIF: Cognitive Level: Analyze REF: 162
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
37. An adult patient comes to the clinic complaining of right ear pain. What technique does the
nurse use to inspect this patient’s auditory canal?
a. Position the otoscope speculum 1.0 to 1.5 cm (about 0.5 inches) into the ear canal.
b. Remove cerumen from each canal before inserting otoscope.
c. Choose the smallest otoscope speculum that will fit the patient’s ear comfortably.
d. Pull the pinna slightly downward and backward before inserting the otoscope
speculum.
ANSWER: A
A
B
C
D
Feedback
This is the correct technique.
Removing cerumen is not necessary.
The largest speculum that comfortably fits in the ear canal is the one that should
be chosen.
For adults, the pinna is pulled up and backward to straighten the ear canal.
DIF: Cognitive Level: Apply REF: 162
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
38. A nurse examines a patient’s auditory canal and tympanic membrane with an otoscope and
observes which finding as normal?
a. Clear fluid lining the auditory canal
b. A firm tympanic membrane without fluctuation with puffs of air
c. A small hole within the cone of light
d. A shiny, translucent tympanic membrane
ANSWER: D
A
B
C
D
Feedback
Clear fluid or bloody drainage following a head injury may indicate a basilar
skull fracture.
An expected response is that the tympanic membrane slightly fluctuates with
puffs of air.
A cone of light is expected, but a hole indicates perforation.
A shiny, translucent tympanic membrane is an expected finding.
DIF: Cognitive Level: Apply REF: 164
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
39. A nurse observes a student using the whisper test to screen a patient with hearing loss. Which
behavior by the student requires a corrective comment from the nurse?
a. Instructing the patient to cover the ear not being tested
b. Standing beside the patient on the side of the ear being tested
c. Shielding the mouth to prevent the patient from reading lips
d. Whispering one or two syllable words and ask the patient to repeat what is heard
ANSWER: B
A
B
Feedback
This is the correct technique.
The student nurse should stand 1 to 2 feet in front or to the side of the patient.
C
D
This is the correct technique.
This is the correct technique.
DIF: Cognitive Level: Apply REF: 165
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
40. A nurse reads in the history that a patient has a new onset of acute otitis media. Based on this
information, how does the nurse expect this patient’s tympanic membrane to appear?
a. Dull
b. Shiny
c. Red
d. Blue to deep red
ANSWER: C
A
B
C
D
Feedback
This indicates fibrosis or scarring.
This is normal for the tympanic membrane.
This indicates infection in the middle ear, such as otitis media.
This indicates blood behind the tympanic membrane, which may have occurred
secondary to injury.
DIF: Cognitive Level: Apply REF: 145| 163
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
41. During the Rinne test, a nurse determines that the patient hears the tuning fork held on the
mastoid process for 15 seconds and hears the tuning fork held in front of the ear for 30
seconds. The same results are found in both ears. Based on this finding, what is the most
appropriate response of the nurse?
a. Repeat the test again using a 2000 Hz tuning fork.
b. Tell the patient that this represents an expected finding.
c. Refer the patient for additional testing to detect hearing abnormality.
d. Perform a Weber test to confirm the findings of the Rinne test.
ANSWER: B
A
B
C
D
Feedback
This is unnecessary because the finding of the Rinne test was normal.
This is a normal finding. Air conduction (30 seconds) is twice as long as bone
conduction (15 seconds).
This is unnecessary because the finding of the Rinne test was normal.
This is unnecessary because the finding of the Rinne test was normal.
DIF: Cognitive Level: Analyze REF: 166
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific
Assessments
42. During a Weber test, a patient with right ear hearing loss reports hearing sound longer in the
right ear than the left ear. What results should the nurse expect to find from this patient during
a Rinne test?
a. Air conduction will be twice as long as bone conduction (2:1 ratio).
b. Air conduction will be 1.5 times as long as bone conduction (1.5:1 ratio).
c. Bone conduction will be longer than air conduction.
d. Bone conduction will be equal to air conduction.
ANSWER: C
A
B
C
D
Feedback
This is an expected finding.
This finding is consistent with a sensorineural hearing loss, but this patient has a
conduction hearing loss based on the results of the Weber test.
This finding from the Rinne test indicates a conduction hearing loss, which is
consistent with the finding from the Weber test described in the question.
This finding is not consistent with the conductive hearing loss described.
DIF: Cognitive Level: Analyze REF: 166
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
43. Which finding indicates that this patient has a sensorineural hearing loss?
a. The patient hears sound by air conduction longer than by bone conduction.
b. The patient hears sound from a vibrating tuning fork in the affected ear only.
c. The patient hears normal conversation at 40 dB and a whisper at 20 dB.
d. The patient hears the rubbing of fingers together from a distance of 4 inches from
each ear.
ANSWER: A
A
B
C
D
Feedback
In the Rinne test, hearing sound from a vibrating tuning fork longer by air
conduction than by bone conduction is consistent with a sensorineural hearing
loss.
This finding from the Weber test is consistent with a conduction hearing loss.
This is an expected finding using audiometry.
This is an expected finding using the finger rubbing screening hearing test.
DIF: Cognitive Level: Apply REF: 166
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
44. How does the nurse perform a Weber test to assess hearing function?
a. Whispers three to four words into the patient’s ear and asks him to repeat the words
heard
b. Places a vibrating tuning fork in the middle of the head and asks the patient if the
sound is heard the same in both ears
c. Places a set of headphones over both ears, plays several tones, and asks the patient
to identify the sounds
d. Places a vibrating tuning fork on the mastoid process and asks the patient to signal
when he can no longer hear the sound
ANSWER: B
A
B
C
D
Feedback
This technique describes the whisper test.
This technique describes the Weber test.
This technique describes the use of an audiometer.
This technique describes part of the Rinne test.
DIF: Cognitive Level: Apply REF: 166
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
45. How does the nurse perform a Rinne test of hearing function?
a. Whispers several words to the patient and requests that the patient repeat the words
heard
b. Places a vibrating tuning fork in the middle of the head and asks the patient if the
sound is heard the same in both ears or if it is louder in one ear than the other
c. Places a set of headphones over both ears, plays several tones, and asks the patient
to identify the sounds
d. Places a vibrating tuning fork on the mastoid process until the patient no longer
hears it, and then moves it in front of the ear until the patient no longer hears it
ANSWER: D
A
B
C
D
Feedback
This technique describes the whisper test.
This technique describes the Weber test.
This technique describes the use of an audiometer.
This technique describes the Rinne test.
DIF: Cognitive Level: Apply REF: 167
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
46. A nurse assessing the hearing of a patient with presbycusis expects which finding on a test for
hearing?
a. Bone conduction will be longer than air conduction on the Rinne test (BC > AC).
b. Air conduction will be longer than bone conduction on the Rinne test (AC > BC).
c. Sound lateralizes to the affected ear on the Weber test.
d. Sound lateralizes to both ears equally on the Weber test.
ANSWER: B
A
Feedback
This finding indicates a conduction hearing loss, rather than a sensorineural
B
C
D
hearing loss.
This finding indicates a sensorineural health loss, the most common cause of
presbycusis.
This finding indicates a conduction hearing loss, rather than a sensorineural
hearing loss.
This is a normal finding on this test.
DIF: Cognitive Level: Analyze REF: 167-168
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
47. While taking a history, the nurse notices that the patient’s family member repeats most of the
questions to the patient in a loud voice. Based on this information, what finding does the nurse
anticipate when assessing this patient’s hearing using an audioscope?
a. 5 dB hearing loss at all frequencies
b. 10 dB hearing loss at all frequencies
c. 20 dB hearing loss at all frequencies
d. 40 dB hearing loss at all frequencies
ANSWER: D
Feedback
A This decibel level is not tested by an audioscope .
B A 10 dB loss in high frequencies results in difficulty hearing quiet sounds, such as
a heartbeat.
C A 20 dB loss in high frequencies results in difficulty hearing high-pitched
consonants, such as a whisper.
D A 40 dB loss in all frequencies causes moderate difficulty in hearing normal
speech.
DIF: Cognitive Level: Apply REF: 168
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
48. A patient is being seen in the clinic for suspected nasal obstruction from a foreign body. The
nurse recognizes which finding as most consistent with this diagnosis?
a. Unilateral foul-smelling drainage
b. Bilateral purulent green-yellow discharge
c. Bilateral bloody discharge
d. Unilateral watery discharge
ANSWER: A
A
B
C
D
Feedback
This is consistent with presence of a foreign object in one side of the nose.
This is consistent with a nasal or sinus infection.
This is consistent with localized trauma, such as a nasal fracture.
This is consistent with a history of head injury and may indicate skull fracture.
DIF: Cognitive Level: Apply REF: 162
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
49. In assessing a patient with head injury, the nurse should be most concerned with which
finding?
a. Pain on palpation of the scalp
b. Unilateral clear, watery nasal discharge
c. A scalp laceration at the sight of injury
d. Complaints of dizziness
ANSWER: B
A
B
C
D
Feedback
This is expected after a head injury and is not a cause for concern.
This may be cerebrospinal fluid, indicating a skull fracture.
This is expected after a head injury and is not a cause for concern.
This is expected after a head injury and is not a cause for concern.
DIF: Cognitive Level: Understand REF: 162
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
50. A patient complains of a lesion in his nose. Which technique does a nurse use to inspect the
nasal mucosa?
a. Inserts a nasal speculum horizontally into the patient’s affected nares
b. Inserts a nasal speculum obliquely into the patient’s affected nares
c. Uses a light source from the ophthalmoscope
d. Inserts a nasal speculum vertically into the patient’s affected nares
ANSWER: B
A
B
C
D
Feedback
Horizontal insertion puts pressure on the nasal septum, which is painful.
This is the appropriate technique for inspecting the nares.
The alternate light source is from an otoscope, rather than an ophthalmoscope.
The otoscope has an ear speculum that can be used when a nasal speculum is
unavailable.
Vertical insertion obstructs the nurse’s view of the internal nares.
DIF: Cognitive Level: Understand REF: 169-170
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
51. When inspecting a patient’s nasal mucous membrane, which finding does the nurse expect to
see?
a. Deep pink turbinates
b. Red, edematous mucous membranes
c. Septum that angles to the left
d. Clear exudate
ANSWER: A
A
B
C
D
Feedback
These are expected for a nasal inspection.
These indicate a local infection within the nose.
This is abnormal.
This occurs with nasal allergies.
DIF: Cognitive Level: Understand REF: 170
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific
Assessments
52. A patient comes to the clinic for evaluation after a sinus infection. To evaluate the therapy, the
nurse uses transillumination to assess the sinuses and notes which finding indicating recovery
from a frontal sinus infection?
a. The soft palate illuminates brightly when the light source is placed against the
lateral nose.
b. No illumination is noted when the light source is placed firmly against the lateral
nose.
c. A bright glow illuminates the hard palate when the light source is placed against
each temporal bone.
d. A reddish light is noted above the eyebrows when the light is placed against each
supraorbital rim.
ANSWER: D
A
B
C
D
Feedback
This describes incorrect technique for transillumination.
An absence of a glow during transillumination of the sinuses may indicate that
the sinuses are congested.
This describes incorrect technique for transillumination.
Finding a reddish light above the eyebrows when the light is placed against each
supraorbital rim is consistent with frontal sinuses free of infection.
DIF: Cognitive Level: Apply REF: 171
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific
Assessments
53. A nurse suspects the patient has an infection of the maxillary sinuses. How can this suspicion
be confirmed?
a. Using a flashlight to illuminate the floor of the mouth
b. Pressing gently with both thumbs into the eyebrow ridges
c. Applying firm pressure with the thumbs below the cheekbones
d. Standing behind the patient and asking him or her to slowly rotate the head
ANSWER: C
A
B
C
D
Feedback
To transilluminate the maxillary sinuses, the nurse places the source of light
lateral to the nose, just beneath the medial aspect of the eye, and looks through
the patient’s open mouth for illumination of the hard palate.
This palpates the frontal sinuses rather than the maxillary sinuses.
This palpates the maxillary sinuses to detect tenderness, which may indicate sinus
congestion or infection.
This is not a correct technique to confirm infection of the maxillary sinuses.
DIF: Cognitive Level: Apply REF: 170
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
54. After assessment of the nose and paranasal sinuses, which finding requires further
investigation by the nurse?
a. Nasal septum off the midline
b. Nose in the midline of the face
c. Middle turbinates deep pink in color
d. Noiseless exchange of air from each naris
ANSWER: A
A
B
C
D
Feedback
A deviated septum is an abnormal finding that needs further investigation.
This is an expected finding.
This is a normal finding.
This is a normal finding.
DIF: Cognitive Level: Understand REF: 170
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
55. When inspecting a patient’s posterior wall of the pharynx and tonsils, a nurse documents
which finding as abnormal?
a. Both tonsils have a smooth surface.
b. Left and right tonsils meet at the midline.
c. Left and right tonsils extend beyond the posterior pillars.
d. Both tonsils have a glistening appearance.
ANSWER: B
Feedback
A A smooth surface is expected for the tonsils.
B This indicates an enlargement documented as 4+.
C This is an expected finding for the tonsils.
D This is an expected finding for the tonsils.
DIF: Cognitive Level: Apply REF: 174
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
56. Wearing gloves, the nurse grasps the patient’s tongue with a gauze pad and palpates a small,
firm nodule on the left side of the tongue. Based upon this finding, what is the nurse’s
appropriate response?
a. Document that the patient’s tongue is normal on palpation.
b. Inspect the left submandibular salivary glands for redness.
c. Ask the patient to move the tongue in all directions.
d. Palpate cervical and submental lymph nodes for enlargement.
ANSWER: D
A
B
C
D
Feedback
The nodule is not an expected finding.
The salivary glands are not affected by a nodule of the tongue.
This assesses the hypoglossal cranial nerve or movement of the tongue, which is
not related to the nodule found.
The nodules may indicate a malignancy of the tongue, which may also cause
enlarged cervical or submental lymph nodes.
DIF: Cognitive Level: Analyze REF: 175
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
57. A nurse assesses neck range of movement of several adults. Which patient has an expected
range of motion of the neck?
a. Patient A is unable to resist the nurse’s attempt to move the head upright.
b. Patient B bends the head to the right and left (ear to shoulder) 15 degrees.
c. Patient C flexes chin toward the chest 45 degrees.
d. Patient D hyperextends the head 30 degrees from midline.
ANSWER: C
Feedback
A This finding is abnormal.
B This finding is abnormal. The patient should be able to laterally bend the head 40
degrees from midline in each direction.
C This is an expected finding.
D The patient should be able to hyperextend the head 55 degrees from midline.
DIF: Cognitive Level: Understand REF: 176
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific
Assessments
58. What technique does a nurse use when palpating the right lobe of a patient’s thyroid gland
using the anterior approach?
a. Pushes the cricoid process to the left with the right thumb
b. Displaces the trachea to the right with the left thumb
c. Manipulates the thyroid between the thumb and index finger
d. Moves the sternocleidomastoid muscle to the right with the left thumb
ANSWER: B
A
B
C
D
Feedback
This is not a correct technique.
This is the correct technique for palpating the thyroid gland using the anterior
approach.
This is not a correct technique.
This is not a correct technique.
DIF: Cognitive Level: Apply REF: 177
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
59. What technique does a nurse use when palpating the right lobe of a patient’s thyroid gland
using the posterior approach?
a. Pushes the cricoid process to the left with the right thumb and feels the right lobe
with the left hand
b. Uses the left hand to push the sternocleidomastoid muscle to the right and feels the
lobe with the right hand
c. Pushes the trachea to the right with the left hand and feels the right lobe with the
right hand
d. Places the fingers on either side of the trachea above the cricoid cartilage and feels
the right lobe
ANSWER: C
A
B
C
D
Feedback
This description is not a correct technique. In the posterior approach, the right
lobe is felt with the right hand.
This description is not a correct technique. The trachea, not the muscle, is moved
to the side.
This is the correct technique.
This description is not a correct technique. The fingers are placed below the
cricoid cartilage.
DIF: Cognitive Level: Apply REF: 177
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
60. What instruction does a nurse give a patient to facilitate palpation of the right lobe of the
thyroid gland?
a. “Swallow for me one time.”
b. “Flex your head down and to the left.”
c. “Rotate your head to the right for me.”
d. “Hold your breath for a few seconds.”
ANSWER: A
A
B
C
D
Feedback
The patient is asked to swallow to make the thyroid lobe easier to palpate.
This is incorrect to palpate the right lobe. The patient flexes the neck toward the
side being palpated.
This is incorrect to palpate the right lobe. The patient flexes the neck toward the
side being palpated, but does not rotate the head.
This is not part of the thyroid palpation.
DIF: Cognitive Level: Apply REF: 177
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
61. When palpating the right lobe of the patient’s thyroid gland using the anterior approach, the
nurse feels the tissue between which two structures?
a. Sternocleidomastoid and the trapezius muscles
b. Trapezius muscle and the trachea
c. Cricoid process and the trachea
d. Sternocleidomastoid muscle and the trachea
ANSWER: D
A
B
C
D
Feedback
This is not the correct location for palpating the thyroid gland using the anterior
approach.
This is not the correct location for palpating the thyroid gland using the anterior
approach.
This is not the correct location for palpating the thyroid gland using the anterior
approach.
This is the correct location for palpating the thyroid gland using the anterior
approach.
DIF: Cognitive Level: Apply REF: 177
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
62. On palpation the nurse determines that the patient’s left thyroid lobe is larger than the right
thyroid lobe. What is the nurse’s most appropriate action at this time?
a. Refer the patient to the health care provider for further evaluation.
b. Document that the patient’s thyroid is normal on palpation.
c. Palpate the left thyroid lobe again using very firm pressure.
d. Ask the patient to flex the chin toward his chest and palpate again.
ANSWER: A
A
B
Feedback
The nurse found an abnormality that needs referral for follow-up.
This is not an appropriate action because the nurse found an abnormality.
C
D
Repeating the examination will yield the same abnormal finding.
Repeating the examination will yield the same abnormal finding.
DIF: Cognitive Level: Analyze REF: 178
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
63. A teenager comes to the clinic complaining about the whiteheads and blackhead on his face
interfering with his social life. During the examination the nurse palpates an enlarged
submental lymph node. Where is this lymph node located?
a. In front of the ear
b. Under the mandible
c. At the base of the skull
d. Along the angle of the jaw
ANSWER: B
A
B
C
D
Feedback
This is the location of the preauricular lymph nodes.
This is the location of the submental lymph node.
This is the location of the occipital lymph nodes.
This is the location of the parotid lymph nodes.
DIF: Cognitive Level: Apply REF: 178
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
64. How does the nurse test the function of the patient’s spinal accessory nerve (CN XI)?
a. Ask the patient to stick out the tongue and move it side to side.
b. Ask the patient to shrug the shoulders against the resistance of the nurse’s hands.
c. Ask the patient to open the mouth and observe the uvula rise when he says “ah.”
d. Ask the patient to move the chin to the chest and then up toward the ceiling.
ANSWER: B
A
B
C
D
Feedback
This is a test of the hypoglossal cranial nerve (XII).
This is the correct technique for assessing the spinal accessory cranial nerve (XI).
This is a test for cranial nerves IX (glossopharyngeal) and X (vagus).
This technique assesses the range motion of the neck.
DIF: Cognitive Level: Apply REF: 176
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
65. A patient complains of sore throat, pain with swallowing, fever, and chills. The nurse suspects
tonsillitis and plans to palpate the anterior cervical lymph nodes. Where does the nurse place
his fingers to palpate these nodes?
a. In front of the ears
b. Under the mandibles
c. Along the angle of the mandibles
d. Adjacent to the sternocleidomastoid muscles
ANSWER: D
A
B
C
D
Feedback
This is the location of the preauricular lymph nodes.
This is the location of the submental and submandibular lymph nodes.
This is the location of the parotid lymph nodes.
This is the location of the anterior cervical lymph nodes.
DIF: Cognitive Level: Understand REF: 178
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: System Specific
Assessments
66. What instructions does the nurse give the patient before palpating the right supraclavicular
lymph nodes?
a. “Lean your head backward and toward the right as far as comfortably possible.”
b. “Lie supine and turn your head away from the right side.”
c. “Draw up your shoulders forward, and flex your chin toward the right side.”
d. “Sit up, raise both arms over your head, and flex your chin away from the right
side.”
ANSWER: C
A
B
C
D
Feedback
This is incorrect. The patient should draw up (hunch) the shoulders forward rather
than leaning back.
The patient should be sitting, rather than lying down.
This is the technique for palpating the supraclavicular nodes.
The shoulders should be drawn up (hunched) forward, rather than raising the
arms.
DIF: Cognitive Level: Apply REF: 178
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
67. A patient has had an infected facial wound for more than 3 months. How does the nurse
expect the patient’s enlarged lymph nodes to feel?
a. Soft, edematous, and tender
b. Round, tender, and movable
c. Hard, nontender, and nonmobile
d. Irregularly shaped, tender, and firm
ANSWER: B
A
Feedback
These are not characteristics of lymph nodes associated with inflammation.
B
C
D
These are characteristics of enlarged lymph nodes associated with inflammation.
These are characteristics of enlarged lymph nodes associated with a malignancy.
These are not characteristics of lymph nodes associated with inflammation.
DIF: Cognitive Level: Analyze REF: 178
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
68. A nurse’s presentation to patients on risk factors for oral cancer includes which fact?
a. The peak incidence oral cancer is before 40 years of age.
b. Women have a higher risk than men.
c. Excessive alcohol consumption is a risk factor.
d. Eating a low fiber diet is a risk factor.
ANSWER: C
Feedback
A There is increased incidence after age 40 with peak incidence between ages 64
and 74.
B There is a 2:1 men-to-women incidence.
C Seventy-five to eighty percent of individuals who develop oral cancer consume
excessive amounts of alcohol.
D A low fiber diet increases the risk for colon cancer, but not oral cancer.
DIF: Cognitive Level: Understand REF: 181
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Health Promotion Programs
69. During the history, a 65-year-old male patient reports smoking two packs of cigarettes a day
for more than 40 years. With this knowledge, what does the nurse expect for during the
examination of this patient’s mouth?
a. Cracks and erythema in the corners of the mouth
b. Slightly rough papillae on the dorsal surface of the tongue
c. Smooth or beefy, red-colored, edematous tongue
d. Painless, nonhealing mouth ulcers
ANSWER: D
A
B
C
D
Feedback
This may be caused by vitamin B deficiencies.
These are an expected finding on the tongue.
This may be an indication of anemia.
This may indicate oral cancer.
DIF: Cognitive Level: Apply REF: 181
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
70. A nurse’s presentation to patients on risk factors for macular degeneration includes which
fact?
a. The peak incidence is before 60 years of age.
b. Women have a higher risk than men.
c. Eating a low fat diet causes a vitamin A deficiency, which increases risk.
d. Cigarette smokers have twice the risk as nonsmokers.
ANSWER: D
A
B
C
D
Feedback
Macular degeneration exists in 25% of those between ages 65 and 74 years, and
33% of those older than 75 years.
There are no differences between genders for macular degeneration.
A diet high in monosaturated, polyunsaturated, and vegetable fats increases risk.
Smoking is a risk factor for macular degeneration.
DIF: Cognitive Level: Understand REF: 181
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Health Promotion Programs
MULTIPLE RESPONSE
1. During an examination of the head and neck of a healthy adult, the nurse expects which
findings? Select all that apply.
a. Small red lesions with white flakes scattered on the scalp
b. The head and facial bones are proportional for the size of the body
c. Depressions palpated on the right and left sides over the parietal bones
d. Head held flexed 15 degrees to the left
e. Face and jaw are symmetric and proportional
f. Temporomandibular joint moves smoothly
ANSWER: B, E, F
Correct: These are expected findings from an assessment of the head of a healthy adult.
Incorrect: Small red lesions with white flakes scattered on the scalp is an abnormal finding.
The scalp should be intact without lesion or flakes. Depressions palpated on the right and left
sides over the parietal bones is an abnormal finding. Perhaps this patient had skull tongs from
cervical traction at one time. Head held flexed 15 degrees to the left is an abnormal finding.
The head should be erect.
DIF: Cognitive Level: Analyze REF: 148| 179
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance
2. A nurse is assessing the eyes of a healthy 72-year-old adult. What findings does the nurse
expect? Select all that apply.
a. Bulbar conjunctiva pink and clear, with small red vessels noted
b. Sclera yellow and moist, cornea transparent
c. Extraocular movement symmetric with peripheral vision noted
d. Newspaper held at 18 inches to see clearly
e. Sclera visible between upper lid and iris
f. Gray to white circle noted where the sclera merges with the cornea
g. Light reflects on the cornea at 12 o’clock in each eye
ANSWER: A, C, G
Correct: These are expected findings from an assessment of the eyes of a healthy adult.
Incorrect: Sclera should be white and moist. Newspaper held at 18 inches to see clearly is
due to presbyopia due to the patient’s age. Patient must hold paper further away to see clearly.
The upper lid should cover the upper part of the iris. Sclera is visible in hyperthyroidism. A
gray to white circle is arcus senilis, which is an abnormal finding in older adults.
DIF: Cognitive Level: Apply REF: 137| 150| 152-153| 179
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
3. During an eye assessment, the nurse asks the patient to keep the head stationary and by
moving the eyes only follow the nurse’s finger as it moves side to side, up and down, and
obliquely. This assessment technique collects what data about which cranial nerves? Select all
that apply.
a. Cranial nerve II (optic)
b. Cranial nerve III (oculomotor)
c. Cranial nerve IV (trochlear)
d. Cranial nerve VI (abducens)
e. Cranial nerve V (trigeminal)
ANSWER: B, C, D
Correct: Cranial nerve III (oculomotor), cranial nerve IV (trochlear), and cranial nerve VI
(abducens) provide muscle movement for the eyes.
Incorrect: Cranial nerve II (optic) provides vision. Cranial nerve V (trigeminal) provides
movement for the jaw and sensation for cornea, conjunctive, eyelids, teeth, tongue, and
mouth.
DIF: Cognitive Level: Apply REF: 154-155
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
4. What findings does the nurse expect when assessing the ears of a healthy adult? Select all that
apply.
a. Cerumen noted in the outer ear canal
b. Pinna located below the external corner of the eye
c. Cone of light located in the 5 o’clock position in the left ear
d. Ratio of air conduction to bone conduction 2:1
e. Tympanic membrane pearly gray
f. Whispered words repeated accurately
ANSWER: A, D, E, F
Correct: These are all expected findings from an assessment of the ears of a healthy adult.
Incorrect: The pinna should align with the outer canthus of the eye. Cone of light should be
located in the 7 o’clock position in the left ear and the 5 o’clock position in the right ear.
DIF: Cognitive Level: Apply REF: 163-165| 168| 179
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
5. Which findings does the nurse expect when assessing the mouth of a healthy adult? Select all
that apply.
a. Lips appear pink, smooth, moist, and symmetric
b. Teeth are white, yellow, or gray, with smooth edges
c. Exposed tooth neck and brown spots between teeth
d. Slight roughness on the dorsum of the tongue
e. Hard palate appears smooth, pale, and immovable
f. Mucous membranes are dry and intact
ANSWER: A, B, D, E
Correct: These are all expected findings from a mouth assessment of a healthy adult.
Incorrect: Receding gums expose tooth neck and may indicate gingival disease. Brown spots
may indicate caries. Dry and intact mucous membranes may indicate dehydration.
DIF: Cognitive Level: Analyze REF: 171| 173-174| 179
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific
Assessments
6. Nurses inquire about lifestyle behaviors in those patients with specific risk factors for
cataracts. Which characteristics are associated with risk factors for cataracts? Select all that
apply.
a. Smoking more than 20 cigarettes a day
b. Having parents with cataracts
c. Chronic consumption of alcohol
d. Having a chronic disease, such as diabetes mellitus
e. Being Asian
f. Being a man
ANSWER: A, C, D
Correct: These are all risk factors for cataracts.
Incorrect: Having parents with cataracts is not a genetic or familial disorder. Being Asian or a
man are not risk factors, but being an African-American or being a woman are risk factors.
DIF: Cognitive Level: Apply REF: 181
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Health Promotion Programs
Chapter 11: Lungs and Respiratory System
Test Bank
MULTIPLE CHOICE
1. A patient tells the nurse that she has smoked two packs of cigarettes a day for 20 years. The
nurse records this as how many pack-years?
a. 10
b. 20
c. 40
d. 60
ANSWER: C
Feedback
A This incorrect calculation was made by dividing 20 years by 2 packs.
B This is correct if the patient smoked 1 pack per day for 20 years.
C Two packs of cigarettes 20 years = 40 pack-years.
D This is correct if the patient smoked 3 packs per day for 20 years or 2 packs a day
for 30 years.
DIF: Cognitive Level: Apply REF: 197, Box 11-1
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific
Assessments
2. After taking a brief health history, a nurse needs to complete a focused assessment on which
patient?
a. A male who works as a painter
b. A male who plays basketball and hockey
c. A female who recently moved into a college dormitory
d. A female who has a history of gout
ANSWER: A
A
B
C
D
Feedback
The fumes and chemicals from the paint may expose the patient to respiratory
irritants. A baseline pulmonary assessment needs to be documented.
This patient is not at risk for pulmonary disease.
This patient is not at risk for pulmonary disease.
This patient is not at risk for pulmonary disease.
DIF: Cognitive Level: Apply REF: 198
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Health Screening
3. During a symptom analysis, a patient describes his productive cough and states his sputum is
thick and yellow. Based on these data, the nurse suspects which factor as the cause of these
symptoms?
a. Virus
b. Allergy
c. Fungus
d. Bacteria
ANSWER: D
A
B
C
D
Feedback
A virus usually produces a nonproductive cough.
An allergy usually produces clear sputum.
A fungus usually produces few symptoms. The sputum used to diagnose the
fungus is obtained from tracheal aspiration rather than the patient coughing up the
sputum.
Bacteria usually produce sputum that is yellow or green in color.
DIF: Cognitive Level: Apply REF: 198
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body
Systems
4. During the problem-based history, a patient reports coughing up sputum when lying on the
right side, but not when lying on the back or left side. The nurse suspects this patient may
have a lung abscess. What additional question does the nurse ask to gather more data?
a. “Does the sputum have an odor?”
b. “Do you have chest pain when you take a deep breath?”
c. “Have you also experienced tightness in your chest?”
d. “Have you coughed up any blood?”
ANSWER: A
A
B
C
D
Feedback
Sputum with odor and sputum production with change of position is associated
with lung abscess or bronchiectasis.
Chest pain on deep breathing is associated with pleural lining irritation.
Tightness in the chest is associated with asthma.
Coughing up rust-colored sputum is associated with pneumonia, but coughing up
blood may be associated with lung cancer.
DIF: Cognitive Level: Apply REF: 198
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body
Systems
5. Which question will give the nurse additional information about the nature of a patient’s
dyspnea?
a. “How often do you see the physician?”
b. “How has this condition affected your day-to-day activities?”
c. “Do you have a cough that occurs with the dyspnea?”
d. “Does your heart rate increase when you are short of breath?”
ANSWER: B
Feedback
A
B
C
D
This question does not relate specifically to the patient’s dyspnea.
This question provides data about the severity of the dyspnea and what actions
the patient has taken to cope with the dyspnea on a daily basis.
This question provides data, but does not give additional facts about the patient’s
dyspnea.
This is a closed-ended question that does not collect additional data about this
episode of dyspnea.
DIF: Cognitive Level: Apply REF: 199
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body
Systems
6. A patient complains of shortness of breath and having to sleep on three pillows to breathe
comfortably at night. During the nurse’s examination, what findings will suggest that the
cause of this patient’s dyspnea is due to heart disease rather than respiratory disease?
a. Increased anteroposterior diameter
b. Clubbing of the fingers
c. Bilateral peripheral edema
d. Increased tactile fremitus
ANSWER: C
A
B
C
D
Feedback
This is seen with lung hyperinflation and may be associated with emphysema.
This is associated with chronic hypoxia and may be associated with cystic fibrosis
or chronic obstructive pulmonary disease.
This indicates heart failure; dyspnea occurs because the heart cannot adequately
perfuse the lungs.
This occurs when vibrations are enhanced and is associated with consolidation
that may occur in pneumonia or tumor.
DIF: Cognitive Level: Analyze REF: 199
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body
Systems
7. During a history, a nurse notices a patient is short of breath, is using pursed-lip breathing, and
maintains a tripod position. Based on these data, what abnormal finding should the nurse
expect to find during the examination?
a. Increased tactile fremitus
b. Inspiratory and expiratory wheezing
c. Tracheal deviation
d. An increased anteroposterior diameter
ANSWER: D
A
B
Feedback
Increased tactile fremitus occurs when vibrations are enhanced and is associated
with consolidation that may occur in pneumonia or tumor.
Inspiratory and expiratory wheezing is associated with asthma.
C
D
Tracheal deviation is associated with tension pneumothorax.
An increased anteroposterior diameter is consistent with emphysema.
DIF: Cognitive Level: Analyze REF: 199| 207
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body
Systems
8. A nurse notices a patient’s chest wall moving in during inspiration and out during expiration.
What additional assessment must the nurse perform immediately?
a. Palpate for tracheal deviation.
b. Auscultate for bronchovesicular breath sounds in the lung periphery.
c. Palpate posterior thoracic muscles for tenderness.
d. Auscultate for absence of breath sounds in the lung periphery.
ANSWER: A
A
B
C
D
Feedback
Chest wall moving in during inspiration and out during expiration is paradoxical
chest wall movement. It can be caused by a tension pneumothorax, which
increases intrathoracic pressure in the thorax, causing tracheal deviation and
indicating mediastinal shift.
Tension pneumothorax does not create bronchovesicular breath sounds in the lung
periphery.
This is performed when the patient has air in the subcutaneous tissue or pleural
friction rub.
Absent breath sounds may be found in pneumothorax, but if the patient has a
tension pneumothorax, tracheal deviation is a more important sign.
DIF: Cognitive Level: Apply REF: 199| 213-214| 220
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body
Systems
9. A nurse inspects a patient’s hands and notices clubbing of the fingers. The nurse correlates this
finding with what condition?
a. Pulmonary infection
b. Trauma to the thorax
c. Chronic hypoxemia
d. Allergic reaction
ANSWER: C
A
B
C
D
Feedback
Pulmonary infection is acute and not associated with chronic hypoxia.
Trauma to the thorax is acute and not associated with chronic hypoxia.
Clubbing develops due to chronic hypoxemia, which occurs in chronic
obstructive pulmonary disease.
Allergic reaction is acute and not associated with chronic hypoxia.
DIF: Cognitive Level: Apply REF: 202
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body
Systems
10. A nurse is assessing a patient who was diagnosed with emphysema and chronic bronchitis 5
years ago. During the assessment of this patient’s integumentary system, what finding should
the nurse correlate to this respiratory disease?
a. Dry, flaky skin
b. Clubbing of the fingers
c. Hypertrophy of the nails
d. Hair loss from the scalp
ANSWER: B
A
B
C
D
Feedback
Dry, flaky skin occurs with dehydration.
Clubbing of the fingers develops due to chronic hypoxemia, which occurs in
chronic obstructive pulmonary disease.
Hypertrophy of the nails occurs with repeated trauma.
Hair loss from the scalp is alopecia, which occurs with many systemic diseases,
but not chronic pulmonary disease.
DIF: Cognitive Level: Apply REF: 202
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body
Systems
11. A nurse is auscultating the lungs of a healthy male patient and hears crackles on inspiration.
What action can the nurse take to ensure this is an accurate finding?
a. Make sure the bell of the stethoscope is used, rather than the diaphragm.
b. Hold stethoscope firmly to prevent movement when placed over chest hair.
c. Ask the patient not to talk while the nurse is listening to the lungs.
d. Change the patient’s position to ensure accurate sounds.
ANSWER: B
A
B
C
D
Feedback
Using the bell will provide inaccurate sounds, but not mimic crackles.
The stethoscope moving even slightly on chest hair can mimic the sound of
crackles.
When the patient talks during auscultation, it does interfere with data collection,
but the sound is a muffled voice.
Changing the position will not affect the outcome of the assessment if the initial
problem remains.
DIF: Cognitive Level: Apply REF: 203-204
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
12. A patient is admitted to the emergency department with a tracheal obstruction. What sound
does the nurse expect to hear as this patient breathes?
a. Dull sounds on percussion
b. Soft, muffled rhonchi heard over the trachea
c. Bubbling or rasping sounds heard over the trachea
d. High-pitched sounds on inspiration and exhalation
ANSWER: D
A
B
C
D
Feedback
Dull sounds on percussion occur with pneumonia, pleural effusion, or atelectasis.
Soft, muffled rhonchi heard over the trachea is not a description of stridor.
Bubbling or rasping sounds heard over the trachea is not a description of stridor.
High-pitched sounds on inspiration and exhalation are consistent with stridor.
DIF: Cognitive Level: Understand REF: 206
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body
Systems
13. A nurse auscultates low-pitched, coarse snoring sounds in a patient’s lungs during inhalation.
What is the most appropriate action for the nurse to take at this time?
a. Palpate the posterior thorax for vocal fremitus.
b. Ask the patient to cough and repeat auscultation.
c. Auscultate the posterior thorax for vocal sounds.
d. Percuss the posterior thorax for tone.
ANSWER: B
A
B
C
D
Feedback
An abnormal vocal fremitus (decreased or increased vibrations) is not expected
for this patient.
The sounds indicate rhonchi, or secretions in the bronchi. The first action to take
is to determine if the rhonchi clear with coughing. If the rhonchi clear, there is no
need to further investigate this finding.
Abnormal vocal sounds (clear and loud sounds) are not expected for this patient.
An abnormal percussion tone (hyperresonance or dull) is not expected for this
patient.
DIF: Cognitive Level: Apply REF: 203-204
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body
Systems
14. A nurse had previously heard crackles over both lungs of a patient. As the patient improves,
what lung sounds does the nurse expect to hear in the patient’s lungs?
a. Vesicular breath sounds heard in peripheral lung fields
b. Bronchial breath sounds heard over the bronchi
c. Bronchovesicular breath sounds heard over the apices
d. Rhonchi heard over the main bronchi
ANSWER: A
A
B
C
D
Feedback
Vesicular breath sounds heard in peripheral lung fields are an expected finding for
healthy lungs.
Bronchial breath sounds are heard over the trachea.
Bronchovesicular breath sounds are heard anteriorly near the sternal border first
and second intercostals space.
Rhonchi are adventitious sounds indicating secretions in the bronchi.
DIF: Cognitive Level: Apply REF: 206
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific
Assessments
15. The nurse is comparing pitch and duration of the various types of a patient’s breath sounds
and recognizes which one of these as an expected finding?
a. Bronchial sounds are low-pitched and have a 2:1 inspiratory-versus-expiratory
ratio.
b. Bronchovesicular sounds have a moderate pitch and 1:1 expiratory-versusinspiratory
ratio.
c. Vesicular breath sounds are high-pitched and have a 1:2 inspiratory-versusexpiratory
ratio.
d. Wheezes are low-pitched and have a 2.5:1 inspiratory-versus-expiratory ratio.
ANSWER: B
A
B
C
D
Feedback
Bronchial sounds are high pitched with a duration of 1:2 inspiration-to-expiration
is the correct statement.
Bronchovesicular sounds having a moderate pitch and 1:1 expiratory-versusinspiratory
ratio is a normal finding.
Vesicular sounds are low pitched with a duration of 2.5:1 inspiration-to-expiration
is the correct statement.
Wheezes are high-pitched and have no specific duration because they are
adventitious sounds.
DIF: Cognitive Level: Understand REF: 205-206
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific
Assessments
16. On inspection, a nurse finds the patient’s anteroposterior diameter of the chest to be the same
as the lateral diameter. Based on this finding, what additional data does the nurse anticipate?
a. Increased vocal fremitus on palpation
b. Dull tones heard on percussion
c. Decreased breath sounds on auscultation
d. Complaint of sharp chest pain on inspiration
ANSWER: C
A
B
C
D
Feedback
Increased fremitus occurs when the vibrations feel enhanced. This is found when
lung tissues are congested or consolidated, which may occur in patients who have
pneumonia or a tumor.
Dull tones may be heard in patients with pneumonia, pleural effusion, or
atelectasis.
The equal anteroposterior and lateral diameters of the chest indicate air trapping
from enlarged or destroyed alveoli. This air trapping causes decreased to absent
breath sounds on auscultation.
Complaint of sharp chest pain on inspiration is pleuritic chest pain associated
with pleural lining irritation and may occur in a patient with pleurisy or
pneumonia.
DIF: Cognitive Level: Apply REF: 206-208| 219
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body
Systems
17. Where does a nurse expect to hear bronchovesicular lung sounds in a healthy adult?
a. In the lower lobes
b. Over the trachea
c. In the apices of the lungs
d. Near the sternal border
ANSWER: D
A
B
C
D
Feedback
Vesicular breath sounds are normally heard in the lower lobes.
Bronchial sounds are normally heard over the trachea.
Vesicular breath sounds are normally heard in the apices of the lungs.
Bronchovesicular breath sounds are normally heard over the central area of the
anterior thorax around the sternal border.
DIF: Cognitive Level: Remember REF: 205-206
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Health Screening
18. A nurse in the emergency department is assessing a patient with a moderate left
pneumothorax. What does this nurse expect to find during the respiratory examination?
a. Increased fremitus over the left chest
b. Tracheal deviation to the left side
c. Hyporesonant percussion tones over the left chest
d. Distant to absent breath sounds over the left chest
ANSWER: D
A
B
C
Feedback
Increased fremitus occurs over lung consolidation as in lobar pneumonia or
tumor.
If this patient had a tension pneumothorax, the trachea would deviate to the right.
Hyperresonant percussion tones are heard when the lung is overinflated as in
D
emphysema.
The air separating the lung from the chest where the nurse is auscultating creates
distant to absent breath sounds.
DIF: Cognitive Level: Apply REF: 206| 220
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body
Systems
19. A nurse suspects a patient has a chest wall injury and wants to collect more data about
thoracic expansion. Which is the appropriate technique to use?
a. Place the palmar side of each hand against the lateral thorax at the level of the
waist, ask the patient to take a deep breath, and observe lateral movement of the
hands.
b. Place both thumbs on either side of the patient’s T9 to T10 spinal processes, extend
fingers laterally, ask the patient to take a deep breath, and observe lateral movement
of the thumbs.
c. Place both thumbs on either side of the patient’s T7 to T8 spinal processes, extend
fingers laterally, ask the patient to exhale deeply, and observe lateral inward
movement of the thumbs.
d. Place the palmar side of each hand on the shoulders of the patient, ask the patient to
sit up straight and take a deep breath, and observe symmetric movement of the
shoulders.
ANSWER: B
A
B
C
D
Feedback
The palms of the hands are not used and hands are not placed on the lateral
thorax.
This is the correct technique to assess thoracic expansion.
The thoracic level is too high and the patient does not exhale.
The hands are not placed on the shoulders.
DIF: Cognitive Level: Understand REF: 209-210| 214
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
20. A patient has right lower lobe pneumonia, creating a consolidation in that lung. In assessing
for vocal fremitus, the nurse found increased fremitus over the right lower lung. What finding
does the nurse anticipate when assessing vocal resonance to confirm the consolidation?
a. Bronchophony reveals the patient’s spoken “99” as clear and loud.
b. No sounds are expected since sounds cannot be transmitted through consolidation.
c. Egophony reveals indistinguishable sounds when the patient says “e-e-e.”
d. Whispered pectoriloquy reveals a muffled sound when the patient says “1-2-3.”
ANSWER: A
A
B
Feedback
This is an abnormal finding and occurs in consolidation.
The abnormal finding is hearing a clear sound.
C
D
This is a normal finding.
This is a normal finding.
DIF: Cognitive Level: Analyze REF: 213| 218
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body
Systems
21. A nurse is assessing for vocal (tactile) fremitus on a patient with pulmonary edema. Which is
the appropriate technique to use?
a. Systematically percuss the posterior chest wall following the same pattern that is
used for auscultation and listen for a change in tone from resonant to dull.
b. Place the pads of the fingers on the right and left thoraces and palpate the texture
and consistency of the skin feeling for a crackly sensation under the fingers.
c. Place the palms of the hands on the right and left thoraces, ask the patient to say
“99,” and feel for vibrations.
d. Place both thumbs on either side of the patient’s spinal processes, extend fingers
laterally, ask the patient to take a deep breath, and feel for vibrations.
ANSWER: C
A
B
C
D
Feedback
This is the technique for percussing the thorax for tones.
This is the technique for detecting crepitus.
This is the correct technique for vocal fremitus.
This is not the correct technique.
DIF: Cognitive Level: Understand REF: 210| 215
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
22. A nurse examines a patient with a pleural effusion and finds decreased fremitus. What
additional abnormal finding should the nurse anticipate during further examination?
a. An increase in the anteroposterior to lateral ratio
b. Hyperresonance over the affected area
c. Absent breath sounds in the affected area
d. Increased vocal fremitus over the affected area
ANSWER: C
A
B
C
D
Feedback
An increase in the anteroposterior to lateral ratio occurs in overinflated lungs as
in emphysema.
Hyperresonance over the affected area occurs in overinflated lungs as in
emphysema.
Absent breath sound in the affected area is anticipated because the fluid in the
pleural space prevents breath sounds from being heard.
Increased vocal fremitus over the affected area is associated with consolidation
that occurs with pneumonia or tumor. Fremitus is decreased to absent in pleural
effusion.
DIF: Cognitive Level: Analyze REF: 206| 210| 215| 218
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body
Systems
23. A patient is suspected of having a lung consolidation. A nurse uses the three techniques for
assessing vocal resonance in this patient. What is the expected finding among the three
procedures that will help eliminate consolidation as a problem?
a. The nurse documents clearly hearing the patient say “99.”
b. The nurse documents hearing muffled sounds when the patient says “1-2-3.”
c. The nurse documents hearing no sounds when the patient says “e-e-e.”
d. The nurse documents clearly hearing the patient say “a-a-a.”
ANSWER: B
A
B
C
D
Feedback
Clear sounds are heard when a consolidation is present.
Muffled sounds of “1-2-3,” “e-e-e,” or “99” are heard when no consolidation is
found.
Clear sounds are heard when a consolidation is present.
Clear sounds are heard when a consolidation is present.
DIF: Cognitive Level: Analyze REF: 213
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body
Systems
24. In reviewing the patient’s record, the nurse notes that the patient has air in the subcutaneous
tissue. The nurse validates that this patient has crepitus with which finding?
a. Asymmetric expansion of the chest wall on inhalation
b. Increased transmission of vocal vibrations on auscultation
c. Crackling sensation under the skin of the chest on palpation
d. Coarse grating sounds heard over the mediastinum on inspiration
ANSWER: C
A
B
C
D
Feedback
Asymmetric chest expansion occurs with rib fracture or chest wall injury.
Increased vocal fremitus occurs with lung consolidation.
A crackling sensation is the finding when crepitus is present.
Coarse grating sounds heard over the mediastinum on inspiration does not
validate crepitus.
DIF: Cognitive Level: Apply REF: 209
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body
Systems
25. Which patient should the nurse assess first?
a. The patient whose respiratory rate is 26 breaths per minute and whose trachea
deviates to the right.
b. The patient who has pleuritic chest pain, bilateral crackles, a productive cough of
yellow sputum, and fever.
c. The patient who is short of breath, using pursed-lip breathing, and in a tripod
position.
d. The patient whose respiratory rate is 20 breaths/min, and has 8-word dyspnea and
expiratory wheezes.
ANSWER: A
A
B
C
D
Feedback
This is a description of a left tension pneumothorax. The key manifestation is
deviation of the trachea from midline, which indicates high intrathoracic pressure
from the left that is pushing the mediastinum out of alignment. The respiratory
rate indicates tachypnea.
This is a description of a patient with pneumonia who needs to be examined, but
this is not a life-threatening condition.
This is a description of a patient with emphysema, a chronic disease. This patient
may have these manifestations frequently and does not need to be examined
immediately.
This is a description of a patient who is having an asthma attack, but it is not a
life threatening attack; the respiratory rate is the upper limits of normal; the
dyspnea is abnormal, but not far from normal; and the wheezing is on expiration
only.
DIF: Cognitive Level: Analyze REF: 201| 213-214| 220
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body
Systems
26. A patient reports a productive cough with yellow sputum, fever, and a sharp pain when taking
a deep breath to cough. Based on these data, what abnormal finding will the nurse anticipate
on examination?
a. Decreased breath sounds on auscultation
b. Increased tactile fremitus and dull percussion tones
c. Inspiratory wheezing found on auscultation
d. Muffled sounds heard when the patient says “e-e-e”
ANSWER: B
A
B
C
D
Feedback
Decreased breath sounds on auscultation is consistent with emphysema or
atelectasis when alveoli are narrowed or destroyed.
The data describe purulent sputum and inflammation of the pleura that may occur
in pneumonia. Additional findings include increased tactile fremitus and dull
percussion tones, indicating congested or consolidated lung tissues.
Inspiratory wheezing found on auscultation is consistent with narrowing of
bronchi that may occur in asthma.
Muffled sounds heard when the patient says “e-e-e” is a normal finding on vocal
resonance (bronchophony or egophony).
DIF: Cognitive Level: Apply REF: 198-199| 210| 215| 218
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body
Systems
27. A nurse palpating the chest of a patient finds increased fremitus bilaterally. What is the
significance of this finding?
a. An expected finding
b. Chronic obstructive pulmonary disease
c. Bilateral pneumonia
d. Bilateral pneumothorax
ANSWER: C
A
B
C
D
Feedback
An increase in fremitus from normal is not an expected finding.
Air trapping in chronic obstructive pulmonary disease causes a decreased
fremitus.
Increased fremitus occurs when lung tissues are congested or consolidated, which
may occur in patients who have pneumonia or a tumor.
Air in the pleural space causes a decreased fremitus.
DIF: Cognitive Level: Apply REF: 210| 215| 218
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body
Systems
MULTIPLE RESPONSE
1. What are the functions of the upper airways? Select all that apply.
a. Conduct air to lower airway.
b. Provide area for gas exchange.
c. Prevent foreign matter from entering respiratory system.
d. Warm, humidify, and filter air entering lungs.
e. Provide transportation of oxygen and carbon dioxide between alveoli and cells.
ANSWER: A, C, D
Correct: These are functions of the upper airway.
Incorrect: Gas exchange occurs in the alveoli. The cardiovascular system provides
transportation of oxygen and carbon dioxide between alveoli and cells.
DIF: Cognitive Level: Remember REF: 193-194
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific
Assessments
2. On inspection, the nurse finds the patient’s anteroposterior diameter of the chest to be the
same as the lateral diameter. What other findings does this nurse expect during the
examination? Select all that apply.
a. Inspiratory wheezing found on auscultation
b. Hyperresonance heard on percussion
c. Decreased breath sounds heard on auscultation
d. Deceased diaphragmatic excursion on percussion
e. A sharp, abrupt pain reported when the patient breathes deeply
f. Decreased to absent vibration on vocal fremitus
ANSWER: B, C, D, F
Correct: These are all indications of enlargement or destruction of alveoli that occurs in
emphysema. Air is trapped, which increases the anteroposterior to lateral diameter creating a
barrel chest, and pushes the diaphragm down decreasing the excursion and causing
hyperresonance. The destroyed alveoli decrease the breath sounds and create absent vibration
on vocal fremitus.
Incorrect: Inspiratory wheezing found on auscultation indicates narrowed airways as found in
asthma. A sharp, abrupt pain reported when the patient breathes deeply is pleuritic chest pain
associated with pleural lining irritation that may occur in a patient with pleurisy or
pneumonia.
DIF: Cognitive Level: Analyze REF: 207| 210-213| 215| 219
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body
Systems
3. On examination, a nurse finds the patient has a productive cough with green sputum and
inspiratory crackles. What other findings does this nurse expect during the examination?
Select all that apply.
a. Dull tones to percussion
b. Increased vibration on vocal fremitus
c. Fever
d. Decreased diaphragmatic excursion
e. A sharp, abrupt pain reported when patient breathes deeply
f. Muffled sounds heard when the patient says “e-e-e”
ANSWER: A, B, C, E
Correct: These abnormal findings are consistent with consolidation that may occur with
pneumonia.
Incorrect: Decreased diaphragmatic excursion occurs when the lung is overinflated as in
emphysema. Muffled sounds when the patient says “e-e-e” is an expected finding. With a
consolidation, the sound of “e-e-e” would be clear.
DIF: Cognitive Level: Analyze REF: 198-199| 210-211| 215| 218
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body
Systems
4. A nurse is assessing the respiratory system of a healthy adult. Which findings does this nurse
expect to find? Select all that apply.
a. Thoracic expansion that is symmetric bilaterally
b. Respiratory rate of 24 breaths/min
c. Bronchophony revealing clear voice sounds
d. Breath sounds clear with vesicular breath sounds heard over most lung fields
e. Anteroposterior diameter of the chest about a 1:2 ratio of anteroposterior to lateral
diameter
f. Symmetric thorax with ribs sloping downward at about 45 degrees relative to the
spine
ANSWER: A, D, E, F
Correct: These are expected findings from a lung and respiratory assessment of a healthy
adult.
Incorrect: A respiratory rate of 24 breaths/min is considered tachypnea. Bronchophony
revealing clear voice sounds is not performed unless there is an indication of consolidation of
the lung, or if there was an abnormal finding of tactile fremitus. The expected finding is
muffled voiced sounds rather than clear.
DIF: Cognitive Level: Apply REF: 204| 207-208| 210| 214| 217
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific
Assessments
COMPLETION
1. A patient tells the nurse that he has smoked 1 packs of cigarettes a day for 14 years. The
nurse records this as pack-years?
ANSWER:
21
1 packs of cigarettes 14 years = 21 pack-years.
DIF: Cognitive Level: Apply REF: 197
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific
Assessments
Chapter 12: Heart and Peripheral Vascular System
Test Bank
MULTIPLE CHOICE
1. A nurse informs a patient that her blood pressure is 128/78. The patient asks what the number
128 means. What is the nurse’s appropriate response? The 128 represents the pressure in your
blood vessels when:
a. “The ventricles relax and the aortic and pulmonic valves open.”
b. “The ventricles contract and the mitral and tricuspid valves close.”
c. “The ventricles contract and the mitral and tricuspid valves open.”
d. “The ventricles relax and the aortic and pulmonic valves close.”
ANSWER: B
A
B
C
D
Feedback
The aortic and pulmonic valves open during systole, but ventricles fill during
diastole.
During systole the ventricles contract, creating a pressure that closes the
atrioventricular (AV) valves (mitral and tricuspid).
During systole the ventricles contract, creating a pressure that closes the AV
valves (mitral and tricuspid).
The ventricles are relaxed and the aortic and pulmonic valves close during
diastole, rather than systole.
DIF: Cognitive Level: Understand REF: 225
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific
Assessments
2. A nurse determines that a patient has a heart rate of 42 beats per minute. What might be a
cause of this heart rate?
a. Sinoatrial (SA) node failure
b. Atrial bradycardia
c. A well-conditioned heart muscle
d. Left ventricular hypertrophy
ANSWER: A
A
B
C
D
Feedback
If the SA node is ineffective, the atrioventricular node may initiate contraction,
but at a rate of 40 to 60 beats/min.
The heart rate reflects the ventricular rate rather than the atrial rate.
Although well-conditioned athletes may have slower heart rates, this rate is too
slow for even an athlete.
Left ventricular hypertrophy alters the strength of contraction rather than the heart
rate.
DIF: Cognitive Level: Apply REF: 226
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body
Systems
3. While taking a history, a nurse learns that a patient had rheumatic heart disease as a child.
Based on this information, what abnormal data might this nurse expect to find during an
examination?
a. An extra beat just before the S 2 heart sound heard during auscultation
b. A raspy machine-like or blowing sound heard during auscultation
c. A prominent thrust of the heart against the chest wall felt on palpation
d. A visible indentation of pericardial tissue noted during inspection
ANSWER: B
A
B
C
D
Feedback
An extra beat just before the S 1 heart sound heard during auscultation is a
description of the S 4 heart sound that occurs when there is hypertrophy of the
ventricle.
A raspy machine-like or blowing sound heard during auscultation is a description
of a murmur that can develop after rheumatic heart disease.
A prominent thrust of the heart against the chest wall felt on palpation is a
description of a heave, which may occur from left ventricular hypertrophy due to
increased workload.
A visible indentation of pericardial tissue noted during inspection is a description
of a retraction that begins in the intercostal spaces and occurs with increased
respiratory effort.
DIF: Cognitive Level: Analyze REF: 229| 259
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
4. A nurse is completing a symptom analysis with a patient complaining of chest pain. When
asked what makes the chest pain worse, the patient reports that coughing and sneezing
increase the chest pain. Based on these data, what does the nurse suspect as the cause of this
patient’s chest pain?
a. Stable angina
b. Esophageal reflux disease
c. Mitral valve prolapse
d. Costochondritis
ANSWER: D
A
B
C
D
Feedback
Physical exertion, emotional stress, and cold worsen the chest pain associated
with stable angina.
A spicy or acidic meal, alcohol, or lying supine may worsen the chest pain
associated with esophageal reflux.
Only occasional position changes worsen the chest pain associated with mitral
valve prolapse.
Coughing, deep breathing, laughing, and sneezing worsen the chest pain
associated with costochondritis.
DIF: Cognitive Level: Apply REF: 230-231
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
5. The patient describes her chest pain as “squeezing, crushing, and 12 on a scale of 10.” This
pain started more than an hour ago while she was resting, and she also feels nauseous. Based
on these findings, the nurse should assess for which associated symptoms?
a. Tachycardia, tachypnea, and hypertension
b. Dyspnea, diaphoresis, and palpitations
c. Hyperventilation, fatigue, anorexia, and emotional strain
d. Fever, dyspnea, orthopnea, and friction rub
ANSWER: B
A
B
C
D
Feedback
Tachycardia, tachypnea, and hypertension are symptoms associated with cocaineinduced
chest pain.
Dyspnea, diaphoresis, and palpitations are symptoms associated with unstable
angina.
Hyperventilation, fatigue, anorexia, and emotional strain are symptoms associated
with panic disorder.
Fever, dyspnea, orthopnea, and friction rub are symptoms associated with
pericarditis.
DIF: Cognitive Level: Analyze REF: 230-231
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
6. When auscultating the heart of a patient with pericarditis, the nurse expects to hear which
sound?
a. A systolic murmur
b. An S 3 heart sound
c. A friction rub
d. An S 4 heart sound
ANSWER: C
A
B
C
D
Feedback
Most systolic murmurs are caused by obstruction of the outflow of the semilunar
valves or by incompetent AV valves.
An S 3 heart sound occurs when there is heart failure.
Two classic findings of pericarditis are pericardial friction rub and chest pain.
An S 4 heart sound occurs when there is hypertrophy of the ventricle.
DIF: Cognitive Level: Apply REF: 230-231
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
7. Which patient’s statement helps a nurse distinguish between chest pain originating from
pericarditis rather than from angina?
a. “No, I have not done anything to strain chest muscles.”
b. “If I take a deep breath, the pain gets much worse.”
c. “This pain feels like there’s an elephant sitting on my chest.”
d. “Whenever this pain happens, it goes right away if I lie down.”
ANSWER: B
A
B
C
D
Feedback
Chest pain from muscle strain may be aggravated by movement of arms.
The chest pain from pericarditis is aggravated by deep breathing, coughing, or
lying supine.
“This pain feels like there’s an elephant sitting on my chest” is associated with a
myocardial infarction.
Chest pain relieved by rest occurs with angina.
DIF: Cognitive Level: Analyze REF: 230-231
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
8. While taking a history, a nurse learns that this patient experiences shortness of breath
(dyspnea). If the cause of the dyspnea is a cardiovascular problem, the nurse expects which
abnormal finding on examination?
a. Flat jugular neck veins
b. Red, shiny skin on the legs
c. Weak, thready peripheral pulses
d. Edema of the feet and ankles
ANSWER: D
A
B
C
D
Feedback
Flat jugular veins indicate a fluid deficit, which is not associated with dyspnea.
Red, shiny skin on the legs is associated with peripheral arterial disease and is not
associated with dyspnea.
Weak, thready peripheral pulses indicate fluid deficit, which is not associated
with dyspnea.
This patient may have heart failure. Edema of the feet occurs with right
ventricular heart failure. Dyspnea occurs with left ventricular heart failure.
DIF: Cognitive Level: Analyze REF: 230| 232-233
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
9. A nurse is assessing a patient’s peripheral circulation. Which finding indicates venous
insufficiency of this patient’s legs?
a. Paresthesias and weak, thin peripheral pulses
b. Leg pain that can be relieved by walking
c. Edema that is worse at the end of the day
d. Leg pain that increases when the legs are lowered
ANSWER: C
A
B
C
D
Feedback
Paresthesias and weak, thin peripheral pulses are characteristics of arterial
insufficiencies rather than venous.
Pain caused by arterial insufficiency gets worse by walking, because walking
requires additional arterial blood.
Dependent edema is an indication of venous insufficiency.
Arterial pain is relieved by lowering the leg and aggravated by elevating the legs.
DIF: Cognitive Level: Apply REF: 233| 255
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
10. A patient reports having leg pain while walking that is relieved with rest. Based on these data,
the nurse expects which finding on inspection and palpation of this patient?
a. 1+ edema of the feet and ankles bilaterally
b. The circumference of the right leg is larger than the left leg
c. Patchy petechiae and purpura of the lower extremities
d. Cool feet with capillary refill of toes greater than 3 seconds
ANSWER: D
A
B
C
D
Feedback
Edema of 1+ of the feet and ankles bilaterally is an indication of a venous
problem rather than an arterial problem.
When one leg is larger in circumference than the other, it could be due to
lymphedema or a deep vein thrombosis.
Petechiae and purpura of the lower extremities indicate a bleeding problem, such
as low platelets, rather than an arterial problem.
The pain while walking that is relieved by rest is called intermittent claudication
and is an indication of arterial insufficiency. Cool feet and prolonged capillary
refill also occur due to arterial insufficiency.
DIF: Cognitive Level: Analyze REF: 233| 241
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
11. How does a nurse accurately palpate carotid pulses?
a. Two fingers of each hand are placed firmly over the right and left temples at the
same time.
b. One finger is placed gently in the space between the biceps and triceps muscles.
c. Two fingers are placed at the thumb side of the forearm at the wrist.
d. One finger is placed along the right and then the left medial sternocleidomastoid
muscle.
ANSWER: D
A
B
C
D
Feedback
Two fingers of each hand placed firmly over the right and left temples at the same
time is the correct procedure for palpating the temporal pulse.
One finger placed gently in the space between the biceps and triceps muscles is
the correct procedure for palpating the brachial pulse.
Two fingers placed at the thumb side of the forearm at the wrist is the correct
procedure for palpating the radial pulse.
One finger placed along the right and then the left medial sternocleidomastoid
muscle is the correct procedure for palpating the carotid pulses, checking each
side separately.
DIF: Cognitive Level: Understand REF: 234-235
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
12. To document the palpation of a pulse, the nurse is correct in making which notation about the
rhythm?
a. “Rhythm 100 beats/min”
b. “Irregular rhythm”
c. “Rhythm noted at +2”
d. “Bounding rhythm”
ANSWER: B
A
B
C
D
Feedback
This notation refers to the rate rather than the rhythm.
The rhythm should be an equal pattern or spacing between beats. Irregular
rhythms without any pattern should be noted.
This notation refers to the amplitude rather than the rhythm.
This notation refers to the contour rather than the rhythm.
DIF: Cognitive Level: Apply REF: 236
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific
Assessments
13. A nurse expects which finding during a cardiovascular assessment of a healthy adult?
a. Visible, consistent pulsations of the jugular vein
b. Pink nail beds with a 90-degree angle at the base
c. Capillary refill of the toes greater than 5 seconds
d. Bruits heard on auscultation of the carotid arteries
ANSWER: A
A
B
Feedback
Visible, consistent pulsations of the jugular vein is an expected finding.
Pink nail beds with a 90-degree angle at the base is not a normal finding; the
angle at the base should be 160 degrees.
C
D
Capillary refill of the toes greater than 5 seconds is not a normal finding.
Capillary refills should be 2 seconds or less.
Bruits heard on auscultation of the carotid arteries is not a normal finding. Bruits
indicate occlusion of a blood vessel.
DIF: Cognitive Level: Apply REF: 235| 237
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific
Assessments
14. Which pulse may be a challenge for a nurse to palpate?
a. Temporal
b. Femoral
c. Popliteal
d. Dorsalis pedis
ANSWER: C
A
B
C
D
Feedback
The temporal pulse is palpated over the temporal bone on each side of the head.
For the femoral pulse, palpate below the inguinal ligament, midway between the
symphysis pubis and anterior superior iliac.
For the popliteal pulse, palpate the popliteal artery behind the knee in the
popliteal fossa to assess perfusion. This pulse may be difficult to find.
For the dorsalis pedis pulse, palpate on the inner aspect of the ankle below and
slightly behind the medial malleolus (ankle bone).
DIF: Cognitive Level: Understand REF: 241-242
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
15. When assessing a patient with aortic valve stenosis, the nurse listens for which sound to detect
a thrill?
a. Sustained thrust of the heart against the chest wall during systole
b. Visible sinking of the tissues between and around the ribs
c. Fine, palpable vibration felt over the precordium
d. Bounding pulse noted bilaterally
ANSWER: C
A
B
C
D
Feedback
A sustained thrust of the heart against the chest wall during systole is a
description of a lift.
A visible sinking of the tissues between and around the ribs is a description of a
retraction.
A thrill is a palpable vibration over the precordium or artery.
A thrill feels like a palpable vibration rather than a bounding pulse.
DIF: Cognitive Level: Understand REF: 243| 248
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
16. A nurse is having difficulty auscultating a patient’s heart sounds because the lung sounds are
too loud. What does the nurse ask the patient to do to improve hearing the heart sounds?
a. Lie in a supine position.
b. Cough.
c. Hold his or her breath for a few seconds.
d. Sit up and lean forward.
ANSWER: C
A
B
C
D
Feedback
Lying in a supine position will not reduce the noise of breathing.
Coughing may clear some secretions, but when the lung sounds are so noisy that
the heart sounds are difficult to hear, coughing is not sufficient to eliminate the
noise from respirations.
Holding the breath for a few seconds eliminates the noise of breathing long
enough to hear several cardiac cycles of heart sounds. The holding of the breath
can be repeated if needed to hear the heart sounds again.
Sitting up and leaning forward brings the heart closer to the thoracic wall, but will
not eliminate noise produced by the lungs.
DIF: Cognitive Level: Analyze REF: 244
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
17. While assessing edema on a male patient’s lower leg, the nurse notices that there is a slight
imprint of his fingers where he palpated the patient’s leg. How does the nurse document this
finding?
a. No edema
b. 1+ edema
c. 2+ edema
d. 3+ edema
ANSWER: B
A
B
C
D
Feedback
No pit left after palpation indicates no edema.
A barely perceptible pit is detected after palpation.
A deeper pit that rebounds in a few seconds after palpation is 2+ edema.
A deep pit that rebounds in 10 to 20 seconds after palpation is 3+ edema.
DIF: Cognitive Level: Apply REF: 238
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
18. Where does a nurse place a stethoscope to auscultate the mitral valve area? Choose the letter
that corresponds to the correct stethoscope placement.
a. A
b. B
c. D
d. E
ANSWER: D
A
B
C
D
Feedback
A is the location of the aortic valve area—second intercostal space, right sternal
border.
B is the location of the pulmonic valve area—fifty-second intercostal space, left
sternal border.
D is the location of the tricuspid valve area—fourth intercostal space, left sternal
border.
E is the location of the mitral valve area—the fifth intercostal space,
midclavicular line.
DIF: Cognitive Level: Understand REF: 245-246
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific
Assessments
19. Which valve does a nurse auscultate when the stethoscope is placed on the fourth intercostal
space at the left of the sternal border?
a. Pulmonic
b. Tricuspid
c. Mitral
d. Aortic
ANSWER: B
A
B
C
Feedback
Pulmonic valve sounds are best heard in the second intercostal space at the left of
the sternal border.
Tricuspid valve sounds are best heard in the fourth intercostal space at the left of
the sternal border.
Mitral valve sounds are best heard in the fifth intercostal space at the
midclavicular line.
D
Aortic valve sounds are best heard in the second intercostal space at the right of
the sternal border.
DIF: Cognitive Level: Remember REF: 245-246
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
20. A patient reports that he has coronary artery disease with ventricular hypertrophy. Based on
these data, what finding should the nurse expect during assessment?
a. S 4 heart sound
b. Clubbing of fingers
c. Splitting of the S 1 heart sound
d. Pericardial friction rub
ANSWER: A
A
B
C
D
Feedback
An S 4 heart sound signifies a noncompliant or “stiff’’ ventricle. Coronary artery
disease is a major cause of a stiff ventricle.
Clubbing of fingers occurs due to chronic hypoxia rather than a stiff ventricle.
Splitting of the S 1 heart sound indicates a valve problem rather than ventricular
hypertrophy. When the mitral and tricuspid valves do not close at the same time,
S 1 sounds as if it were split into two sounds instead of one.
Pericardial friction rubs are caused by inflammation of the layers of the
pericardial sac.
DIF: Cognitive Level: Apply REF: 225-226| 248
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
21. What does the S 2 heart sound represent?
a. The beginning of systole.
b. The closure of the aortic and pulmonic valves.
c. The closure of the tricuspid and mitral values
d. A split heard sound on exhalation
ANSWER: B
A
B
C
D
Feedback
The beginning of systole is the S 1 heart sound.
The second heart sound is made by the closing of these valves, which indicates
the beginning of diastole.
The tricupid and mitral valves create the S 1 heart sound.
A split sound on exhalation is not a correct statement.
DIF: Cognitive Level: Remember REF: 226| 244
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific
Assessments
22. How is the first heart sound (S 1 ) created?
a. Pulmonic and tricuspid valves close.
b. Mitral and aortic valves close.
c. Aortic and pulmonic valves close.
d. Mitral and tricuspid valves close.
ANSWER: D
A
B
C
D
Feedback
The pulmonic and tricuspid valves are the valves of the right side of the heart, and
they do not close simultaneously in the cardiac cycle.
The mitral and aortic valves are the valves of the left side of the heart, and they
do not close simultaneously in the cardiac cycle.
The aortic and pulmonic valves are the semilunar valves that create the second
heart sound.
The first heart sound (S 1 ) is made by the closing of the mitral (M1) and tricuspid
(T1) valves.
DIF: Cognitive Level: Remember REF: 226| 244
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific
Assessments
23. A nurse learns from a report that a patient has aortic stenosis. Where does the nurse place the
stethoscope to hear this stenotic valve?
a. Second intercostal space, right sternal border
b. Second intercostal space, left sternal border
c. Fourth intercostal space, left sternal border
d. Fifth intercostal space, left midclavicular line
ANSWER: A
A
B
C
D
Feedback
Second intercostal space, right sternal border is the location for listening to the
aortic valve.
Second intercostal space, left sternal border is the location for listening to the
pulmonic valve.
Fourth intercostal space, left sternal border is the location for listening to the
tricuspid valve.
Fifth intercostal space, left midclavicular line is the location for listening to the
mitral valve.
DIF: Cognitive Level: Apply REF: 244-246
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
24. A nurse who is auscultating a patient’s heart hears a harsh sound, a raspy machine-like
blowing sound, after S 1 and before S 2 . How does this nurse document this finding?
a. An opening snap
b. A diastolic murmur
c. A systolic murmur
d. A pericardial friction rub
ANSWER: C
A
B
C
D
Feedback
An opening snap is caused by the opening of the mitral or tricuspid valve and is
an abnormal sound heard in diastole when either valve is thickened, stenotic, or
deformed. The sounds are high pitched and occur early in diastole.
A diastolic murmur is heard after the S 2 heart sound at the beginning of diastole.
The blowing sound is a murmur. The nurse determines whether it is a systolic or a
diastolic murmur based on where it is heard during the cardiac cycle. S 1 indicates
the beginning of systole; the sound is made by the closing of the mitral and
tricuspid valves, which is followed by ventricular contraction or systole.
Pericardial friction rubs have a rubbing sound that is usually present in both
diastole and systole, and is best heard over the apical area.
DIF: Cognitive Level: Apply REF: 248-249
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
25. A nurse determines that a patient’s jugular venous pressure is 3.5 inches. What additional data
does the nurse expect to find?
a. Weight loss
b. Tented skin turgor
c. Peripheral edema
d. Capillary refill greater than 5 seconds
ANSWER: C
A
B
C
D
Feedback
Weight loss occurs with loss of fluid rather than fluid overload.
Tented skin turgor occurs with fluid loss rather than fluid overload.
The pressure should not rise more than 1 inch (2.5 cm) above the sternal angle. A
pressure of 3.5 inches indicates fluid volume excess, which causes peripheral
edema due to excessive fluid in blood vessels.
Capillary refill greater than 5 seconds occurs with arterial insufficiency rather
than fluid overload.
DIF: Cognitive Level: Analyze REF: 252-253| 260-261
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
26. How does a nurse assess the competence of venous valves in patients who have varicose
veins?
a. Notes how quickly veins fill after lifting one leg above the level of the heart
b. Assesses for Homan sign in both lower extremities while the patient is supine
c. Assesses capillary refill on the toes of both feet while the patient is sitting in the
chair
d. Measures the circumference of both calves and compares the results
ANSWER: A
A
B
C
D
Feedback
Noting how quickly veins fill after lifting one leg above the level of the heart is
the procedure to test for incompetent veins.
Homan sign is an unreliable test for deep vein thrombosis.
Assessing capillary refill assesses perfusion (blood flow from arteries) rather than
competence of venous valves.
Measuring the circumference of both calves and comparing the results is used to
assess deep vein thrombosis.
DIF: Cognitive Level: Apply REF: 255
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
27. Which patient does the nurse identify as the one at greatest risk for hypertension?
a. Woman with coronary artery disease
b. Hispanic male
c. Obese male with diabetes mellitus
d. Postmenopausal woman
ANSWER: C
A
B
C
D
Feedback
Although hypertension is a risk factor for coronary artery disease, coronary artery
disease is not a risk factor for hypertension.
Although male gender is a risk factor, African-American men have a greater risk
than Hispanic men.
Obese men with diabetes mellitus have three risk factors: obesity, gender, and
comorbidity of diabetes mellitus.
Postmenopausal women do not have an increased risk for developing
hypertension.
DIF: Cognitive Level: Apply REF: 260
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Health Promotion Programs
28. After two separate office visits, the nurse suspects that a patient is developing Stage 1
hypertension based on which consecutive blood pressure readings?
a. Visit 1, 118/78; Visit 2, 116/76
b. Visit 1, 130/88; Visit 2, 134/88
c. Visit 1, 144/92; Visit 2, 150/90
d. Visit 1, 162/100; Visit 2, 166/104
ANSWER: C
Feedback
A These readings are within normal limits.
B These readings are prehypertension because the systolic pressures are 120 to 139
and diastolic pressures are greater than 80 mm Hg.
C These readings are stage 1 because the systolic pressures are 140 to 159 and
diastolic pressures are 90 mm Hg or greater.
D These readings are stage 2 because the systolic pressures are greater than 160 and
diastolic pressures are 100 mm Hg or greater.
DIF: Cognitive Level: Analyze REF: 261
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
MULTIPLE RESPONSE
1. During a health fair, the nurse is alert for which risk factors for hypertension? Select all that
apply.
a. Excessive protein intake
b. Having parents with hypertension
c. Excessive alcohol intake
d. Being Asian
e. Experiencing persistent stress
f. Elevated serum lipids
ANSWER: B, C, E, F
Correct: These are all risk factors for hypertension.
Incorrect: Excessive protein is not a risk factor for hypertension, but excessive sodium intake
is a risk factor. Being Asian is not a risk factor, but being African-American is a risk factor.
DIF: Cognitive Level: Analyze REF: 261
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: Potential for
Alteration in Body Systems
2. A patient with heart failure reports having a cough with frothy sputum and awakening during
the night to urinate. Based on this information, what abnormal data might this nurse expect to
find during an examination? Select all that apply.
a. S 4 heart sound
b. Dyspnea
c. Jugular vein distention
d. Pericardial friction rub
e. Edema of ankle and feet at the end of the day
f. S 3 heart sound
ANSWER: B, C, E, F
Correct: All of these manifestations are consistent with fluid overload that occurs in heart
failure because the cardiac output is decreased.
Incorrect: S 4 heart sounds signifies a noncompliant or “stiff’’ ventricle. Hypertrophy of the
ventricle precedes a noncompliant ventricle. Also, coronary artery disease is a major cause of
a stiff ventricle. Pericardial friction rubs are caused by inflammation of the layers of the
pericardial sac.
DIF: Cognitive Level: Analyze REF: 230| 233| 238| 247| 252-253| 260
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body
Systems
3. What findings does the nurse expect when assessing the cardiovascular system of a healthy
adult? Select all that apply.
a. Heart rate of 102 beats/min
b. S 1 and S 2 present with regular rhythm
c. Capillary refill greater than 3 seconds
d. Blood pressure of 124/86
e. Warm, elastic turgor
f. Pulse of smooth contour with 2+ amplitude
ANSWER: B, E, F
Correct: These are all expected findings.
Incorrect: A heart rate of 102 beats/min is tachycardia. Capillary refill should be 2 seconds or
less. Blood pressure of 124/86 is prehypertension. Normal is less than 120 and less than 80
mm Hg.
DIF: Cognitive Level: Analyze REF: 238-239| 241| 244| 259
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific
Assessments
COMPLETION
1. A patient’s blood pressure using the posterior tibial pulse is 104/72 while blood pressure using
the brachial pulse is 112/84. This patient’s ankle-brachial index (ABI) is .
ANSWER:
0.92
Posterior tibial systolic pressure (104) divided by the brachial systolic pressure (112) = 0.92.
The systolic pressures are the numbers used to calculate the ABI.
DIF: Cognitive Level: Apply REF: 256
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific
Assessments
Chapter 13: Abdomen and Gastrointestinal System
Test Bank
MULTIPLE CHOICE
1. A patient tells the nurse, “I’ve been having pain in my belly for several days that gets worse
after eating.” Which datum from the symptom analysis is consistent with the nurse’s suspicion
of peptic ulcer disease?
a. Gnawing epigastric pain radiates to the back or shoulder that worsens after eating.
b. Sharp midepigastric pain radiates to the jaw.
c. Intermittent cramping pain in the left lower quadrant is relieved by defecation.
d. Colicky pain is felt near the umbilicus with vomiting and constipation.
ANSWER: A
A
B
C
D
Feedback
Gnawing epigastric pain that radiates to the back or shoulder and worsens after
eating is a symptom that is consistent with peptic ulcer disease.
Sharp midepigastric pain that radiates to the jaw is not a symptom of peptic ulcer
disease.
Intermittent cramping pain in the left lower quadrant relieved by defecation is a
symptom of diverticular disease rather than peptic ulcer disease.
Colicky pain felt near the umbilicus with vomiting and constipation is a symptom
of an intestinal obstruction rather than peptic ulcer disease.
DIF: Cognitive Level: Apply REF: 268-269
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
2. During an assessment for abdominal pain, a patient reports a colicky abdominal pain and pain
in the right shoulder that gets worse after eating fried foods. What question does the nurse ask
to confirm the suspicion of cholelithiasis?
a. “Have you noticed any swelling in your ankles or feet at the end of the day?”
b. “Have you noticed a change in the color of your urine or stools?”
c. “Have you vomited up any blood in the last 24 hours?”
d. “Have you experienced fever, chills, or sweating?”
ANSWER: B
A
B
C
D
Feedback
This question is related to fluid retention, which may be asked if the patient has
renal or heart failure.
Gallstones can obstruct the flow of bile to the gastrointestinal tract making urine
darker and stools lighter in color.
This question applies if the patient has peptic ulcer disease or esophageal varices.
This question applies if the patient has gastroenteritis or a urinary tract infection.
DIF: Cognitive Level: Analyze REF: 268-269
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific
Assessments
3. A patient reports having frequent heartburn. Which question does the nurse ask in response to
this information?
a. “Has your abdomen been distended when you feel the heartburn?”
b. “What have you eaten in the last 24 hours?”
c. “Is there a history of heart disease in your family?”
d. “How long after eating do you have heartburn?”
ANSWER: D
A
B
C
D
Feedback
The question “Has your abdomen been distended when you feel the heartburn?”
is not related to the heartburn. Distention usually is related to intestinal
obstruction or liver disease.
The question “What have you eaten in the last 24 hours?” relates more to
gastroenteritis. Indigestion is usually caused by food eaten in the last meal rather
than in the last 24 hours.
The question “Is there a history of heart disease in your family?” points to
myocardial ischemia. Although heartburn may be a symptom of myocardial
ischemia, asking the patient about the family history is not relevant in this case.
Asking “How long after eating do you have heartburn?” can aid in determining if
the patient has gastroesophageal reflux disease or a hiatal hernia. Both are
common disorders that cause indigestion a few hours after meals.
DIF: Cognitive Level: Apply REF: 268-270
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
4. A patient reports having abdominal distention. The nurse notices that the patient’s sclerae are
yellow. What question is appropriate for the nurse to ask in response to this information?
a. “Has there been a change in your usual pattern of urination?”
b. “Have you had any nausea or vomiting?”
c. “Has there been a change in your bowel habits?”
d. “Have you had indigestion or heartburn?”
ANSWER: B
A
B
C
D
Feedback
“Has there been a change in your usual pattern of urination?” is not a question
related to the abdominal distention and jaundice.
“Have you had any nausea or vomiting?” is an appropriate question because the
nurse suspects the patient may have a liver disease based on the abdominal
distention and jaundice. The nurse interprets the relationship with data gathered
from the history and the observation.
“Has there been a change in your bowel habits?” is a question that may be related
to the abdominal distention, but not the jaundice.
“Have you had indigestion or heartburn?” is not a question related to the
abdominal distention and jaundice. It applies more to gastric disorders, such as
gastroesophageal reflux disease or hiatal hernia.
DIF: Cognitive Level: Analyze REF: 269-270
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
5. A patient reports having abdominal distention and having vomited several times yesterday and
today. What question is appropriate for the nurse to ask in response to this information?
a. “Has there been a change in your usual pattern of urination?”
b. “Did you have heartburn before the vomiting?”
c. “What did the vomitus look like?”
d. “Have you noticed a change in the color of your urine or stools?”
ANSWER: C
A
B
C
D
Feedback
“Has there been a change in your usual pattern of urination?” is not a question
related to abdominal distention and vomiting.
Have you noticed a change in the color of your urine or stools?” is not a question
related to abdominal distention and vomiting. It is related to elevated bilirubin
from liver or gallbladder disease and is accompanied by jaundice.
“What did the vomitus look like?” is an appropriate question because the
characteristics of the vomitus may help determine its cause. Acute gastritis leads
to vomiting of stomach contents, obstruction of the bile duct results in greenishyellow
vomitus, and an intestinal obstruction may cause a fecal odor to the
vomitus.
This is not a question related to the abdominal distention and vomiting. Heartburn
applies more to gastric disorders, such as gastroesophageal reflux disease or hiatal
hernia.
DIF: Cognitive Level: Apply REF: 268| 270
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
6. A patient reports a change in the usual pattern of urination. What question does the nurse ask
to determine if incontinence is the reason for these symptoms?
a. “Do you have the feeling that you cannot wait to urinate?”
b. “Are you urinating a large amount each time you go to the bathroom?”
c. “Has the color of your urine changed lately?”
d. “Have you noticed any swelling in your ankles at the end of the day?”
ANSWER: A
A
B
Feedback
“Do you have the feeling that you cannot wait to urinate?” is a question that asks
about urgency, a symptom of incontinence.
Are you urinating a large amount each time you go to the bathroom?” is not a
question related to incontinence. Usually patients with incontinence void
frequently in small amounts.
C
D
Has the color of your urine changed lately?” is a question that is asked when the
nurse suspects the patient has gallbladder or liver disease.
Have you noticed any swelling in your ankles at the end of the day?” is a question
that relates to patients who have renal or heart disease.
DIF: Cognitive Level: Apply REF: 270-271
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
7. In assessing a patient with renal disease, the nurse palpates edema in both ankles and feet.
Based on this finding, what question does the nurse ask the patient?
a. “Have you had any pain in your abdomen?”
b. “Have you had an unexpected weight gain?”
c. “Have you noticed a change in the color of your skin?”
d. “Have you had any nausea or vomiting?”
ANSWER: B
A
B
C
D
Feedback
“This question does not relate to renal disease. The pain experienced with renal
disease is usually flank pain over the costovertebral angle.
This question relating to weight gain and edema suggests fluid retention that
occurs with renal or heart disease, particularly renal failure.
This question does not relate to renal disease. It might relate to liver or
gallbladder disease if the change in skin color was yellow, indicating jaundice.
This question usually relates to disorders within the gastrointestinal tract itself
and not renal disease.
DIF: Cognitive Level: Apply REF: 270-271
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
8. A patient reports having abdominal distention. The nurse observes that the patient’s sclerae are
yellow. Which abnormal finding does the nurse anticipate on examination of this patient’s
abdomen?
a. Decreased bowel sounds in all quadrants
b. Glistening or taut skin of the abdomen
c. Bulge in the abdomen when coughing
d. Bruit around the umbilicus
ANSWER: B
A
B
Feedback
Decreased bowel sounds in all quadrants may be present if the abdominal
distention was from an intestinal obstruction, but the observation of jaundice
suggests liver disease, which does not decrease bowel sounds.
Glistening or taut skin of the abdomen is consistent with ascites that appear as
abdominal distention. Jaundice and ascites suggest liver disease. There would
also be an increase in abdominal girth.
C
D
A bulge in the abdomen when coughing is a finding associated with abdominal or
incisional hernias.
Bruit around the umbilicus is a finding associated with an abdominal aortic
aneurysm.
DIF: Cognitive Level: Analyze REF: 270
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
9. When inspecting a patient’s abdomen, which finding does the nurse note as normal?
a. Engorgement of veins around the umbilicus
b. Sudden bulge at the umbilicus when coughing
c. Visible peristalsis in all quadrants
d. Silver-white striae extending from the umbilicus
ANSWER: D
A
B
C
D
Feedback
Engorgement of veins around the umbilicus is an abnormal finding.
Sudden bulge at the umbilicus when coughing is an abnormal finding and may
indicate a hernia.
Visible peristalsis in all quadrants is an abnormal finding.
Silver-white striae extending from the umbilicus is a normal finding, particularly
in women who have been pregnant or in any adult who has lost weight after
having an obese abdomen.
DIF: Cognitive Level: Understand REF: 272
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
10. When inspecting a patient’s abdomen, the nurse notes which finding as abnormal?
a. Protruding abdomen with skin that is lighter in color than the arms and legs
b. Marked rhythmic pulsation to the left of the midline
c. Faint, fine vascular network
d. Small shadows created by changes in contour
ANSWER: B
A
B
C
D
Feedback
Obesity may cause a protruding abdomen and although obesity is not an indicator
of health, it does not necessarily indicate a disease is present.
Marked rhythmic pulsation to the left of the midline is an abnormal finding that
may indicate an abdominal aortic aneurysm.
A faint, fine vascular network is a normal finding. If the vessels were engorged, it
would be an abnormal finding.
Small shadows created by changes in contour are a normal finding and they are
seen by using a light source to inspect the contour.
DIF: Cognitive Level: Understand REF: 272
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
11. On inspection of a female patient’s abdomen, the nurse asks the patient to raise her head
without using her arms and notes a midline bulge. What is the appropriate response of the
nurse at this time?
a. Ask the patient to cough to see if the bulge reappears.
b. Auscultate the patient’s abdomen for hypoactive bowel sounds.
c. Document this as a normal finding and continue the examination.
d. Perform light and deep palpation of the abdomen.
ANSWER: C
A
B
C
D
Feedback
Ask the patient to cough to see if the bulge reappears. A bulge that appears with
coughing is an abnormal finding revealed by the increase in intrathoracic pressure
during the cough.
Auscultating the patient’s abdomen for hypoactive bowel sounds is not indicated
because the bulge is a normal finding.
Document this as a normal finding and continue the examination. This is a normal
finding on a patient
Performing light and deep palpation of the abdomen are not indicated because the
bulge is a normal finding.
DIF: Cognitive Level: Understand REF: 273
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
12. A nurse notices abdominal distention when inspecting a patient’s abdomen. What action does
the nurse take next to gain further objective data?
a. Place a measuring tape around the superior iliac crests.
b. Assist the patient to turn on to the left side and then the right side.
c. Ask the patient to cough while lying supine.
d. Use the fingertips to sharply strike one side of the abdomen.
ANSWER: A
A
B
C
D
Feedback
This is the procedure for measuring abdominal girth.
This procedure is unnecessary. The distention will remain in a side-lying position.
Having the patient cough is used to assess for bulges rather than distention.
This is part of the procedure to test for a fluid wave, which is not indicated in this
patient.
DIF: Cognitive Level: Understand REF: 273
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
13. A nurse inspects the abdomen for skin color, surface characteristics, and surface movement.
What part of the abdominal assessment does the nurse perform next?
a. Palpate lightly for tenderness and muscle tone.
b. The tip of the middle finger of the dominant hand strikes the nail of the middle
finger touching the skin of the abdomen.
c. Palpate deeply for masses or aortic pulsation.
d. Percuss for tones.
ANSWER: B
A
B
C
D
Feedback
Palpating lightly for tenderness and muscle tone is performed after auscultation.
Auscultation for bowel sounds occurs before palpating and percussing the
abdomen.
Palpating deeply for masses or aortic pulsation is performed after light palpation.
Percussion for tones is performed after palpation.
DIF: Cognitive Level: Apply REF: 273
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
14. How does the nurse accurately assess bowel sounds?
a. Press the diaphragm of the stethoscope firmly against the abdomen in each
quadrant.
b. Hold the diaphragm of the stethoscope lightly against the abdomen in each
quadrant.
c. Press the bell of the stethoscope firmly against the abdomen in each quadrant.
d. Hold the bell of the stethoscope lightly against the abdomen in each quadrant.
ANSWER: B
A
B
C
D
Feedback
Pressing the diaphragm of the stethoscope firmly against the abdomen in each
quadrant is not the correct technique for listening to bowel sounds.
Holding the diaphragm lightly against the abdomen in each quadrant is the correct
technique for listening to bowel sounds.
The bell is used to listen to vascular sounds of the abdomen, which are normally
not heard.
The bell is used to listen to vascular sounds of the abdomen, which are normally
not heard.
DIF: Cognitive Level: Understand REF: 273
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
15. When auscultating a patient’s abdomen using the bell of the stethoscope, the nurse hears soft,
low-pitched murmurs over the right and left upper midline. What do these sounds indicate?
a. Expected peristalsis
b. Femoral artery stenosis
c. Renal artery stenosis
d. Hyperactive bowel sounds
ANSWER: C
A
B
C
D
Feedback
Expected peristalsis would be heard using the diaphragm of the stethoscope and
would be a gurgling sound.
Femoral artery stenosis is a vascular sound heard with the bell, but located in the
lower abdomen.
Renal artery stenosis is a vascular sound heard with the bell and located in the
upper abdomen.
Hyperactive bowel sounds would be heard using the diaphragm and would be
present in all quadrants.
DIF: Cognitive Level: Understand REF: 274
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
16. What sound does a nurse expect to hear when using the bell of the stethoscope over the
epigastric area of the abdomen of a healthy patient?
a. Bowel sounds
b. Venous hum
c. Soft, low-pitched murmur
d. No sounds
ANSWER: D
A
B
C
D
Feedback
Bowel sounds are heard with the diaphragm of the stethoscope.
Venous hum is not a normal finding.
Soft, low-pitched murmur is not a normal finding.
The bell is used to listen for vascular sounds and normally no vascular sounds are
heard in the abdomen.
DIF: Cognitive Level: Understand REF: 274
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
17. What instructions does the nurse give a patient before palpating the abdomen?
a. Bend the knees.
b. Take a deep breath and hold it.
c. Take a deep breath and cough.
d. Place the hands over the head.
ANSWER: A
A
B
Feedback
Bend the knees to relax the abdominal muscles.
This action is not needed to assess the abdomen.
C
D
This action is used to detect bulges in the abdomen, but not used before palpation.
This action is not needed to assess the abdomen.
DIF: Cognitive Level: Remember REF: 275
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
18. A patient reports intermittent cramping abdominal pain that is relieved by having a bowel
movement. The patient complains of having the pain at this time, which is why she is seeking
care. Which abnormal finding does the nurse anticipate finding on examination of this
patient’s abdomen?
a. Decreased bowel sounds
b. Bulge in the abdomen when coughing
c. Palpable mass in the left lower quadrant
d. Bruit around the umbilicus
ANSWER: C
A
B
C
D
Feedback
Decreased bowel sounds are not expected if the patient is having bowel
movements.
Bulge in the abdomen when coughing is a finding associated with abdominal or
incisional hernias.
Palpable mass in the left lower quadrant is expected when interpreted with other
data—age of the patient, intermittent cramping abdominal pain relieved by a
bowel movement—as consistent with diverticular disease.
Bruit around the umbilicus is a finding associated with an abdominal aortic
aneurysm.
DIF: Cognitive Level: Analyze REF: 269| 276
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
19. Using deep palpation of a patient’s epigastrium, a nurse feels a rhythmic pulsation of the
aorta. Based on this finding, what is the nurse’s most appropriate response?
a. Auscultate this area using the bell of the stethoscope.
b. Percuss the area for tones.
c. Ask the patient if there is pain in this area.
d. Document this as a normal finding.
ANSWER: D
A
B
C
D
Feedback
Auscultating this area using the bell of the stethoscope is not necessary because
this is a normal finding. Vascular sounds are usually not heard.
Percussing the area for tones is not necessary because this is a normal finding.
Asking the patient if there is pain in this area is not necessary because this is a
normal finding.
Document this as a normal finding. The aorta is often palpable at the epigastrium.
DIF: Cognitive Level: Apply REF: 276
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific
Assessments
20. What technique does a nurse use when performing deep palpation of a patient’s abdomen?
a. Places the left hand under the ribs to lift them up
b. Asks the patient to breathe slowly through the mouth
c. Positions the patient on the right side with knees flexed
d. Uses the heel of the hand to depress the abdomen
ANSWER: B
A
B
C
D
Feedback
Placing the left hand under the ribs to lift them up is the technique for palpating
the liver.
Asking the patient to breathe slowly through the mouth while the nurse uses the
pads of the fingers to depress the abdomen is the correct procedure.
Positioning the patient on the right side with knees flexed is an alternate strategy
for palpating the spleen.
Using the heel of the hand to depress the abdomen is not a correct technique; the
pads of the fingers are used.
DIF: Cognitive Level: Understand REF: 275
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
21. To correctly percuss the abdomen, a nurse places the distal aspect of the middle finger of the
nondominant hand against the skin of the abdomen, and the other fingers are spread apart and
slightly lifted off the skin. How does the nurse use the fingers of the dominant hand?
a. The pad of the middle finger strikes the distal interphalangeal joint of the middle
finger touching the skin of the abdomen.
b. The tip of the middle finger strikes the nail of the middle finger touching the skin
of the abdomen.
c. The tip of the middle finger strikes the distal interphalangeal joint of the middle
finger touching the skin of the abdomen.
d. The pads of the index and middle fingers strike the nail of the middle finger
touching the skin of the abdomen.
ANSWER: C
A
B
C
D
Feedback
This description is incorrect because the tip of the finger is used rather than the
pad.
This description is incorrect because the distal joint is struck rather than the nail.
This is the correct technique.
This description is incorrect because the tip of the middle finger strikes the distal
joint.
DIF: Cognitive Level: Understand REF: 276
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
22. Which sound does a nurse expect to hear when percussing a patient’s abdomen?
a. Tympany over all quadrants
b. Resonance over the upper quadrants and tympany in the lower quadrants
c. Dull sounds over the upper quadrants and hollow sounds over the lower quadrants
d. Dull sounds over the stomach and resonant sounds over the bladder
ANSWER: A
A
B
C
D
Feedback
Tympany over all quadrants is a normal finding, which represents the presence of
gas.
Resonance in the upper quadrants and tympany over the lower quadrants are not
normal findings. There would be tympany in the lower quadrants, but also in the
upper quadrants.
Dull sounds over the lower quadrants and hollow sounds over the upper quadrants
are not normal findings. There would be tympany over the lower quadrants, but
also in the upper quadrants.
Dull sounds over the stomach and resonant sounds over the bladder are not
normal findings.
DIF: Cognitive Level: Understand REF: 276
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific
Assessments
23. A nurse expects which finding when assessing the abdomen of a patient who has been unable
to void for 12 hours?
a. Absent bowel sounds
b. Hyperactive bowel sounds
c. Tympanic tones over the lower abdomen
d. Dull tones over the suprapubic area
ANSWER: D
A
B
C
D
Feedback
Absent bowel sounds is incorrect because the bowel sounds would not be affected
by a full bladder.
Hyperactive bowel sounds is incorrect because the bowel sounds would not be
affected by a full bladder.
Tympanic tones over the lower abdomen is incorrect because tympany sound is
created by gas in the abdomen.
Dull tones over the suprapubic area would be found. The urine in the bladder
would create a dull sound when the bladder is percussed similar to the sounds
when an abdominal mass is present.
DIF: Cognitive Level: Apply REF: 276
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific
Assessments
24. When assessing an adult’s liver, the nurse percusses the lower border and finds it to be 5 cm
below the costal margin. What is the nurse’s appropriate action at this time?
a. Document this as an expected finding for this adult.
b. Palpate the gallbladder for tenderness.
c. Palpate the upper liver border on deep inspiration.
d. Use the hooking technique to palpate the lower border of the liver.
ANSWER: C
A
B
C
D
Feedback
Documenting this as a normal finding for an adult patient is incorrect because this
finding indicates an enlarged liver.
Palpating the gallbladder for tenderness is not indicated for an enlarged liver.
Palpating the upper border of the liver on deep inspiration is the correct technique
to use when an enlarged liver is found (as indicated by the liver being percussed 5
cm below the costal margin).
Using the hooking technique to palpate the lower border of the liver is not needed
because the liver is enlarged.
DIF: Cognitive Level: Apply REF: 277
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific
Assessments
25. Which location does a nurse select when palpating a patient’s liver?
a. A (right lower quadrant)
b. B (right upper quadrant)
c. C (left upper quadrant)
d. D (left lower quadrant)
ANSWER: B
A
B
C
Feedback
The majority of the liver is located in the right upper quadrant of the abdomen.
The majority of the liver is located in the right upper quadrant of the abdomen.
C is the left upper quadrant.
D
D is the left lower quadrant.
DIF: Cognitive Level: Understand REF: 273| 277
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
26. On palpation of the left upper quadrant of the abdomen of a female patient, the nurse notes
tenderness. This finding may indicate a disorder in which organ?
a. Spleen
b. Gallbladder
c. Sigmoid colon
d. Left ovary
ANSWER: A
A
B
C
D
Feedback
The spleen is located in the left upper quadrant of the abdomen.
The gallbladder is located in the right upper quadrant of the abdomen.
The sigmoid colon is located in the left lower quadrant of the abdomen.
The left ovary is located in the left lower quadrant of the abdomen.
DIF: Cognitive Level: Apply REF: 265| 278
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
27. The nurse recognizes which clinical finding as expected on palpation of the abdomen?
a. Inability to palpate the spleen
b. Left kidney rounded at 2 cm below the costal margin
c. Slight tenderness of the gallbladder on light palpation
d. Bounding pulsation of the aorta over the umbilicus
ANSWER: A
A
B
C
D
Feedback
Inability to palpate the spleen is the expected finding on palpating the abdomen.
A rounded left kidney at 2 cm below the costal margin is not an expected finding.
Kidneys are usually not palpated.
Slight tenderness of the gallbladder on light palpation is not an expected finding;
the gallbladder is usually not palpable.
Bounding pulsation of the aorta over the umbilicus would be an abnormal
finding, perhaps indicating an aneurysm.
DIF: Cognitive Level: Understand REF: 280
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific
Assessments
28. The nurse observes a patient rocking back and forth on the examination table in pain. Based
on the patient’s history, the nurse suspects kidney stones. What additional examination
technique does the nurse perform to confirm this suspicion?
a. Palpating the flank area for rebound tenderness
b. Percussing the bladder for fullness
c. Percussing the costal vertebral margins for tenderness
d. Palpating McBurney point for tenderness
ANSWER: C
A
B
C
D
Feedback
Palpating the flank area for rebound tenderness is the correct location (flank
area), but rebound tenderness is performed on the abdomen to detect peritoneal
inflammation.
Percussing the bladder for fullness would provide data about bladder distention,
but is not a technique to detect for kidney stones.
Percussing the costal vertebral margins for tenderness is the appropriate technique
to detect kidney stones. The nurse recognizes the relationship between the history
and the observation with further assessment techniques needed to confirm kidney
stones.
Palpating McBurney point for tenderness is a technique to detect appendicitis.
DIF: Cognitive Level: Analyze REF: 281-282
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
29. Which techniques does a nurse use to palpate a patient’s right kidney?
a. Asks the patient to take a deep breath, elevates the patient’s eleventh and twelfth
ribs with the left hand, and deeply palpates for the right kidney with the right hand
b. Asks the patient to exhale, elevates the patient’s eleventh and twelfth ribs with the
left hand, and deeply palpates for the right kidney with the right hand
c. Asks the patient to take a deep breath, elevates the patient’s right flank with the left
hand, and deeply palpates for the right kidney with the right hand
d. Asks the patient to exhale, elevates the patient’s right flank with the left hand, and
deeply palpates for the right kidney with the right hand
ANSWER: C
A
B
C
Feedback
Asking the patient to take a deep breath, elevating the patient’s eleventh and
twelfth ribs with the left hand, and deeply palpating for the right kidney with the
right hand is incorrect because the flank is elevated rather than the ribs.
Asking the patient to exhale, elevating the patient’s eleventh and twelfth ribs with
the left hand, and deeply palpating for the right kidney with the right hand is
incorrect because the flank is elevated rather than the ribs and the patient is asked
to inhale rather than exhale.
Asking the patient to take a deep breath, elevating the patient’s right flank with
the left hand, and deeply palpating for the right kidney with the right hand is the
correct technique.
D
Asking the patient to exhale, elevating the patient’s right flank with the left hand,
and deeply palpating for the right kidney with the right hand is incorrect because
the patient is asked to inhale rather than exhale.
DIF: Cognitive Level: Apply REF: 280
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
30. When assessing the abdomen of a patient who has fluid in the peritoneal cavity, the nurse
expects what change to occur when the patient turns from supine to the left side?
a. Movement of the tympanic tones from lateral in the supine position to closer to
midline when lying on the left side
b. Movement of the dull tones from lateral in the supine position to closer to midline
when lying on the left side
c. Change in bowel sounds from hypoactive in the supine position to hyperactive
when lying on the left side
d. Change in bowel sounds from hyperactive in the supine position to hypoactive
when lying on the left side
ANSWER: B
A
B
C
D
Feedback
Movement of the tympanic tones from lateral in the supine position to closer to
midline when lying on the left side is incorrect because the tone will be dull,
rather than tympanic, due to the fluid.
Movement of the dull tones from lateral in the supine position to closer to midline
when lying on the left side is the expected change when assessing for shifting
dullness.
A change in bowel sounds from hypoactive in the supine position to hyperactive
when lying on the left side is incorrect because bowel sounds would not be
affected by the fluid.
A change in bowel sounds from hyperactive in the supine position to hypoactive
when lying on the left side is incorrect because bowel sounds would not be
affected by the fluid.
DIF: Cognitive Level: Understand REF: 282-283
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
31. The patient reports right lower quadrant (RLQ) pain that is worse with coughing. Based on the
patient’s history, the nurse suspects appendicitis. What additional examination technique does
the nurse perform to confirm this suspicion?
a. Placing the hand over the lower right thigh and asking the patient to flex the knee
while pushing down on the knee to resist it and noting if the patient complains of
pain
b. Palpating deeply a point of the abdomen, located halfway between the umbilicus
and the left anterior iliac crest
c. Asking the patient to flex the right hip and knee to 90 degrees, then abducting the
leg and noting if the patient complains of pain
d. Pressing down in an area away from the RLQ at a 90-degree angle to the abdomen,
then releasing the fingers quickly and noting any complaint of pain
ANSWER: D
A
B
C
D
Feedback
This is an incorrect description of the iliopsoas muscle test.
This is an incorrect description of the testing for McBurney point. McBurney
point is located to the right of the umbilicus.
This is an incorrect description of the obturator muscle test.
This describes rebound tenderness, which is performed to detect peritoneal
inflammation.
DIF: Cognitive Level: Analyze REF: 284-285
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific
Assessments
32. When palpating the abdomen to determine a floating mass, a nurse presses on the abdomen at
a 90-degree angle with the fingertips. Which finding indicates a mass?
a. An increase in abdominal girth
b. A complaint from the patient of a dull pain in the flank area
c. A freely movable mass will float upward and touch the fingertips
d. Fluid in the abdomen will shift upward and touch the fingertips
ANSWER: C
A
B
C
D
Feedback
An increase in abdominal girth does not occur as a result of ballottement.
A complaint from the patient of a dull pain in the flank area is not an expected
finding.
A freely movable mass floating upward and touching the fingertips is the
expected finding (ballottement).
Fluid in the abdomen shifting upward and touching the fingertips does not occur;
it is the mass on the abdomen that shifts upward.
DIF: Cognitive Level: Apply REF: 285
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
33. A 75-year-old male patient asks how to reduce his risk of esophageal cancer. What is the
nurse’s most appropriate response?
a. “Don’t worry about it, esophageal cancers have a low incidence in men.”
b. “You should not be concerned about esophageal cancer at your age.”
c. “You should consider limiting your alcohol intake to two drinks per day.”
d. “Increasing the fiber and protein in your diet can help you lower your risk.”
ANSWER: C
Feedback
A
B
C
D
Men have a rate three times that of women.
The risk increases with age, with the peak between 70 and 80 years.
“You should consider limiting your alcohol intake to two drinks per day. Longterm
alcohol intake increases your risk for esophageal cancer.”
Although fiber and protein are important for the diet, their intake does not affect
the risk of esophageal cancer.
DIF: Cognitive Level: Understand REF: 287
TOP: Nursing Process: Intervention
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Disease Prevention
34. Which patient has the lowest risk for colon cancer?
a. Patient A is 50 years old, is obese, and has type 2 diabetes mellitus.
b. Patient B is 60 years old, has alcoholism, and smokes a pack of cigarettes daily.
c. Patient C is 55 years old, has ulcerative colitis, and inflammatory bowel disease.
d. Patient D is 45 years old and has diverticulosis.
ANSWER: D
A
B
C
D
Feedback
Patient A has three risk factors for colon cancer.
Patient B has three risk factors for colon cancer.
Patient C has two risk factors for colon cancer.
Patient D has the lowest risk of colon cancer. Ninety percent of colon cancers
occur in adults older than 50 years of age. Although this patient does have a
disorder of the colon, it is not linked to an increased risk of colon cancer.
DIF: Cognitive Level: Analyze REF: 287
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Disease Prevention
35. Which assessment technique is the nurse performing in the figure below?
a. Direct percussion
b. Indirect percussion
c. Light palpation
d. Deep palpation
ANSWER: B
A
B
Feedback
Direct percussion is performed with one hand.
Indirect percussion is the technique shown.
C Light palpation is performed using the pads of the fingers depressing the tissue 1
to 2 cm, usually on the abdomen.
D Deep palpation is performed using the pads of the fingers depressing the tissue 4
to 6 cm, usually on the abdomen.
DIF: Cognitive Level: Apply REF: 282
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
MULTIPLE RESPONSE
1. A nurse suspects appendicitis in a patient with abdominal pain. Which findings are suggestive
of appendicitis? Select all that apply.
a. Pain radiating to the right shoulder
b. Pain around the umbilicus
c. Pain relieved by lying still
d. Right lower quadrant pain
e. Increased peristalsis
ANSWER: B, C, D
Correct: These are all descriptions of pain related to appendicitis.
Incorrect: Pain radiating to the right shoulder is associated with gallbladder disease.
Increased peristalsis can be associated with gastroenteritis or diarrhea.
DIF: Cognitive Level: Understand REF: 278-279
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
2. Alcoholism increases the risk of cancers of the gastrointestinal tract. Which cancer risk is
increased in patients with alcoholism? Select all that apply.
a. Esophageal cancer
b. Stomach cancer
c. Pancreatic cancer
d. Liver cancer
e. Colon cancer
f. Bladder cancer
ANSWER: A, B, D, E
Correct: The risk of esophageal, stomach, liver, and colon cancers are increased by heavy
intake of alcohol.
Incorrect: The risk of pancreatic and bladder cancers are increased with tobacco. However,
the risk for esophageal, stomach, liver, and colon cancers are also increased with tobacco use.
DIF: Cognitive Level: Understand REF: 285-285
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Disease Prevention
OTHER
1. Put in correct order the steps used to palpate the liver.
A. Place your right hand parallel to the right costal margin.
B. Ask the patient to take a deep breath.
C. Place your right hand parallel to the right costal margin.
D. Lift up the eleventh and twelfth ribs with the left hand.
E. Press your right hand down and under the coastal margin.
F. Ask the patient to take some deep breaths
ANSWER:
D, C, A, E, B, F
DIF: Cognitive Level: Apply REF: 287
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
Chapter 14: Musculoskeletal System
Test Bank
MULTIPLE CHOICE
1. Which description of pain from the patient makes a nurse suspect the patient’s pain is
originating from a muscle?
a. “Crampy”
b. “Dull and deep”
c. “Boring and intense”
d. “Sharp upon movement”
ANSWER: A
A
B
C
D
Feedback
Muscle pain is often described as “crampy.”
Bone pain typically is described as “deep” and “dull.”
Bone pain typically is described as “boring” and “intense.”
Muscle pain usually remains crampy on movement.
DIF: Cognitive Level: Understand REF: 301
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
2. A nurse asks a patient to describe his new onset of leg pain. He slept well through the night,
but this morning he suddenly developed pain in his left lower leg that is red and too painful to
touch. Nothing relieves the pain. Based on these data, the nurse suspects which disorder is
causing this pain?
a. Rheumatoid arthritis
b. Osteoarthritis
c. Gout
d. Tendonitis
ANSWER: C
Feedback
A Patients with rheumatoid arthritis often have morning stiffness lasting 1 to 2
hours.
B Patients with osteoarthritis experience pain when bearing weight that is relieved
by rest.
C Sudden onset of pain and erythema in the great toe, ankle, and lower leg suggests
gout (also called gouty arthritis).
D Tendonitis may awaken the patient, especially when the patient is lying on the
affected limb.
DIF: Cognitive Level: Apply REF: 301| 332
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
3. During a history, the patient reports having gout. Based on this information, what findings
does the nurse anticipate during a focused assessment?
a. Warm, tender, and deformed wrists and peripheral interphalangeal (PIP) joints
bilaterally
b. Edema, warmth, and redness of one great toe and pea-like nodules in the ear lobes
c. Enlarged and tender PIP or distal interphalangeal (DIP) joints on one or several
fingers
d. Tenderness with pronation and supination of the elbow and point tenderness on the
lateral epicondyle
ANSWER: B
A
B
C
D
Feedback
This is a description of findings of a patient who has rheumatoid arthritis.
Bilateral joint involvement is common.
This is a description of gout. The pealike nodules are tophi, collections of uric
acid in subcutaneous tissue.
This is a description of findings of a patient who has osteoarthritis. Enlarged and
tender PIP joints refer to Heberden nodes and DIP joints refer to Bouchard nodes.
This is a description of epicondylitis (tennis elbow).
DIF: Cognitive Level: Apply REF: 301| 332
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
4. A patient reports joint pain interfering with sleep and morning joint stiffness for the first hour
after getting out of bed. Considering this report, what abnormal findings does the nurse
anticipate during the examination?
a. Abrupt onset of local tenderness, edema, and decreased range of motion of the
shoulder and hip bilaterally
b. Decreased range of motion of one hip and knee with pain on flexion and crepitus
during movement of these joints
c. Erythema in one great toe, ankle, and lower leg that is painful to the touch
d. Hot, painful, deformed, and edematous wrists and peripheral interphalangeal joints
bilaterally
ANSWER: D
A
B
C
D
Feedback
This examination finding is more consistent with bursitis.
This examination finding is more consistent with osteoarthritis.
This examination finding is more consistent with gout.
The history and these examination findings are consistent with rheumatoid
arthritis. Joints are involved bilaterally in rheumatoid arthritis because it is a
systemic autoimmune disorder.
DIF: Cognitive Level: Analyze REF: 301| 318| 332
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
5. In assessing a patient with a history of poliomyelitis, the nurse suspects the right leg muscles
are smaller than the left leg. What is the best approach for the nurse to confirm or reject this
suspicion?
a. Palpating both legs using the pads of the thumb and index fingers and comparing
one side with another
b. Using a tape to measure each leg’s circumference at the same location, above or
below the nearest joint
c. Using a goniometer to measure the upper and lower legs with the patient in supine
and standing positions
d. Palpating the legs using the tips of the thumb and index fingers, and comparing the
findings with the Lovett scale
ANSWER: B
A
B
C
D
Feedback
This describes an appropriate procedure to determine tenderness of muscles, but
not muscle size.
This technique is correct, provides a baseline for future comparisons, and
provides measurements for side-to-side comparisons.
The goniometer is used to measure the degree of joint flexion and extension
rather than muscle size.
The Lovett scale is used to grade and record muscle strength, rather than muscle
size.
DIF: Cognitive Level: Apply REF: 304
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: System Specific
Assessments
6. In assessing the joint range of motion of a patient’s knees, the nurse notices the flexion is less
than expected in both knees. What is the next appropriate action for the nurse?
a. Documenting this finding as expected for this patient because it occurs in both
knees
b. Palpating the suprapatellar pouch on each side of the quadriceps for contour,
tenderness, and edema
c. Using a goniometer to measure the flexion in both knees and comparing the results
with expected flexion
d. Applying opposing force to the lower leg while the patient tries to maintain flexion
and extension
ANSWER: C
A
B
C
Feedback
This is not an expected finding. Even when the finding is bilateral, when it is
abnormal, additional examination is needed.
This is the procedure for palpating the knees, in which data are collected, but it
may not have a direct bearing on the lack of flexion of the knees.
When a joint seems to have increased or decreased range of motion, use a
goniometer to measure the angle.
D
This is the procedure for testing leg muscles for strength, in which data are
collected, but it may not have a direct bearing on the lack of flexion of the knees.
DIF: Cognitive Level: Apply REF: 307
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: System Specific
Assessments
7. The nurse asks the patient to hold the arms straight out, perpendicular to the floor, and the
nurse tries to push the patient’s arms down. This procedure tests the strength of which
muscles?
a. Triceps
b. Biceps
c. Trapezius
d. Deltoid
ANSWER: D
A
B
C
D
Feedback
The nurse would test the triceps muscle strength by having the patient extend the
arm and resist while the nurse tries to push the arm to a flexed position.
The nurse would test the muscle strength of the biceps by having the patient flex
the forearm while the nurse applies resistance.
The nurse would test the trapezius by having the patient shrug the shoulders
against resistance.
The patient uses the deltoid muscles to resist the action of the nurse.
DIF: Cognitive Level: Apply REF: 308| 315
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
8. To assess the triceps and biceps muscle strength, the nurse applies resistance to the patient’s
arm. What should be done to ensure the appropriate muscle is being assessed?
a. The patient pushes up against the nurse’s hand to abduct the triceps muscle and
pushes down against the nurse’s hand to adduct the biceps muscle.
b. The patient pushes forward against the nurse’s hand to extend the triceps muscle
and pulls backward against the nurse’s hand to flex the biceps muscle.
c. The patient pulls backward against the nurse’s hand to flex the triceps muscle and
pushes forward against the nurse’s hand to extend the biceps muscle.
d. The patient pushes up against the nurse’s hand to abduct the biceps muscle and
pushes down against the nurse’s hand to adduct the triceps muscle.
ANSWER: B
A
B
C
D
Feedback
Abducting and adducting test range of motion rather than muscle strength.
This is the correct technique for assessing these muscles.
This is a reversal of the correct technique.
Abducting and adducting test range of motion rather than muscle strength.
DIF: Cognitive Level: Apply REF: 308| 315
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
9. The nurse notes that there is an audible clicking sound when the patient opens and closes the
mouth. What is the appropriate response of the nurse at this time?
a. Recording this as an abnormal finding, requiring additional assessment
b. Measuring the distance between each side of the mandible and the eyes
c. Applying resistance to the maxilla and asking the patient to repeat the motion
d. Documenting this finding as expected if no other signs or symptoms are found
ANSWER: D
A
B
C
D
Feedback
This would be an incorrect action because clicking of the mandible with no other
associated signs or symptoms is a normal finding.
This is not a correct assessment technique to use.
This is not a correct assessment technique to use.
The mandible should move smoothly and painlessly. An audible or palpable
snapping or clicking in the absence of other symptoms is not unusual.
DIF: Cognitive Level: Apply REF: 309-310
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: System Specific
Assessments
10. A nurse palpates the patient’s jaw movement by placing two fingers in front of each ear and
asking the patient to slowly open and close the mouth. What movement does the nurse ask the
patient to do next?
a. Move the jaw side to side.
b. Swallow.
c. Smile.
d. Clench the teeth together.
ANSWER: A
A
B
C
D
Feedback
Moving the jaw side to side assesses the range of motion of the jaw; asking the
patient to protrude and retract the jaw also assesses range of motion.
Swallowing assesses cranial nerve IX (glossopharyngeal) and X (vagus).
Smiling assesses cranial nerve VII (facial).
Clenching the teeth together assesses cranial nerve VII (facial).
DIF: Cognitive Level: Apply REF: 309-310
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
11. When assessing the neck of a healthy adult, a nurse expects which findings?
a. A convex contour of the posterior cervical spine
b. Bending of the head to the right and left (ear to shoulder) 15 degrees
c. Turning the chin to the right shoulder and then the left shoulder
d. Hyperextension of the head 30 degrees from midline
ANSWER: C
A
B
C
D
Feedback
The posterior cervical spine should be concave.
The patient should be able to laterally bend the head 40 degrees from midline in
each direction.
This is an expected finding.
The patient should be able to hyperextend the head 55 degrees from midline.
DIF: Cognitive Level: Understand REF: 310-311
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: System Specific
Assessments
12. A patient asks, “Why is touching my toes necessary? This is a sports physical examination,
not exercise class.” What is the most appropriate response by the nurse?
a. “This is the best way to check for symmetry of your arms.”
b. “I am looking at the stretch of your ham strings.”
c. “This allows me to see how straight your spinal column is.”
d. “I am assessing the flexion of your spine.”
ANSWER: C
A
B
C
D
Feedback
This is an incorrect technique for assessing arm symmetry.
The hamstrings are not normally assessed.
This is the correct technique for inspecting the spine and for detecting scoliosis.
This is not a correct statement.
DIF: Cognitive Level: Apply REF: 312-313
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation
13. How does a nurse document the finding from the patient shown below?
a. Kyphosis
b. Lordosis
c. Osteoporosis
d. Scoliosis
ANSWER: D
A
B
C
D
Feedback
Kyphosis is a posterior curvature (convexity) of the thoracic spine.
Lordosis is an anterior curvature (concavity) of the spine.
Osteoporosis occurs when the bones become porous and fracture easily.
Deviation of the spine or asymmetry of shoulder or iliac height is an abnormal
finding. This figure shows a patient who has scoliosis, a lateral curvature of the
spine.
DIF: Cognitive Level: Understand REF: 312-313
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
14. A patient reports a history of compression of the left cranial nerve XI (spinal accessory nerve)
from an old sports injury. Based on this information, what technique does the nurse include in
the focused assessment?
a. Asking the patient to rotate the head against resistance of the nurse’s hand on the
patient’s chin
b. Asking the patient to flex the chin to the chest against resistance of the nurse’s hand
on the patient’s forehead
c. Asking the patient to extend the head back against resistance of the nurse’s hand on
the back of the patient head
d. Asking the patient to shrug the shoulders while the nurse attempts to push them
down
ANSWER: D
A
B
C
D
Feedback
This technique tests the sternocleidomastoid muscle.
This technique tests the sternocleidomastoid muscle.
This technique tests the sternocleidomastoid muscle.
This is the technique to test strength of the trapezius muscle that is innervated by
the cranial nerve XI.
DIF: Cognitive Level: Analyze REF: 314
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: System Specific
Assessments
15. The nurse in the figure below is assessing function and strength of which muscle?
a. Sternocleidomastoid
b. Trapezius
c. Deltoid
d. Pectoralis major
ANSWER: B
A
B
C
D
Feedback
The sternocleidomastoid is tested by the patient flexing the chin to the chest while
the nurse tries to manually force the head upright.
The trapezius muscle is tested by the patient shrugging the shoulders while the
nurse attempts to push them down.
The deltoid muscle is tested by the patient holding the arms up while the nurse
tries to push them down.
The pectoralis major muscle is palpated for tenderness, but its strength is not
usually assessed.
DIF: Cognitive Level: Understand REF: 314
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
16. When a nurse asks a patient to place the right arm behind the back, so that the back of the
hand is touching the lower spine, the nurse is testing for which range of motion?
a. Pronation of the elbow
b. Hyperextension of the elbow
c. Internal rotation and adduction of the shoulder
d. External rotation and abduction of the shoulder
ANSWER: C
A
B
C
D
Feedback
Pronation of the elbow is tested by pronating the palm on a flat surface.
Hyperextension of the elbow. This is not a motion of the elbow.
Internal rotation and adduction of the shoulder is tested by this maneuver.
External rotation and abduction of the shoulder is tested by asking the patient to
place the hand behind the head.
DIF: Cognitive Level: Apply REF: 315
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
17. When a nurse asks a patient to place the right arm behind the head, the nurse is testing for
which range of motion?
a. Flexion of the elbow
b. Hyperextension of the shoulder
c. Internal rotation and adduction of the shoulder
d. External rotation and abduction of the shoulder
ANSWER: D
A
B
C
D
Feedback
Flexion of the elbow requires the patient to flex the elbow, but the elbow flexion
is usually tested by asking the patient to bend the elbow so that the fingers are
touching the shoulder.
Hyperextension of the shoulder is tested by moving the arm straight backward.
Internal rotation and adduction of the shoulder is tested by asking the patient to
place the hand behind the back.
External rotation and abduction of the shoulder is tested by this maneuver.
DIF: Cognitive Level: Apply REF: 315
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
18. The nurse asks the patient to rest the left arm on a table and to move the lower arm so that the
palm of the hand is up and then down. What motion is the nurse testing?
a. Adduction and abduction of the wrist
b. Supination and pronation of the wrist
c. Adduction and abduction of the elbow
d. Supination and pronation of the elbow
ANSWER: D
A
B
C
D
Feedback
The movements of the wrist are flexion, extension, and ulnar and radial deviation.
The movements of the wrist are flexion, extension, and ulnar and radial deviation.
This is not a movement of the elbow. The elbow moves in flexion, extension,
pronation, and supination.
Supination and pronation of the elbow is tested by this maneuver.
DIF: Cognitive Level: Apply REF: 316-317
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
19. On inspection of a patient’s hands, the nurse notices ulnar deviation and swan-neck
deformities bilaterally and correlates this finding with which disorder?
a. Osteoarthritis
b. Osteoporosis
c. Rheumatoid arthritis
d. Gout
ANSWER: C
A
B
C
D
Feedback
The findings are consistent with rheumatoid arthritis.
The findings are consistent with rheumatoid arthritis.
Ulnar deviation, swan-neck, and boutonnière deformities of interphalangeal joints
are manifestations of rheumatoid arthritis.
The findings are consistent with rheumatoid arthritis.
DIF: Cognitive Level: Apply REF: 317| 332
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
20. With the patient lying supine, a nurse raises the patient’s leg to flex the hip. The patient
complains of pain when the leg is raised to 40 degrees. The nurse correlates this finding with
which disorder?
a. Lumbar nerve compression
b. Cervical disk herniation
c. Osteoarthritis
d. Bursitis
ANSWER: A
A
B
C
D
Feedback
To evaluate for nerve root irritation or lumbar disk herniation, perform straight
leg raises. Pain in the back of the leg with 30 to 60 degrees of elevation indicates
pressure on a lumbar peripheral nerve by an intervertebral disk.
Straight leg raises evaluate for herniated disks, but not in the cervical disks in the
neck.
Osteoarthritis is a degenerative disease of articular cartilage that affects weightbearing
joints such as vertebrae, hips, knees, and ankles. Straight leg raises is not
a technique to assess for osteoarthritis.
Bursa become inflamed by constant friction around joints and may be precipitated
by arthritis or injury. The hip is a common site, but not vertebrae. Manifestations
include painful range of motion, point tenderness, and erythema of the affected
joint.
DIF: Cognitive Level: Apply REF: 329| 333
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
21. With the patient in a supine position, how does a nurse test the external rotation of the
patient’s right hip?
a. Asking the patient to move the right leg laterally with the right knee straight
b. Asking the patient to flex the right knee and turn medially toward the left side
(inward)
c. Asking the patient to place the right heel on the left patella
d. Asking the patient to raise the right leg straight up and perpendicular to the body
ANSWER: C
A
B
C
D
Feedback
Moving the right leg laterally with the right knee straight assesses abduction of
the right hip.
Flexing the right knee and turning medially toward the left side (inward)
internally rotates the right hip.
Placing the right heel on the left patella externally rotates the right hip.
Raising the right leg straight up and perpendicular to the body flexes the right hip.
DIF: Cognitive Level: Apply REF: 320-321
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
22. What movement from the patient does a nurse request to assess for hyperextension of the hip?
a. Raise one leg at a time while lying prone.
b. Raise one leg at a time while lying supine.
c. Move one leg at a time laterally, away from midline, while lying prone.
d. Move one leg at a time medially, toward midline, while lying supine.
ANSWER: A
A
B
C
D
Feedback
This procedure tests hyperextension of the hip.
This procedure tests hip flexion.
This procedure tests hip abduction.
This procedure tests hip adduction.
DIF: Cognitive Level: Apply REF: 321-322
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
23. How does a nurse assess the eversion and inversion of a patient’s ankle?
a. For eversion, ask the patient to turn the sole of the foot away from the body and for
inversion turn the sole of the foot toward the midline.
b. For eversion, ask the patient to turn the sole of the inward toward the midline and
for inversion turn the sole of the foot away from the body.
c. For eversion, ask the patient to walk on his toes and, for inversion, to walk on his
heels.
d. For eversion, ask the patient to point the toes forward and, for inversion, to point
the toes backward.
ANSWER: A
A
Feedback
This is the correct maneuver for eversion and inversion of the ankle.
B
C
D
This movement is the opposite of the correct movement.
This is the test for muscle strength of the ankles and feet.
This is the maneuver for dorsiflexion and plantar flexion of the ankle.
DIF: Cognitive Level: Apply REF: 324-325
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
24. While giving a history, the patient reports having carpal tunnel syndrome. Based on this
information, what technique does the nurse include in a focused assessment?
a. Ask the patient to press the pads of the right and left fingers against each other and
hold for 1 minute.
b. Ask the patient to push the hand against the nurse’s forearm while attempting to
flex the wrist.
c. Ask the patient to flex both wrists and press the dorsal aspects of the hands together
for 1 minute.
d. Hold pressure to the radial and ulnar pulses and watch for blanching.
ANSWER: C
A
B
C
D
Feedback
This is not the correct technique for Phalen sign.
This is not the correct technique for Phalen sign.
This is the correct technique for Phalen sign.
This is the technique for Allen’s test, which is used to detect arterial circulation of
the hand, rather than Phalen sign, which is used to test for carpel tunnel
syndrome.
DIF: Cognitive Level: Apply REF: 325
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
25. In teaching the group of patients about osteoporosis, the nurse identifies which one of these
participants as having the highest risk for this disease?
a. A small-boned, thin white American woman
b. An American Indian man who smokes
c. A Hispanic woman who has completed menopause
d. An African American man with a family history of osteoporosis
ANSWER: A
A
B
C
D
Feedback
A small-boned, thin white American woman has three risk factors for
osteoporosis: female gender, white race, and small body size.
This patient has one risk factor: smoking.
This patient has two risk factors: female gender and menopause.
This patient has one risk factor: family history.
DIF: Cognitive Level: Understand REF: 331
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Health Promotion Programs
MULTIPLE RESPONSE
1. Which findings are expected from a musculoskeletal assessment of a left-handed healthy
adult? Select all that apply.
a. Cervical concave, thoracic convex, and lumbar concave contours of the spine
b. Muscle strength of 3/5 bilaterally
c. Circumference of left upper arm larger than right upper arm
d. Lumbar and thoracic spine flexion of 75 degrees
e. External rotation and abduction of left arm of 90 degrees
f. Flexion of right and left knees of 90 degrees
ANSWER: A, C, D, E
Correct: Cervical concave, thoracic convex, and lumbar concave contours of the spine are
expected findings of the spine. The circumference of the left upper arm larger than the right
upper arm is considered an expected finding because this patient is left-handed, which may
account for the increase in circumference. Lumbar and thoracic spine flexion of 75 degrees is
an expected finding of the spine. Ninety-degree external rotation and abduction of the left arm
is an expected finding of the spine.
Incorrect: The expected muscle strength is 5/5. The expected flexion is 120 degrees.
DIF: Cognitive Level: Understand REF: 303-304| 313| 315| 323
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific
Assessments
2. Nurses inquire about lifestyle behaviors of patients with risk factors for osteoarthritis. Which
risk factors for osteoarthritis does the nurse ask about? Select all that apply.
a. Estrogen deficiency
b. Physical inactivity
c. Overuse of joints
d. Smoking
e. Obesity
f. Age
ANSWER: B, C, E
Correct: Lack of exercise weakens muscles that support joints. Overuse of joints damages
cartilage in joints. Being overweight puts stress on joints.
Incorrect: Estrogen deficiency, smoking, and age are risk factors for osteoporosis rather than
osteoarthritis.
DIF: Cognitive Level: Understand REF: 331
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Disease Prevention
3. Which movements does a nurse expect to find when assessing the hip range of motion of a
healthy person? Select all that apply.
a. Pronation and supination
b. Flexion and extension
c. Internal and external rotation
d. Adduction and abduction
e. Hyperextension
ANSWER: B, C, D, E
Correct: These are all expected motions for the hip joint.
Incorrect: Pronation and supination are not expected motions for the hip joint.
DIF: Cognitive Level: Understand REF: 320-322
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific
Assessments
4. Which movements does a nurse expect to find when assessing the ankle range of motion of a
healthy person? Select all that apply.
a. Inversion and eversion
b. Plantar flexion and dorsiflexion
c. Pronation and supination
d. Adduction and abduction
e. Rotation
ANSWER: A, B, D, E
Correct: These are all expected motions for the ankle joint.
Incorrect: Pronation and supination are not expected motions for the ankle joint.
DIF: Cognitive Level: Understand REF: 324-325
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific
Assessments
Chapter 15: Neurologic System
Test Bank
MULTIPLE CHOICE
1. A nurse assesses a patient with a head injury who has slowing intellectual functioning,
personality changes, and emotional lability. The nurse correlates these findings with which
area of the brain?
a. Frontal lobe
b. Parietal lobe
c. Thalamus
d. Temporal lobe
ANSWER: A
A
B
C
D
Feedback
The frontal lobe controls intellectual function, awareness of self, personality, and
autonomic responses related to emotion.
The parietal lobe receives sensory input such as position sense, touch, shape, and
texture of objects.
The thalamus is a relay and integration station from the spinal cord to the cerebral
cortex and other parts of the brain.
The temporal lobe contains the primary auditory cortex. It also interprets auditory,
visual, and somatic sensory inputs that are stored in thought and memory.
DIF: Cognitive Level: Understand REF: 337
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
2. In assessing a patient with damage to the occipital lobe, the nurse correlates which clinical
manifestation to this injury?
a. Intentional tremors
b. Visual changes
c. Decreased hearing
d. Inability to formulate words
ANSWER: B
A
B
C
D
Feedback
Intentional tremors are caused by cerebellar problems.
The occipital lobe contains the visual cortex.
The temporal lobe contains the auditory cortex.
The ability to formulate words comes from the Broca area in the frontal lobe.
DIF: Cognitive Level: Understand REF: 337
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
3. While obtaining a symptom analysis from a patient who has an inner ear infection, the nurse
helps the patient distinguish between dizziness and vertigo. Which description by the patient
indicates vertigo?
a. “I felt lightheaded when I stood up.”
b. “I just could not keep my balance when I sat up.”
c. “It seemed that the room was spinning around.”
d. “I was afraid that I was going to lose consciousness.”
ANSWER: C
A
B
C
D
Feedback
This is a description of dizziness that is often associated with transient ischemia
attacks.
This is a description of disequilibrium, a form of dizziness.
This report is consistent with vertigo because it includes a sensation of motion.
This is a description of presyncope, a form of dizziness.
DIF: Cognitive Level: Apply REF: 344-345
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
4. While obtaining a symptom analysis from a patient who had a transient ischemic attack, the
nurse helps the patient distinguish between dizziness and vertigo. Which description by the
patient indicates dizziness?
a. “I felt lightheaded when I stood up.”
b. “It felt like I was on a merry-go-round.”
c. “The room seemed to be spinning around.”
d. “My body felt like it was revolving and could not stop.”
ANSWER: A
A
B
C
D
Feedback
This is a description of dizziness that is often associated with transient ischemia
attacks.
This report is consistent with objective vertigo because it includes a sensation of
motion.
This report is consistent with objective vertigo because it includes a sensation of
motion.
This report is consistent with subjective vertigo because it includes a sensation of
one’s body rotating in space.
DIF: Cognitive Level: Apply REF: 344
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
5. Which patient behavior indicates to the nurse that the patient’s facial cranial nerve (CN VII) is
intact?
a. The patient’s eyes move to the left, right, up, down, and obliquely.
b. The patient moistens the lips with the tongue.
c. The sides of the mouth are symmetric when the patient smiles.
d. The patient’s eyelids blink periodically.
ANSWER: C
A
B
C
D
Feedback
This finding represents movement of the extraocular muscles, which are
controlled by the oculomotor, trochlear, and abducens cranial nerves (CN III, IV,
and VI, respectively).
This finding represents movement of the tongue, which is controlled by the
hypoglossal cranial nerve (CN XII).
This finding represents facial symmetry, which is controlled by the facial cranial
nerve (CN VII).
This finding represents function of the oculomotor cranial nerve (CN III).
DIF: Cognitive Level: Apply REF: 352-353, Table 15-1
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific
Assessments
6. A nurse assessing a patient who had a cerebrovascular accident involving the Broca area
suspects expressive or nonfluent aphasia. What communication abilities does the nurse
anticipate from this patient?
a. The patient understands speech but is unable to translate ideas into meaningful
speech.
b. The patient is unable to comprehend speech and thus does not respond verbally.
c. The patient is able to understand speech but has difficulty forming words, creating
muffled speech.
d. The patient is unable to comprehend speech and responds inappropriately to
conversation.
ANSWER: A
A
B
C
D
Feedback
The inability to translate ideas into meaningful speech or writing is termed
expressive aphasia or nonfluent aphasia and is associated with lesions in the
Broca area in the frontal lobe.
The inability to comprehend the speech of others is called receptive aphasia or
fluent aphasia and is associated with lesions in the Wernicke area in the temporal
lobe.
This speech pattern is more consistent with patients who have involvement of
muscles of speech rather than neurologic deficits.
This speech pattern is not relevant to this patient.
DIF: Cognitive Level: Apply REF: 337| 339| 346
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
7. The nurse hears in a report that a patient has receptive or fluent aphasia. What communication
abilities does the nurse anticipate from this patient?
a. The patient understands speech but is unable to translate ideas into meaningful
speech.
b. The patient is able to understand speech but has difficulty forming words creating
muffled speech.
c. The patient is unable to comprehend speech and thus does not respond verbally.
d. The patient is emotionally liable and cries easily, which interferes with the ability
to communicate.
ANSWER: C
A
B
C
D
Feedback
The inability to translate ideas into meaningful speech or writing is termed
expressive aphasia or nonfluent aphasia and is associated with lesions in the
Broca area in the frontal lobe.
This speech pattern is more consistent with patients who have involvement of
muscles of speech rather than neurologic deficits.
This deficit is called receptive aphasia or fluent aphasia and is associated with
lesions in the Wernicke area in the temporal lobe.
This speech pattern is not relevant to this patient.
DIF: Cognitive Level: Apply REF: 337| 339| 346
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
8. What is the earliest and most sensitive indication of altered cerebral function?
a. Unequal pupils
b. Loss of deep tendon reflexes
c. Paralysis on one side of the body
d. Change in level of consciousness
ANSWER: D
A
B
C
D
Feedback
Pupillary function represents function of the oculomotor cranial nerve and the
midbrain.
Deep tendon reflexes represent function of the spinal cord and reflex arcs.
Movement represents function of the spinal cord and posterior frontal lobe.
Maintaining consciousness represents the functions of and communication
between the frontal lobe and reticular activating system.
DIF: Cognitive Level: Remember REF: 347
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
9. A patient reports having difficulty swallowing. Based on this information, how does the nurse
assess the cranial nerve related to swallowing?
a. Ask the patient about feeling the blunt end of a paper clip along the jaw line.
b. Observe the rising of the soft palate when the patient says “Ahh.”
c. Observe the symmetry of the face when the patient talks.
d. Assess taste on the anterior part of the tongue.
ANSWER: B
A
B
C
D
Feedback
This tests the sensory function of the trigeminal cranial nerve (CN V).
This tests the glossopharyngeal cranial nerve (CN IX), which is involved in
swallowing. The nurse must correlate difficulty swallowing with the cranial
nerves involved with that function and how to test it. The cranial nerves involved
are IX, X, and XII.
This tests the motor function of the facial cranial nerve (CN VII).
This tests the sensory portion of the facial cranial nerve (CN VII).
DIF: Cognitive Level: Analyze REF: 341| 346| 354
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
10. A patient reports having difficulty swallowing. Based on this information, how does the nurse
assess the appropriate cranial nerve?
a. Ask the patient to stick out the tongue and move it in all directions.
b. Ask the patient to move the head to the right and left.
c. Observe the symmetry of the face when the patient talks.
d. Assess for taste on the anterior part of the tongue.
ANSWER: A
A
B
C
D
Feedback
This tests the hypoglossal cranial nerve (CN XII) that is involved in swallowing.
The nurse must correlate difficulty swallowing with the cranial nerves involved
with that function and how to test them. The cranial nerves involved are IX, X,
and XII.
This tests the function of the spinal accessory cranial nerve (CN XI).
This tests the motor function of the facial cranial nerve (CN VII).
This tests the sensory portion of the facial cranial nerve (CN VII).
DIF: Cognitive Level: Analyze REF: 341| 346| 354
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
11. In assessing a patient’s deep tendon reflexes, a nurse finds a patient has a 4+ triceps response.
How does the nurse interpret this finding?
a. A hyperactive response
b. A diminished response
c. An absent response
d. An expected response
ANSWER: A
A
Feedback
Deep tendon reflexes are graded from 0 to 4+ and 4+ is a hyperactive response.
B A diminished response is 1+.
C An absent response is 0.
D An expected response is 2+.
DIF: Cognitive Level: Understand REF: 342-343| 349-350
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
12. The nurse holds the patient’s relaxed arm with elbow flexed at a 90-degree angle, places a
thumb over a tendon in the antecubital fossa, and strikes the thumb with the pointed end of the
reflex hammer. Which deep tendon reflex is the nurse assessing?
a. Brachioradialis
b. Biceps
c. Triceps
d. Deltoid
ANSWER: B
A
B
C
D
Feedback
The technique described is not the correct one for assessing the brachioradial
deep tendon reflex.
This is the correct technique for assessing the biceps deep tendon reflex.
The technique described is not the correct one for assessing the triceps deep
tendon reflex.
There is no reflex to test the deltoid muscle.
DIF: Cognitive Level: Understand REF: 342-343| 349-350
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
13. A patient has a compression fracture of the cervical spine at C7 to C8 that is impairing deep
tendon reflexes. Which response will the nurse expect from the affected deep tendon reflex?
a. Diminished to absent pronation of the arm
b. Diminished to absent flexion of the elbow
c. Diminished to absent extension of the elbow
d. Diminished to absent adduction of the upper arm
ANSWER: C
A
B
C
D
Feedback
Diminished to absent pronation of the arm is an abnormal response from the
brachioradial deep tendon reflex that is innervated from C5 to C6.
Diminished to absent flexion of the elbow is an abnormal response from the
biceps deep tendon reflex that is innervated from C5 to C6.
Diminished to absent extension of the elbow is an abnormal response from the
triceps deep tendon reflex that is innervated from C6, C7, and C8.
Diminished to absent adduction of the upper arm is not a response of any deep
tendon reflex.
DIF: Cognitive Level: Analyze REF: 342-343| 349-350
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
14. A nurse holds the patient’s relaxed left arm, with elbow flexed at a 90-degree angle, in one
hand. The nurse palpates and then strikes the appropriate tendon just above the elbow with
either end of the reflex hammer. What is the expected response for this deep tendon reflex?
a. Flexion of the left elbow
b. Pronation of the left forearm
c. Supination of the left arm
d. Extension of the left elbow
ANSWER: D
A
B
C
D
Feedback
Flexion of the left elbow would be a normal response for the biceps deep tendon
reflex.
Pronation of the left forearm would be a normal response for the brachioradialis
deep tendon reflex.
Supination of the left arm is not a response of any deep tendon reflex.
Extension of the left elbow is the normal response of the triceps deep tendon
reflex.
DIF: Cognitive Level: Analyze REF: 349-350
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
15. A nurse holds the patient’s relaxed arm with the elbow flexed at a 90-degree angle, places a
thumb over the appropriate tendon in the antecubital fossa, and strikes the thumb with the
pointed end of the reflex hammer. What is the expected response for this deep tendon reflex?
a. Flexion of the left elbow
b. Pronation of the left forearm
c. Supination of the left arm
d. Extension of the left elbow
ANSWER: D
A
B
C
D
Feedback
Pronation of the left forearm is a normal response for the brachioradialis deep
tendon reflex.
Supination of the left arm is not a response of any deep tendon reflex.
Extension of the left elbow is the normal response of the triceps deep tendon
reflex.
Flexion of the left elbow is a normal response for the biceps deep tendon reflex.
DIF: Cognitive Level: Analyze REF: 349-350
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
16. How does a nurse test the brachioradial deep tendon reflex?
a. Uses the end of the handle on the reflex hammer to stroke the lateral aspect of the
sole of the patient’s foot from heel to ball
b. Asks the patient to slightly pronate the relaxed forearm into the nurse’s hand and
strikes the appropriate tendon with the reflex hammer
c. Holds the patient’s relaxed arm with the elbow flexed at a 90-degree angle in one
hand, and palpates and strikes the appropriate tendon just above the elbow with the
flat end of the reflex hammer
d. Holds the patient’s relaxed arm with the elbow flexed at a 90-degree angle, places a
thumb over the appropriate tendon in the antecubital fossa, and strikes the thumb
with the pointed end of the reflex hammer
ANSWER: B
A
B
C
D
Feedback
This is the technique to test plantar flexion, the Babinski reflex.
This is the technique to assess the brachioradial deep tendon reflex.
This is the technique to test the triceps deep tendon reflex.
This is the technique to test the biceps deep tendon reflex.
DIF: Cognitive Level: Understand REF: 349-350
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
17. A nurse dorsiflexes a patient’s right ankle 90 degrees and then uses a reflex hammer to strike
the appropriate tendon. What is the expected response for this deep tendon reflex?
a. Extension of the right lower leg
b. Plantar flexion of the right toes
c. Dorsiflexion of the right foot
d. Plantar flexion of the right foot
ANSWER: D
A
B
C
D
Feedback
This is the expected response for the patellar deep tendon reflex.
This is the expected response for the plantar reflex (Babinski).
This is an incorrect response because the nurse is holding the patient’s foot in
dorsiflexion, therefore dorsiflexion would not be an expected response.
Plantar flexion is the expected response of the Achilles deep tendon reflex.
DIF: Cognitive Level: Analyze REF: 349-350
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
18. The nurse moves a wisp of cotton lightly across the anterior scalp, paranasal sinuses, and
lower jaw to test the function of which cranial nerve?
a. CN IV (trochlear nerve)
b. CN V (trigeminal nerve)
c. CN VI (abducens nerve)
d. CN VII (facial nerve)
ANSWER: B
A
B
C
D
Feedback
The CN IV (trochlear nerve) supplies downward and inward eye movement.
The CN V (trigeminal cranial nerve) supplies sensation to the cornea, iris,
lacrimal glands, conjunctiva, eyelids, forehead, nose, nasal and mouth mucosa,
teeth, tongue, ear, and facial skin.
The CN VI (abducens nerve) supplies lateral eye movement.
The CN VII (facial nerve) supplies movement of facial expression muscles except
the jaw, closes the eyes, and allows labial speech sounds (b, m, w, and rounded
vowels).
DIF: Cognitive Level: Understand REF: 341| 352
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
19. A nurse who is assessing a patient’s eyes finds that the pupils are equal, round, and react to
light and accommodation (PERRLA). These findings verify the expected functioning of which
cranial nerve?
a. Optic cranial nerve (CN II)
b. Oculomotor cranial nerve (CN III)
c. Trochlear cranial nerve (CN IV)
d. Abducens cranial nerve (CN VI)
ANSWER: B
A
B
C
D
Feedback
The optic cranial nerve (CN II) provides vision.
The oculomotor cranial nerve (CN III) provides these eye functions.
The trochlear cranial nerve (CN IV) provides eye movement downward and
inward.
The abducens cranial nerve (CN VI) provides lateral eye movement.
DIF: Cognitive Level: Understand REF: 341| 352
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific
Assessments
20. In assessing a patient with a tumor in the pons, the nurse expects to find which abnormalities
due to pressure on cranial nerves?
a. Dilated pupils and ptosis
b. Facial asymmetry and impaired hearing
c. Difficulty swallowing
d. Impaired gag reflex
ANSWER: B
Feedback
A
B
C
D
These abnormalities represent pressure on the oculomotor (CN III) that exits from
the midbrain.
These abnormalities represent pressure on the facial and acoustic cranial nerves.
The nurse correlates the cranial nerves that exit from the pons which are
trigeminal (CN V), abducens (CN VI), facial (CN VII), and acoustic (CN VIII).
This abnormality represents pressure on the three cranial nerves that affect
swallowing: glossopharyngeal (CN IX), vague (CN X), and hypoglossal (CN
XII). These cranial nerves exit the brainstem in the medulla oblongata.
This reflex is controlled by the vagus cranial nerve (CN IX), which exits the
brainstem in the medulla oblongata.
DIF: Cognitive Level: Analyze REF: 338| 341| 352, Figure 15-5
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
21. The nurse assesses the glossopharyngeal nerve (CN IX) by testing which reflex?
a. Corneal reflex
b. Gag reflex
c. Blink reflex
d. Cough reflex
ANSWER: B
A
B
C
D
Feedback
The corneal reflex is controlled by the trigeminal cranial nerve (CN V).
Movement of the posterior pharynx and gag reflex test is controlled by the
glossopharyngeal cranial nerve (CN IX).
The blink reflex is another name for the corneal reflex.
The cough reflex is controlled from the medulla oblongata.
DIF: Cognitive Level: Understand REF: 341| 354
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
22. Which cranial nerve is assessed when a nurse asks a patient to stick out the tongue and move
it side to side?
a. Vagus nerve (CN X)
b. Facial nerve (CN VII)
c. Abducens nerve (CN VI)
d. Hypoglossal nerve (CN XII)
ANSWER: D
A
B
Feedback
The vagus cranial nerve provides movement for voluntary muscles of phonation
(guttural speech sounds) and swallowing.
The facial cranial nerve provides movement for facial expression muscles except
the jaw, closes the eyes, and allows labial speech sounds (b, m, w, and rounded
vowels).
C
D
The abducens cranial nerve provides for lateral eye movement.
The hypoglossal cranial nerve provides tongue movement for speech sound
articulation (l, t, n) and swallowing.
DIF: Cognitive Level: Understand REF: 341| 354
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
23. As a patient is walking down the hall, the nurse notices the patient’s staggering, unsteady gait.
What findings does the nurse anticipate on the neurologic examination?
a. When the patient stands with feet together, eyes open and then closed, an upright
posture is maintained.
b. When the patient touches the end of each finger to the thumb of the same hand, a
tremor is observed in the fingers.
c. When the patient is giving a history to the nurse, a tremor is noticed as the patient’s
hands rest in the lap.
d. When lying supine, the patient is able to move the heel of one foot down the shin of
the other leg.
ANSWER: B
A
B
C
D
Feedback
This is a result of a negative Romberg test. This patient has a cerebellar problem,
which would result in a positive Romberg test.
This patient has a cerebellar problem as evidenced by the staggering gait (noted at
the beginning of the encounter) and the intention tremor on movement (noted
during the examination).
This describes a tremor at rest that occurs in patients with parkinsonism rather
than with cerebellar problems.
This describes a normal response on an examination of cerebellar function.
DIF: Cognitive Level: Apply REF: 340| 357-358
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
24. A nurse asks the patient to stand with feet together, arms resting at the sides, with eyes open
and then with the eyes closed. Which response by the patient indicates an expected cerebellar
function?
a. Sways slightly and maintains upright posture with feet together
b. Is unable to stand upright after turning around in a circle once
c. Steps sideways when standing with feet together and eyes closed
d. Has to move arms horizontally to maintain balance
ANSWER: A
A
B
Feedback
Maintaining balance indicates function of the cerebellum in the Romberg test.
Losing balance is an abnormal response, but turning in a circle is not a part of the
Romberg test.
C
D
This is an abnormal response for the Romberg test (a positive Romberg test).
This is an abnormal response for the Romberg test (a positive Romberg test).
DIF: Cognitive Level: Apply REF: 355
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
25. The nurse asks the patient to stand with feet together, arms resting at the sides, with eyes open
and then with the eyes closed. Which response by the patient indicates a problem in the
cerebellum?
a. Maintains balance when eyes are open, but loses balance with eyes closed
b. Is unable to stand upright after turning around in a circle once
c. Steps sideways when standing with feet together and eyes closed
d. Sways slightly and maintains upright posture with feet together
ANSWER: C
A
B
C
D
Feedback
This is an abnormal response, but is indicative of a proprioceptive problem rather
than a cerebellar problem.
Losing balance is an abnormal response, but turning in a circle is not a part of the
Romberg test.
This is an abnormal response documented as a “positive Romberg” and indicates
cerebellar dysfunction.
This is an expected response documented as a “negative Romberg,” indicating
appropriate cerebellar function for balance.
DIF: Cognitive Level: Apply REF: 355
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
26. What is the patient’s expected response when the nurse is assessing graphesthesia?
a. Lies supine and runs one heel along the opposite shin
b. Identifies a familiar object placed in the hands
c. Describes where a sensation of a vibrating tuning fork is felt
d. Identifies a letter or number drawn in the hand
ANSWER: D
A
B
C
D
Feedback
This activity tests cerebellar function of the lower extremities.
This is a test of stereognosis that tests the function of the parietal lobe and
sensory tracts.
This is a test of vibratory sense that tests sensory tracts.
This is a test of graphesthesia that assesses the parietal lobe and sensory tracts.
DIF: Cognitive Level: Understand REF: 359-360
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
27. What is the patient’s expected response when the nurse is assessing stereognosis?
a. Identifies an object placed in the hand
b. Distinguishes numbers or letters traced in the palm of the hand
c. Touches the index finger of the nondominant hand to the nose
d. Walks heel to toe in a straight line
ANSWER: A
A
B
C
D
Feedback
A nurse tests stereognosis by asking the patient to close his or her eyes and
placing a small, familiar object in the patient’s hand, asking him or her to identify
it. Stereognosis tests sensory nerve tracts and parietal lobe function.
This activity tests graphesthesia, a test of sensory nerve tracts and parietal lobe
function.
This activity tests cerebellar function of the upper extremities.
This activity tests cerebellar function of the lower extremities.
DIF: Cognitive Level: Understand REF: 337| 359
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
28. A nurse correlates a patient’s altered stereognosis with a neurologic dysfunction in which part
of the nervous system?
a. Midbrain or pons
b. Temporal lobe or ascending nerve tracts
c. Frontal lobe or motor nerve tracts
d. Parietal lobe or sensory nerve tracts
ANSWER: D
A
B
C
D
Feedback
Sensory and motor tracts travel though the midbrain and pons, but they are not
tested with stereognosis.
Ascending tracts carry sensory data, but the temporal lobe provides functions of
hearing rather than perception of touch.
Motor tracts carry impulses for movement and they exit from the frontal lobe,
which also helps to maintain consciousness.
A parietal lobe or sensory nerve tract dysfunction prevents a patient from
identifying a familiar object by touch, which is a definition of stereognosis.
DIF: Cognitive Level: Apply REF: 337| 359
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
29. Which part of the nervous system is a nurse assessing when he places a vibrating tuning fork
on a patient’s wrist or ankle?
a. Frontal lobe and motor tracts
b. Parietal lobe and sensory tracts
c. Hypothalamus and sensory tracts
d. Cerebellum and motor tracts
ANSWER: B
A
B
C
D
Feedback
The frontal lobe sends impulses governing movement through motor (efferent)
tracts.
The parietal lobe receives sensory input, such as vibratory sense and pain,
through sensory (afferent) tracts.
The hypothalamus functions include regulation of body temperature, hunger, and
thirst and formation of autonomic nervous system responses.
The cerebellum provides equilibrium and coordination of movement.
DIF: Cognitive Level: Understand REF: 337| 340| 358-359
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific
Assessments
30. A patient has a herniated disk compressing the lumbar spine at L2, L3, and L4 that is
impairing deep tendon reflexes. Which response does a nurse expect from this patient?
a. Diminished contraction of the gastrocnemius muscle with plantar flexion of the
foot
b. Diminished contraction of the quadriceps muscle with extension of the lower leg
c. Diminished plantar flexion of the toes
d. Diminished dorsiflexion of the foot and flexion of the toes
ANSWER: B
A
B
C
D
Feedback
This is an abnormal response from the Achilles tendon reflex that is innervated
from S1 and S2.
This is an abnormal response from the patellar deep tendon reflex that is
innervated from L2, L3, and L4.
This is an abnormal response from the plantar reflex or a positive Babinski sign.
This is an abnormal response of ankle clonus.
DIF: Cognitive Level: Analyze REF: 343| 350
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
31. What technique does the nurse use to test the patellar deep tendon reflex?
a. Using the end of the handle on the reflex hammer, the nurse strokes the lateral
aspect of the sole of the patient’s foot from heel to ball.
b. Ask the patient to flex one knee to 90 degrees, while the nurse dorsiflexes the ankle
and strikes the appropriate tendon on the foot with the flat end of the reflex
hammer.
c. Ask the patient to flex one knee to 45 degrees, while the nurse plantar flexes the
ankle and strikes the appropriate tendon of the ankle with the pointed end of the
reflex hammer.
d. Ask the patient to flex one knee to 90 degrees, while the nurse strikes the
appropriate tendon in the knee with the blunt end of the reflex hammer.
ANSWER: D
A
B
C
D
Feedback
This is the technique for testing plantar flex or the Babinski reflex.
This is the technique for testing the Achilles deep tendon reflex.
This is not a correct technique for testing any reflex.
This is the technique for testing the patella deep tendon reflex.
DIF: Cognitive Level: Understand REF: 350
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
32. What technique does the nurse use to test ankle clonus?
a. Strokes the lateral aspect of the sole of the patient’s foot from heel to ball with a
reflex hammer
b. Supports the patient’s knee in flexed position and sharply dorsiflexes the foot and
maintains the flexion
c. Plantar flexes the ankle and strikes the appropriate tendon of the ankle with the
hammer
d. Everts the ankle and slowly moves the ankle into plantar flexion and quickly
release the foot
ANSWER: B
A
B
C
D
Feedback
This is the technique for testing plantar flex or the Babinski reflex.
This is the correct technique for assessing ankle clonus.
This is not a correct technique for testing any reflex.
This is not a correct technique for testing any reflex.
DIF: Cognitive Level: Understand REF: 350
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
33. Which response does a nurse expect when testing ankle clonus of a healthy woman?
a. No movement of the foot
b. Plantar flexion of the foot
c. Extension of the lower leg
d. Dorsiflexion of the foot
ANSWER: A
A
B
Feedback
No movement of the foot is the expected response from a healthy woman.
Plantar flexion of the foot is not a response to ankle clonus.
C
D
Extension of the lower leg is not a response to ankle clonus.
Dorsiflexion of the foot is an abnormal response of ankle clonus.
DIF: Cognitive Level: Understand REF: 350
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
MULTIPLE RESPONSE
1. To complete a symptom analysis, which questions does a nurse ask patient who recently had a
seizure for the first time? Select all that apply.
a. “Did you have any warning signs before the seizure started?”
b. “Did you lose consciousness during the seizure?”
c. “Did the room seem to be spinning around before the seizure?”
d. “Did you urinate during the seizure?”
e. “What did you hear while you were seizing?”
f. “How did you feel after the seizure?”
ANSWER: A, B, D, F
Correct: These are all appropriate questions to ask to gather more data about this patient’s
first seizure.
Incorrect: “Did the room seem to be spinning around before the seizure?” This question is
about vertigo, which does not relate to this patient. “What did you hear while you were
seizing?” The answer to this question is not needed in the data for this patient.
DIF: Cognitive Level: Analyze REF: 345
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
2. Which characteristics are risk factors for cerebrovascular accident? Select all that apply.
a. Excessive alcohol intake
b. Smoking
c. Eating large amounts of smoked foods
d. Obesity
e. Atherosclerosis
f. High blood pressure
ANSWER: A, B, D, E, F
Correct: All of these are risk factors for cerebrovascular accident.
Incorrect: Eating large amounts of smoked foods is a risk factor for stomach cancer.
DIF: Cognitive Level: Remember REF: 362
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: Potential for
Alteration in Body Systems
3. Which manifestations does a nurse correlate with a patient with suspected meningitis? Select
all that apply.
a. Ptosis
b. Loss of balance when standing with feet together and the eyes closed
c. Confusion, agitation, and irritability
d. Severe headache
e. Stiff neck
f. Lethargy
ANSWER: C, D, E, F
Correct: Confusion, agitation, and irritability; severe headache—this is a symptom of
meningeal irritation due to inflammation of the meninges; stiff neck; lethargy. Patients may
have changes in level of consciousness.
Incorrect: Ptosis is drooping of eyelids controlled by the oculomotor cranial nerve. Loss of
balance when standing with feet together and the eyes closed. This describes a positive
Romberg test indicating a cerebellar problem.
DIF: Cognitive Level: Understand REF: 362
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
Chapter 16: Breasts and Axillae
Test Bank
MULTIPLE CHOICE
1. In teaching a patient about breast self-examination, why does the nurse emphasize palpation
of the axillary areas?
a. Because deep muscles in that area can mask changes
b. Because some patients avoid this area because of tenderness
c. Because most lymph draining from the breast flows through this area
d. Because supporting ligaments in this area may present as tissue changes
ANSWER: C
A
B
C
D
Feedback
Because deep muscles in that area can mask changes. This answer is incorrect.
Palpating the axilla for enlarged lymph nodes is very important.
Because some patients avoid this area because of tenderness. This answer is
incorrect. Palpating the axilla for enlarged lymph nodes is very important.
Because most lymph draining from the breast flows through this area. More than
75% of lymph drainage from the breast flows outward toward the axillary lymph
node.
Because supporting ligaments in this area may present as tissue changes. This
answer is incorrect. Palpating the axilla for enlarged lymph nodes is very
important.
DIF: Cognitive Level: Understand REF: 367| 370| 375
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Need Category: Physiologic Integrity: Reduction of Risk Potential: System
Specific Assessments
2. In reviewing the charts of several patients in the clinic, a nurse recognizes which patient as
being at highest risk of breast cancer?
a. A woman who had her first child at age 26
b. A woman who reached menopause at age 58
c. A woman who breastfed all four of her children
d. A woman who states that she reached menarche at age 14
ANSWER: B
A
B
C
D
Feedback
A woman who had her first child at age 26 has a low risk.
A woman who reached menopause at age 58. A long menstrual history
(menopause after age 50) increases risk.
A woman who breastfed all four of her children has a low risk.
A woman who states that she reached menarche at age 14 has a low risk because
the menarche was after 12 years of age.
DIF: Cognitive Level: Understand REF: 381
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Need Category: Physiologic Integrity: Reduction of Risk Potential: Potential
for Alteration in Body Systems
3. While giving a presentation about breast health, a nurse informs patients about which
recommendation?
a. Women in their 30s should have annual clinical breast examinations.
b. Women at high risk of breast cancer should have semiannual mammograms.
c. Women who are postmenopausal require clinical breast examination every 5 years.
d. A screening mammogram is recommended for all women beginning at age 50
years.
ANSWER: D
A
B
C
D
Feedback
Clinical breast examinations are recommended as part of a periodic health
examination at least every 3 years for average-risk, asymptomatic women in their
20s and 30s, and annually for asymptomatic women age 40 and older.
Having semiannual mammograms is more often than necessary.
Clinical breast examinations are recommended as part of a periodic health
examination at least every 3 years for average-risk, asymptomatic women in their
20s and 30s, and annually for asymptomatic women age 40 and older.
This is the recommendation of the U.S. Preventive Services Task Force.
DIF: Cognitive Level: Remember REF: 370
TOP: Nursing Process: Intervention
MSC: NCLEX Patient Need Category: Health Promotion and Maintenance: Health Promotion
Programs
4. Based on the history, a nurse determines that the patient with which finding requires further
assessment?
a. Occasional discharge from nipples
b. Supernumerary nipples along the milk line
c. Rash in the axillae associated with change in deodorant
d. Mild breast swelling that fluctuates with the menstrual cycle
ANSWER: A
A
B
C
D
Feedback
Nipple discharge is usually an abnormal finding. A specimen of the discharge
should be collected.
Supernumerary nipples along the milk line are a normal finding in some women.
A rash in the axillae associated with change in deodorant can be solved by
changing deodorant and treating the rash.
Mild breast swelling that fluctuates with the menstrual cycle is consistent with
fibrocystic breast disease.
DIF: Cognitive Level: Analyze REF: 369| 374| 377
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Need Category: Physiologic Integrity: Physiologic Adaptation: Alteration in
Body Systems
5. During a breast examination of a healthy female, the nurse recognizes which finding as
normal?
a. Asymmetrical venous pattern
b. Unequal nipple size
c. Supernumerary nipples along the milk line
d. Pink discharge from one nipple when manipulated
ANSWER: C
A
B
C
D
Feedback
The venous patterns should be bilaterally similar.
Nipple size should be symmetric.
Supernumerary nipples are considered a normal variation, although they are
uncommon.
Nipple discharge is usually considered an abnormal finding.
DIF: Cognitive Level: Remember REF: 372-373| 379
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Need Category: Physiologic Integrity: Reduction of Risk Potential: System
Specific Assessments
6. A patient comes to the clinic complaining of a new onset of nipple discharge. After inspection
of the breast and discharge, what action of the nurse has the highest priority?
a. Palpating both breasts comparing amount of discharge
b. Asking the patient about breast pain
c. Asking the patient to raise her arms and comparing the movement of the breasts
d. Obtaining a specimen of the discharge for cytology
ANSWER: D
A
B
C
D
Feedback
Getting a specimen is more important than palpating breasts at this time.
Asking the patient about breast pain is not a priority action at this time.
Asking the patient to raise her arms and comparing the movement of the breasts is
not a priority action at this time.
If a patient has nipple discharge, a specimen should be collected for cytologic
examination to detect malignant cells.
DIF: Cognitive Level: Analyze REF: 374| 377
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Need Category: Physiologic Integrity: Physiologic Adaptation: Alteration in
Body Systems
7. What is the purpose of asking a female to lean forward during the breast examination?
a. To accentuate the Montgomery glands
b. To observe for symmetry of the suspensory ligaments
c. To compare nipple symmetry
d. To identify any breast masses in the subcutaneous tissues
ANSWER: B
Feedback
A
B
C
D
Montgomery glands are located within the areolar surface and would be difficult
to inspect when the patient leans forward.
Observing these ligaments can be accomplished with the patient leaning forward.
Nipple symmetry is better evaluated with the patient sitting up or lying supine.
Palpation is a better way to identify a breast mass in subcutaneous tissue.
DIF: Cognitive Level: Understand REF: 374-375
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Need Category: Health Promotion and Maintenance: Techniques of Physical
Assessment
8. Which technique does a nurse use to palpate the patient’s axillary lymph nodes?
a. With the patient sitting, the nurse places fingers of both hands deep into the axilla,
one hand on either side, and firmly pushes the axillary tissue toward the center to
feel for enlarged nodes.
b. With the patient lying supine with arms at the sides, the nurse uses the tips of the
fingers of one hand to palpate the axilla moving from the posterior to the anterior
aspect of the axilla to feel for enlarged nodes.
c. With the patient lying supine with the hand behind the head of the side being
assessed, the nurse uses the pads of fingers of one hand to systematically palpate
the axilla using small circular motions to feel for enlarged nodes.
d. With the patient sitting, the nurse places fingers of one hand deep into the axilla
and firmly slides the fingers along the patient’s middle, anterior, and posterior of
the axilla to feel for enlarged nodes.
ANSWER: D
A
B
C
D
Feedback
This is incorrect technique.
This is incorrect technique.
This is incorrect technique.
This is the correct technique.
DIF: Cognitive Level: Understand REF: 375-376
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Need Category: Health Promotion and Maintenance: Techniques of Physical
Assessment
9. When examining the lymph nodes of an adult female patient, the nurse recognizes which
finding as normal?
a. Visible superficial nodes
b. Palpable supraclavicular nodes
c. Nonpalpable lymph nodes in the axilla
d. Enlarged, fixed nodes in the neck
ANSWER: C
A
B
Feedback
Lymph nodes are not normally palpable or visible.
Lymph nodes are not normally palpable. Enlarged supraclavicular nodes often
indicate a malignancy.
C
D
Lymph nodes are not normally palpable.
Lymph nodes are not normally palpable.
DIF: Cognitive Level: Apply REF: 375
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Need Category: Physiologic Integrity: Reduction of Risk Potential: System
Specific Assessments
10. A nurse performing a breast examination on a female patient places the patient in a supine
position, places a pillow under the right shoulder, and asks the patient to place her right lower
arm above her head. What is the reason for this position?
a. Flatten the breast tissue evenly over the chest wall.
b. Help the patient to relax and feel more comfortable.
c. Reveal lumps deep in the breast more easily.
d. Expose any drainage from the nipples.
ANSWER: A
A
B
C
D
Feedback
This is the reason for the position.
Flattening the breast tissue, not relaxation, is the reason.
Lumps are detected by palpation rather than inspection.
Drainage is revealed by palpation of the nipples.
DIF: Cognitive Level: Apply REF: 376
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Need Category: Health Promotion and Maintenance: Techniques of Physical
Assessment
11. What instructions does the nurse give a female patient when she is learning to perform breast
self-examination?
a. Press the pads of the fingers firmly to compress breast tissue against the rib cage.
b. Lie in front of a mirror and observe for dimpling of the skin.
c. Lift the fingers from the chest wall during palpation to better define the breast
tissue.
d. Apply gentle pressure while moving the fingers in a pattern across the breast.
ANSWER: D
A
B
C
D
Feedback
Gentle rather than firm pressure is used.
A patient stands in front of a mirror to inspect symmetry; she does not lie in front
of a mirror.
The fingers should not be lifted from the breast to prevent breaking the continuity
of palpation.
This is appropriate technique.
DIF: Cognitive Level: Apply REF: 376
TOP: Nursing Process: Intervention
MSC: NCLEX Patient Need Category: Health Promotion and Maintenance: Techniques of Physical
Assessment
12. In assessing the breast of a male patient, the nurse places him in which position?
a. Standing with hands over the head
b. Supine with the hand on the side being examined placed behind the head
c. Sitting with arms at the side
d. Bending forward 45 degrees at the waist
ANSWER: C
A
B
C
D
Feedback
This is part of the examination for female patients.
This is part of the examination for female patients.
This is the appropriate position for the male breast examination.
This is part of the examination for female patients.
DIF: Cognitive Level: Understand REF: 378
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Need Category: Health Promotion and Maintenance: Techniques of Physical
Assessment
13. During a breast examination of a male patient, the nurse recognizes which finding as normal?
a. Bilateral nontender flat breasts with symmetric nipple and areolar areas
b. A fibrous layer of subcutaneous breast tissue that is thicker than in women
c. Breast tenderness on the dominant side but not on the other side
d. Bilateral symmetry of breasts with absence of hair in the areolar areas
ANSWER: A
A
B
C
D
Feedback
This is a description of a normal finding.
This is not a normal finding.
This is not a normal finding.
This is not a normal finding.
DIF: Cognitive Level: Understand REF: 378-379
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Need Category: Physiologic Integrity: Reduction of Risk Potential: System
Specific Assessments
14. Which statement by a 40-year old man would be most indicative of possible breast cancer?
a. “I had embarrassing breast enlargement when I was a teenager.”
b. “I think I felt a hard spot in my left breast, but it does not hurt.”
c. “My right breast has always been a little smaller than the left.”
d. “My father’s breasts got larger after he was older.”
ANSWER: B
A
B
C
Feedback
This describes gynecomastia.
A breast malignancy usually manifests in one breast as a hard, painless, irregular
nodule, often fixed.
One larger breast is not indicative of breast cancer and may be a normal variation.
D
This report is not indicative of breast cancer.
DIF: Cognitive Level: Understand REF: 379
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Need Category: Physiologic Integrity: Physiologic Adaptation: Alteration in
Body Systems
15. What technique does a nurse use when performing a breast examination on a patient who has
had a mastectomy?
a. Excludes palpation of the axillary area where there was lymph node dissection
b. Inspects and palpates both the operative and the nonoperative sides
c. Avoids palpating the scar to prevent causing the patient any discomfort
d. Palpates only the muscle tissue on the affected side
ANSWER: B
A
B
C
D
Feedback
Axilla is still palpated after node dissection.
Women who have had a mastectomy require the same breast assessment as all
other women.
The scar tissue should not be tender and the technique of palpation on the
operative side should be the same as the nonoperative side.
Women who have had a mastectomy require the same breast assessment as all
other women.
DIF: Cognitive Level: Apply REF: 380
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Need Category: Health Promotion and Maintenance: Techniques of Physical
Assessment
16. In a presentation on breast cancer risk factors, a nurse would be accurate in making which
statement?
a. “Women who breastfeed their children are at increased risk of breast cancer.”
b. “Women who are more than 30% overweight are at increased risk of breast cancer.”
c. “African American women have the highest risk of breast cancer.”
d. “Women who have children before age 30 are at increased risk of breast cancer.”
ANSWER: B
A
B
C
D
Feedback
Breastfeeding is not a risk factor for breast cancer.
Obesity especially after age 50 or increased weight gain as an adult increases
breast cancer risk.
White women have the highest incidence of breast cancer.
First full-term pregnancy after age 30 increases risk.
DIF: Cognitive Level: Understand REF: 381
TOP: Nursing Process: Intervention
MSC: NCLEX Patient Need Category: Physiologic Integrity: Reduction of Risk Potential: Potential
for Alteration in Body Systems
17. A patient comes to the clinic because she found a mass in her left breast that is present during
and after her menstrual periods. On palpation the nurse finds a mass in the left breast that is
round, rubbery, mobile, and nontender. This finding is consistent with which breast disorder?
a. Fibrocystic breast disease
b. Invasive breast cancer
c. Mastitis
d. Fibroadenoma
ANSWER: D
A
B
C
D
Feedback
Findings of this disorder affect both breasts and produce tenderness that subsides
between menstrual periods.
Masses of breast cancer are irregular, hard, and fixed.
Mastitis is an inflammation of the entire breast that produces tissue that is red,
edematous, tender, and warm to the touch.
These findings are consistent with fibroadenoma.
DIF: Cognitive Level: Apply REF: 381-382
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Need Category: Physiologic Integrity: Physiologic Adaptation: Alteration in
Body Systems
18. A patient had a left radical mastectomy last year. The nurse assesses for painless and
nonpitting swelling of the arm on that side. Which complication of a mastectomy is the nurse
assessing for?
a. Infection
b. Lymphedema
c. Inflammation
d. Lymphoma
ANSWER: B
A
B
C
D
Feedback
Localized signs of infection include redness, heat, and pain; there can also be
edema, which, when associated with infection, is pitting.
Lymphedema is a localized accumulation of lymph fluid in the interstitial spaces
caused by removal of the lymph nodes.
Localized signs of inflammation include redness, heat, and pain; there can also be
edema, which, when associated with inflammation, is pitting.
The sign of lymphoma is an enlarged lymph node rather than generalized
swelling.
DIF: Cognitive Level: Apply REF: 380
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Need Category: Physiologic Integrity: Physiologic Adaptation: Alteration in
Body Systems
19. In assessing a patient with lymphedema after a mastectomy, the nurse expects which finding?
a. Fragile, thin, pale skin covering the area of lymphedema
b. Several brownish-red discolorations in the center of the affected arm
c. Unilateral nonpitting edema of the affected arm
d. Pitting edema of affected arm
ANSWER: C
A
B
C
D
Feedback
This is an incorrect description of lymphedema.
This is more consistent with a description of chronic venous insufficiency than
lymphedema.
Lymphedema is a localized accumulation of lymph fluid in the interstitial spaces
caused by removal of the lymph nodes.
The fluid accumulation in lymphedema usually is not enough to cause pitting.
DIF: Cognitive Level: Apply REF: 380
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Need Category: Physiologic Integrity: Physiologic Adaptation: Alteration in
Body Systems
20. A nurse is performing a breast examination of a patient who complains of pain in both breasts
that occurs around the time of her menstrual period. The nurse expects which findings during
the breast examination?
a. Masses in the breasts that are round, soft, mobile, and well-delineated
b. Masses in the breasts that are round, firm, mobile, and well-delineated
c. Masses in the breasts that are irregular, hard, and fixed
d. Breast tissue that is red, edematous, tender, and warm to the touch
ANSWER: A
A
B
C
D
Feedback
This finding is consistent with fibrocystic breast disease. The findings are almost
the same as fibroadenoma (except for consistency of the masses), but the nurse
must correlate the history (occurs during the menses) with the findings for
fibrocystic disease.
These findings are consistent with fibroadenoma.
These findings are consistent with breast cancer.
These findings are consistent with mastitis.
DIF: Cognitive Level: Apply REF: 381
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Need Category: Physiologic Integrity: Physiologic Adaptation: Alteration in
Body Systems
21. The nurse notices dimpling of the skin surrounding a palpable mass in the right breast of a
female patient. What is the most appropriate action for the nurse to take next?
a. Record this as an expected finding.
b. Palpate the area of dimpling for pain.
c. Palpate the borders of the area of dimpling for irregularity.
d. Tell the patient that dimpling indicates the mass is benign.
ANSWER: C
Feedback
A
B
C
D
This finding is not normal.
Malignant breast masses are not tender.
Malignant breast masses are irregular and poorly delineated. As the mass grows,
there may be breast asymmetry, discoloration (erythema or ecchymosis),
unilateral vein prominence, peau d’orange, ulceration, dimpling, puckering, or
retraction of the skin.
Dimpling may indicate a malignant mass rather than a benign mass.
DIF: Cognitive Level: Apply REF: 371-372| 383
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Need Category: Physiologic Integrity: Physiologic Adaptation: Alteration in
Body Systems
22. A nurse becomes suspicious that a patient may have breast cancer based on which abnormal
finding?
a. An irregularly shaped hard mass in one breast
b. Bilateral, small, nontender nodes close to the surface
c. Multiple rubbery-feeling lumps with well-defined borders
d. A mobile, firm lump located in the upper outer quadrant of the left breast
ANSWER: A
A
B
C
D
Feedback
Malignant masses are solitary, irregularly-shaped, unilateral, nontender, and
immobile.
Malignant masses are unilateral.
Malignant masses have irregular, poorly defined borders.
Breast cancer often occurs in the upper outer quadrant, but is immobile.
DIF: Cognitive Level: Understand REF: 376| 383
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Need Category: Physiologic Integrity: Physiologic Adaptation: Alteration in
Body Systems
23. The nurse would give immediate attention to the patient who presents with which complaint?
a. Bilateral breast swelling
b. Unilateral nipple discharge
c. A breast lump that changes during the menstrual cycle
d. Unequal breast size
ANSWER: B
A
B
C
D
Feedback
Bilateral breast swelling is frequently related to fibrocystic breast disease.
A breast malignancy usually manifests in one breast, and a serosanguineous or
clear nipple discharge may be present.
A breast lump that changes during the menstrual cycle is frequently related to
fibrocystic breast disease.
Unequal breast size that does not include a mass in one breast is not an immediate
concern.
DIF: Cognitive Level: Understand REF: 374| 377
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Need Category: Physiologic Integrity: Physiologic Adaptation: Alteration in
Body Systems
MULTIPLE RESPONSE
1. Which life style behaviors do nurses ask about to identify patients with risk factors for breast
cancer? Select all that apply.
a. Obesity after age 50
b. Smoking more than one pack of cigarettes a day
c. Never having given birth to a viable infant
d. Drinking two to five alcoholic beverages a day
e. Estrogen replacement therapy for more than 5 years
f. High blood pressure for more than 3 years
ANSWER: A, C, D, E
Correct: Obesity after age 50, never having given birth to a viable infant (nulliparity),
drinking two to five alcoholic beverages a day, and estrogen replacement therapy for more
than 5 years are all risk factors for breast cancer.
Incorrect: Although smoking and high blood pressure are risk factors for many disorders,
they are not risk factors for breast cancer.
DIF: Cognitive Level: Understand REF: 381
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Need Category: Physiologic Integrity: Reduction of Risk Potential: Potential
for Alteration in Body Systems
Chapter 17: Reproductive System and the Perineum
Test Bank
MULTIPLE CHOICE
1. During the initial inspection of the female genitalia, the nurse recognizes which finding as
normal?
a. The labia minora are hair-covered and lying within the labia majora.
b. The cervical os in the multiparous woman has the shape of a small circle.
c. The vaginal vestibule lies between the labia minora and contains the urinary
meatus.
d. The openings of Skene and Bartholin glands are visible posteriorly.
ANSWER: C
A
B
C
D
Feedback
The labia majora, rather than the labia minora, are covered with hair.
The os of parous women is the shape of a slit.
This description is of normal female anatomy.
The opening of these glands is on either side of the vaginal vestibule.
DIF: Cognitive Level: Understand REF: 386| 401
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific
Assessments
2. The pregnant patient tells the nurse that she has had three pregnancies and two live births to
date. How does the nurse record this in the patient’s history?
a. Gravida 3, para 3
b. Gravida 3, para 2
c. Gravida 2, para 3
d. Gravida 2, para 2
ANSWER: B
A
B
C
D
Feedback
Gravida 3, para 3 represents three pregnancies and three that reached 20 weeks or
longer.
Gravida 3, para 2 represents three pregnancies and two that reached 20 weeks or
longer, which is consistent with what the patient reported.
Gravida 2, para 3 represents two pregnancies and three that reached 20 weeks or
longer, which is not possible.
Gravida 2, para 2 represents two pregnancies and two that reached 20 weeks or
longer.
DIF: Cognitive Level: Apply REF: 394
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific
Assessments
3. A mother asks a nurse when her daughter should get immunized again for human papilloma
virus (HPV). What is the nurse’s most appropriate response to this question?
a. “Your daughter does not need this immunization until she becomes sexually
active.”
b. “The recommended age for this immunization is between ages 25 and 30 years of
age.”
c. “Between the ages of 11 and 26 years is the recommended time for this
immunization.”
d. “When she begins having menstrual periods is the best time for this immunization.”
ANSWER: C
A
B
C
D
Feedback
This is not the recommendation of the CDC.
This is not the recommendation of the CDC.
This is the recommendation from the Centers for Disease Control and Prevention
(CDC).
This is not the recommendation of the CDC.
DIF: Cognitive Level: Apply REF: 398
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Health Promotion Programs
4. A patient asks when she should make an appointment for her first Pap (Papanicolaou) test to
screen for cervical cancer. What is the nurse’s most appropriate response?
a. “There is no need for Pap tests until after you have become pregnant.”
b. “All women should have the first Pap test after reaching menarche.”
c. “All women should have the first Pap test after they are 19 years of age.”
d. “All women should have the first Pap test when they become sexually active or at
age 21.”
ANSWER: D
A
B
C
D
Feedback
The recommendation is when females become sexually active or 21 years old.
The recommendation is when females become sexually active or 21 years old.
All females should be screened when they become sexually active or 21 years
old, whichever happens first.
This is the recommendation from the U.S. Preventive Services Task Force. All
females should be screened when they become sexually active or age 21,
whichever happens first.
DIF: Cognitive Level: Apply REF: 399
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Health Promotion Programs
5. A patient asks when she can stop having Pap (Papanicolaou) tests. What is the nurse’s most
appropriate response?
a. “Until you are no longer sexually active.”
b. “Through age 65.”
c. “Until you begin menopause.”
d. “Through the end of menopause.”
ANSWER: B
A
B
C
D
Feedback
The recommendation from the U.S. Preventive Services Task Force is through
age 65.
This is the recommendation from the U.S. Preventive Services Task Force. All
females should be screened after the onset of sexual activity through age 65.
The recommendation from the U.S. Preventive Services Task Force is through
age 65.
The recommendation from the U.S. Preventive Services Task Force is through
age 65.
DIF: Cognitive Level: Apply REF: 399
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Health Promotion Programs
6. When performing a well woman examination, the nurse expects what findings?
a. The inner surface of the vestibule is deep pink and moist with a smooth texture.
b. The inguinal skin appears wrinkled and moist with sparse hair distribution.
c. The labia minora is deeply pigmented, and the tissue is ragged and asymmetrical.
d. Pubic hair is distributed evenly over the mons and shaped as a triangle with the
apex over the mons.
ANSWER: A
A
B
C
D
Feedback
This is a normal finding of female external genitalia.
The inguinal area would normally not be wrinkled.
The labia minora is not normally ragged and asymmetric.
Normally the base of the triangle is over the mons.
DIF: Cognitive Level: Understand REF: 401
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific
Assessments
7. The nurse documents which finding as expected on inspection of the anus?
a. Skin tone darker and coarser than that of the surrounding skin
b. Sphincter lightly closed when the patient is relaxed
c. Large amount of stiff, curling hair surrounding the anus
d. Slight protrusion under the skin when the patient strains or bears down
ANSWER: A
A
B
C
D
Feedback
This is the normal finding.
The anal sphincter should be tight.
The anus is typically hairless.
A protrusion may be a hemorrhoid, which is not an expected finding.
DIF: Cognitive Level: Understand REF: 392| 402
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific
Assessments
8. On inspection of the internal structure of the vagina, the nurse notes a rounded protrusion on
the posterior wall of the vagina. How does the nurse document this finding?
a. Rectocele
b. Cystocele
c. Bartholin cyst
d. Nabothian cyst
ANSWER: A
A
B
C
D
Feedback
Rectocele is a hernia type of protrusion of the rectum against the posterior wall of
the vagina.
Cystocele is a hernia type of protrusion of the bladder against the posterior wall
of the vagina.
The Bartholin glands are external structures.
Nabothian cysts appear on the cervix.
DIF: Cognitive Level: Understand REF: 403| 437
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
9. During the examination of the internal genitalia with the speculum, the nurse records which
finding as normal?
a. A healed laceration of the cervix in a nulliparous patient
b. A large amount of thick white drainage from the cervical os
c. Deviation of the cervix toward the posterior vaginal wall
d. Pink cervix with a small ring of reddened tissue near the os
ANSWER: D
A
B
C
D
Feedback
This is an abnormal finding; a laceration is not expected in nulliparous women.
This is an abnormal finding; this drainage may indicate a sexually transmitted
disease.
This is an abnormal finding.
This is a normal finding.
DIF: Cognitive Level: Understand REF: 406
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific
Assessments
10. The nurse recognizes that a Papanicolaou (Pap) test is indicated for which patient?
a. A 12-year-old who has not yet reached menarche.
b. A 30-year-old who had a normal Pap test 12 months ago.
c. A 45-year-old who had a total hysterectomy for cervical cancer.
d. A 55-year-old who had a total hysterectomy to treat endometriosis.
ANSWER: C
A
B
C
D
Feedback
A Pap test is not indicated for this patient.
A Pap test is not indicated for this patient.
In women who have undergone a hysterectomy in which the cervix was removed,
Pap testing is not required unless the hysterectomy was performed because of
cervical cancer or its precursors.
A Pap test is not indicated for this patient.
DIF: Cognitive Level: Understand REF: 406
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific
Assessments
11. What technique does the nurse use to obtain a cervical tissue sample for a Papanicolaou (Pap)
test?
a. A Cervex-Brush is inserted into the cervix and rotated to obtain a sample of
ectocervical and endocervical cells.
b. A wooden spatula scrapes the cervix to obtain a sample of endocervical cells.
c. A pipette is placed inside the cervical os and rotated to obtain a thick layer of
endocervical and ectocervical cells.
d. A cotton-tipped applicator is used on the outside of the cervix to obtain ectocervical
cells.
ANSWER: A
A
B
C
D
Feedback
This is the correct technique.
A wooden spatula is not used and ectocervical cells are needed as well as
endocervical cells.
A pipette is not used and the cells are not contained in a thick layer.
Using a brush as opposed to a cotton-tipped applicator has improved the quality
of the sample of endocervical cells and ectocervical cells.
DIF: Cognitive Level: Understand REF: 407-408
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
12. A nurse expects which normal findings when performing a bimanual palpation of the cervix
and uterus?
a. The uterus feels firm and slightly nodular.
b. The cervix feels soft, smooth, and slightly rounded.
c. The uterus of a nonpregnant patient cannot be felt with the internal fingers.
d. The cervix is tender when moved laterally.
ANSWER: B
A
B
C
D
Feedback
The uterus normally does not feel nodular.
These are the normal findings from a bimanual examination of the cervix.
The uterus of a nonpregnant woman can be palpated.
The cervix normally is not tender; if it is, it may indicate a sexually transmitted
disease.
DIF: Cognitive Level: Remember REF: 409
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific
Assessments
13. A nurse expects which normal findings when palpating a patient’s ovaries?
a. Nodular and nonmovable
b. Smooth, fluid-filled, and nonmovable
c. Smooth, firm, and about the size of a walnut
d. Spongy, mobile, and about the size of a peanut
ANSWER: C
A
B
C
D
Feedback
Normally the ovaries do not feel nodular and nonmovable.
Normally the ovaries do not feel fluid-filled and nonmovable.
This is a correct description of a normal finding when palpating an ovary.
Normally the ovaries do not feel spongy or mobile.
DIF: Cognitive Level: Remember REF: 411
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific
Assessments
14. After a rectal examination of a patient with obstructive jaundice, the nurse expects the stool to
be what color?
a. Tan
b. Pale yellow
c. Black
d. Bright red
ANSWER: A
A
B
C
D
Feedback
Tan stool indicates a lack of bile caused by obstructive jaundice.
Pale yellow stools indicate a malabsorption syndrome.
Black stools indicate upper intestinal tract bleeding or excessive iron or bismuth
ingestion.
Bright red indicates bleeding from the lower rectum or hemorrhoids.
DIF: Cognitive Level: Understand REF: 414
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
15. On inspection of the external male genitalia, the nurse notes which finding as abnormal?
a. The scrotum is covered with dark rugous skin.
b. The skin covering the penis is hairless and loose.
c. The urinary meatus is located on the upper surface of the penis.
d. The left side of the scrotum hangs slightly lower than the right.
ANSWER: C
A
B
C
D
Feedback
This is a normal finding.
This is a normal finding.
This is called epispadias.
This is a normal finding.
DIF: Cognitive Level: Understand REF: 417
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
16. The nurse observes that the urinary meatus is located on the under surface of the penis. How
does the nurse document this finding?
a. Balanitis
b. Phimosis
c. Epispadias
d. Hypospadias
ANSWER: D
A
B
C
D
Feedback
Balanitis is inflammation of the glans that occurs in patients with phimosis.
Phimosis is a very tight foreskin that cannot be retracted over the glans.
Epispadias occur when the urinary meatus is on the upper (dorsum) surface of the
penis.
Hypospadias occur when the urinary meatus is on the undersurface of the penis.
DIF: Cognitive Level: Understand REF: 417
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
17. In inspecting the scrotum, the nurse documents which finding as normal?
a. The epididymides are round, solid nodular masses.
b. The scrotum is deeply pigmented with a rugous surface.
c. The scrotal skin is a lighter color than the body skin.
d. The vas deferens is palpable bilaterally.
ANSWER: B
Feedback
A
B
C
D
Normally the epididymis is a tubular, comma-shaped structure.
This is an expected finding.
Normally the scrotal skin is more deeply pigmented than the body skin.
Normally the vas deferens is not palpable.
DIF: Cognitive Level: Understand REF: 419
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific
Assessments
18. Which assessment technique does a nurse use to assess the inguinal region and femoral area of
a male patient as he is standing and straining?
a. Palpates the femoral artery
b. Palpates the inguinal lymph nodes
c. Observes for a bulge through the inguinal region
d. Observes for discoloration of the inguinal ring
ANSWER: C
A
B
C
D
Feedback
The nurse palpates the femoral artery when the patient is lying supine.
The nurse palpates the inguinal lymph nodes when the patient is lying supine.
The nurse observes for a bulge that may indicate a hernia; the normal finding is
no bulge.
The nurse cannot see the inguinal ring; it must be palpated.
DIF: Cognitive Level: Apply REF: 419
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
19. When palpating the epididymis, the nurse considers which finding to be abnormal?
a. The epididymis is located on the posterolateral surface of each testis.
b. The epididymis feels like a tubular, comma-shaped structure.
c. The epididymis collapses on palpation.
d. The epididymis has an irregular, nodular surface.
ANSWER: D
A
B
C
D
Feedback
This is an expected finding.
This is an expected finding.
This is an expected finding.
The surface should be smooth and nontender.
DIF: Cognitive Level: Understand REF: 420
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
20. When does a nurse use transillumination of the scrotum?
a. When the patient has tortuosity of the veins along the spermatic cord
b. When the patient has an indirect hernia
c. When there is a mass or fluid in the epididymis
d. When there is twisting of the testicle and spermatic cord
ANSWER: C
A
B
C
D
Feedback
This is a description of a varicocele, which does not transilluminate.
Hernias do not transilluminate.
This is a description of a spermatocele, which does transilluminate, as does a
hydrocele.
This is a description of testicular torsion.
DIF: Cognitive Level: Understand REF: 420
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
21. What procedure does a nurse use to assess the inguinal ring of a male patient for a hernia?
a. Asks the patient to lie supine, lifts the scrotum, asks the patient to take a deep
breath, and observes for a bulge
b. Asks the patient to lean over the examination table, inserts a gloved finger into the
lower part of the scrotum into the inguinal canal, asks the patient to cough, and
palpates for a bulge
c. Asks the patient to lie on the side not being assessed, inserts a gloved finger into
the lower part of the scrotum into the inguinal canal, asks the patient to exhale
completely, and palpates for a bulge
d. Asks the patient to stand, inserts a gloved finger into the lower part of the scrotum
into the inguinal canal, asks the patient to cough, and palpates for a bulge
ANSWER: D
A
B
C
D
Feedback
This has the patient in the wrong position with the wrong technique and wrong
instruction given.
This has the patient in the wrong position.
This has the patient in the wrong position with the wrong instruction given.
This describes the correct procedure.
DIF: Cognitive Level: Understand REF: 421
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
22. The nurse places a male patient in which position for rectal examination?
a. Lithotomy position
b. Prone with the knees fully extended
c. Bending over the table, with feet everted
d. Left lateral position with knees and hips flexed
ANSWER: D
A
B
C
D
Feedback
This is the appropriate position for a rectal examination for a female patient.
This position is not used; a knee chest position may be used instead.
This is the appropriate position of a rectal examination for a male patient, except
that the feet are inverted, rather than everted.
This is the appropriate position for a rectal examination for a male patient.
DIF: Cognitive Level: Understand REF: 421-422
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
23. During an internal examination of a patient’s anus, the nurse notes that the patient has a
hypertonic sphincter. What is the most relevant action for the nurse to take at this time?
a. Ask the patient about anxiety or pain related to the examination.
b. Inquire if the patient has had any neurologic injury that causes a hypertonic
sphincter.
c. Refer the patient to the physician for evaluation.
d. Question the patient about a history of anal trauma.
ANSWER: A
A
B
C
D
Feedback
This is the relevant action for the nurse to collect more data from the patient
about the reaction to the examination.
This datum probably would have been gathered during the history, so that the
nurse would have anticipated an abnormal finding.
This is not the action of most importance at this time. The nurse needs to collect
more data from the patient before considering a referral.
This is not the action of most importance at this time. The nurse needs to collect
more data from the patient before asking about trauma.
DIF: Cognitive Level: Understand REF: 421
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
24. What normal finding does a nurse expect to find when palpating a male patient’s prostate
gland?
a. Is approximately 4.5 cm in diameter and is highly mobile
b. Feels smooth, firm, and slightly mobile
c. Is deeply divided into three lobes, each approximately 2 cm in length
d. Feels hard, asymmetrical, and has a palpable ridge that divides the gland into two
lobes
ANSWER: B
A
Feedback
A normal prostate is 1.5 inches in diameter and slightly mobile.
B
C
D
This is a normal finding.
The prostate consists of two lobes.
The prostate feels firm, smooth, and symmetric.
DIF: Cognitive Level: Understand REF: 423
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific
Assessments
25. A 50-year-old patient asks the nurse about her risk of developing a cancer of the reproductive
system. What is the appropriate response by the nurse?
a. “Human papilloma virus infection and cigarette smoking are major risk factors for
cervical cancer.”
b. “Some of the risk factors for endometrial cancer include being age 40 or older and
having a history of infertility.”
c. “Ovarian cancer is not often seen in women under age 50 or those who have a
family history of breast cancer.”
d. “Women who have had menstrual irregularities for many years are at lower risk of
developing any of the reproductive system cancers.”
ANSWER: A
A
B
C
D
Feedback
Human papilloma virus infection and cigarette smoking are risk factors for
cervical cancer.
These are not risk factors for endometrial cancer.
These are not risk factors for ovarian cancer.
These are not risk factors for gynecologic cancers.
DIF: Cognitive Level: Understand REF: 424
TOP: Nursing Process: Intervention
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Health Promotion Programs
26. The nurse recognizes which patient has the highest risk of endometrial cancer?
a. A 24-year old woman with menarche at age 9
b. A 30-year old woman who started menstruating at age 19
c. A 42-year old woman who reached menopause at age 40
d. A 64-year old woman who had irregular, heavy menstrual cycles
ANSWER: A
A
B
C
D
Feedback
Early menarche is a risk factor.
This age of menarche is not a risk factor for endometrial cancer.
This age of menopause is not a risk factor for endometrial cancer. Patients who
have late onset menopause are at risk.
An irregular, heavy menstrual cycle is not a risk factor for endometrial cancer.
DIF: Cognitive Level: Understand REF: 424
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Health Promotion Programs
27. Which patient does the nurse recognize as having the highest risk for ovarian cancer?
a. A 24-year-old nulliparous woman who has a history of multiple sexual partners
b. A 32-year-old woman who has had six live births and a history of human papilloma
virus (HPV) infection
c. A 55-year-old woman who reached menarche at age 12 and menopause at age 54
d. A 64-year-old nulliparous woman who has taken hormone replacement therapy for
eight years
ANSWER: D
A
B
C
D
Feedback
This patient has no risk factor for ovarian cancer.
This patient has a risk factor for cervical cancer (HPV), but not ovarian cancer.
This patient has no risk factors for ovarian cancer.
This patient has a risk factor for ovarian cancer.
DIF: Cognitive Level: Understand REF: 424
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Health Promotion Programs
28. The nurse correlates which factor to an increased risk of endometrial cancer in women with
early menarche or late menopause?
a. Total number of ovulatory cycles
b. Less hormone stimulation
c. Need for estrogen replacement in these patients
d. Extended duration of the menstrual cycle in these patients
ANSWER: A
A
B
C
D
Feedback
More ovulatory cycles increases risk. These risk factors represent an increased
cumulative exposure to estrogen.
Hormone stimulation does not increase risk in endometrial cancer.
Estrogen replacement does not increase risk in endometrial cancer.
Extended duration of the menstrual cycle is not a risk factor.
DIF: Cognitive Level: Understand REF: 424
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Health Promotion Programs
29. A patient complains of dysuria, yellow-green vaginal discharge, and vulvar itching. The nurse
suspects which sexually transmitted disease?
a. Syphilis
b. Gonorrhea
c. Genital warts
d. Chlamydia
ANSWER: B
Feedback
A
B
C
D
Primary syphilis produces a single, firm, painless open sore or chancre with
indurated borders at the site of entry on the genitals.
Gonorrhea causes a yellow or green vaginal discharge, dysuria, pelvic or
abdominal pain, and vaginal itching and burning.
Genital warts appear as soft, papillary, pink to brown, elongated lesions that may
occur singularly or in clusters on the internal genitalia, the external genitalia, and
the anal-rectal region.
Chlamydia infection is asymptomatic in up to 75% of women because it often
does not cause enough inflammation to produce symptoms.
DIF: Cognitive Level: Remember REF: 425
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
30. In assessing a patient with suspected Chlamydia, the nurse’s actions are guided by which
characteristic of this disease?
a. Chlamydia is frequently asymptomatic and requires screening.
b. Chlamydia is associated with a yellow-green vaginal discharge.
c. Chlamydia is accompanied by heavy bleeding and headache.
d. Chlamydia is only seen in immunocompromised patients.
ANSWER: A
A
B
C
D
Feedback
This answer is consistent with clinical findings of Chlamydia.
This answer is consistent with clinical findings of gonorrhea.
Chlamydia is not accompanied by heavy bleeding and headache.
Chlamydia is seen in patients with healthy immune systems who are not
immunocompromised.
DIF: Cognitive Level: Understand REF: 425
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
31. A nurse examines a patient and finds a single, firm, painless open sore with indurated borders
on the vulva. The nurse correlates this finding with which disorder?
a. Human papillomavirus (HPV) infection
b. Herpes infection
c. Gonorrhea
d. Syphilis
ANSWER: D
A
B
C
D
Feedback
HPV infection causes wartlike growths.
Herpes infection forms vesicles rather than chancres.
Gonorrhea produces a yellow or green vaginal discharge.
The clinical finding is consistent with a chancre found in syphilis.
DIF: Cognitive Level: Apply REF: 425
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
32. A nurse expects to find which manifestations in the male patient who has both Chlamydia and
gonorrhea?
a. Painful urination and purulent urethral discharge
b. A single, firm painless open sore on the shaft of the penis
c. Red superficial vesicles on the shaft of the penis
d. A single or a cluster of wartlike growth in the anal-rectal area
ANSWER: A
A
B
C
D
Feedback
These are manifestations of Chlamydia and gonorrhea. Dysuria means painful
urination.
This is a description of a lesion consistent with syphilis.
This is a description of lesions consistent with herpes genitalis.
This is a description of lesions consistent with genital warts caused by human
papillomavirus.
DIF: Cognitive Level: Apply REF: 427
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
33. While giving a history, the patient reports having herpes genitalis. Based on this information,
which finding does the nurse anticipate during the assessment?
a. Small vesicles on the genitalia
b. Single, firm, painless, open sore
c. Pain when palpating the cervix
d. Malodorous greenish-yellow vaginal discharge
ANSWER: A
A
B
C
D
Feedback
Small vesicles on the genitalia are consistent with genital herpes.
Single, firm, painless, open sore is consistent with primary syphilis.
Pain when palpating the cervix is consistent with Chlamydia.
Malodorous greenish-yellow vaginal discharge is consistent with trichomonas.
DIF: Cognitive Level: Apply REF: 427
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
34. In teaching a class of adolescents about sexually transmitted diseases, a nurse includes which
information about the human papillomavirus (HPV)?
a. HPV is fragile and not easily transmitted.
b. Wartlike growths in the genital area are a sign of HPV infection.
c. There is a specific blood test needed to screen for HPV.
d. Heavy, purulent vaginal discharge is the primary sign of HPV.
ANSWER: B
A
B
C
D
Feedback
HPV is highly contagious.
This is the correct description of the clinical findings of HPV.
There is no specific blood test to detect HPV.
HPV is a virus that develops warts.
DIF: Cognitive Level: Understand REF: 427
TOP: Nursing Process: Intervention
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
35. The patient is unable to tolerate a bimanual pelvic examination due to pain in ovaries and
fallopian tubes. Which disorder does the nurse suspect?
a. Tertiary syphilis
b. Genital herpes
c. Human papillomavirus (HPV) infection
d. Pelvic inflammatory disease
ANSWER: D
A
B
C
D
Feedback
Tertiary syphilis does not cause much pain.
Genital herpes does not cause much pain.
HPV infection does not cause much pain.
Typically, the pain is so severe that the patient with pelvic inflammatory disease
is unable to tolerate bimanual pelvic examination.
DIF: Cognitive Level: Understand REF: 428
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
36. A patient with testicular torsion is experiencing which abnormality?
a. Abnormal dilation and tortuosity of the veins along the spermatic cord
b. Twisting of the testicle and spermatic cord
c. A cystic mass filled with sperm and seminal fluid in the epididymis
d. An accumulation of fluid in the scrotum
ANSWER: B
A
B
C
Feedback
Abnormal dilation and tortuosity of the veins along the spermatic cord describes a
varicocele.
Twisting of the testicle and spermatic cord describes testicular torsion.
A cystic mass filled with sperm and seminal fluid in the epididymis describes a
spermatocele.
D
An accumulation of fluid in the scrotum describes a hydrocele.
DIF: Cognitive Level: Understand REF: 430
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
37. How does a nurse recognize when a patient has a testicular torsion?
a. The nurse sees a light red glow on transillumination of the scrotum.
b. The nurse palpates testicular edema that is painless.
c. The patient reports a pulling sensation and dull ache of the scrotum.
d. The patient complains of sudden onset of severe pain with edema of the scrotum.
ANSWER: D
A
B
C
D
Feedback
This is a clinical finding of hydrocele.
This is a clinical finding of spermatocele.
This is a clinical finding of varicocele.
These are clinical findings of testicular torsion.
DIF: Cognitive Level: Understand REF: 430
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
38. In educating a male patient about testicular cancer, the nurse includes which statement?
a. The highest incidence of this cancer is in men between 20 and 34 years of age.
b. The incidence of this cancer is correlated with human papillomavirus (HPV)
infection.
c. The risk of this cancer increases with multiple sexual partners.
d. This type of cancer more commonly affects uncircumcised males.
ANSWER: A
A
B
C
D
Feedback
This is a true statement of risk.
HPV infection is correlated with cervical cancer, rather than testicular cancer.
The risk of sexually transmitted diseases increases with multiple sexual partners
rather than testicular cancer.
This is not a risk factor.
DIF: Cognitive Level: Remember REF: 431
TOP: Nursing Process: Intervention
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Health Promotion Programs
39. While taking a history of a patient with an enlarged prostate, the nurse expects the patient to
report which symptom?
a. Painful urination with each voiding
b. Blood in the urine upon arising
c. Waking from sleep to urinate
d. Incontinence throughout the day
ANSWER: C
A
B
C
D
Feedback
There is no pain associated with an enlarged prostate.
This is not a manifestation of a prostate disorder.
Compression of the urethra by the enlarged prostate may cause men to be
awakened from sleep to urinate (nocturia).
The urinary problem associated with a prostate disorder is difficulty in starting
the urinary stream because the enlarged prostate gland compresses the urethra,
thus incontinence is not associated with a prostate disorder.
DIF: Cognitive Level: Understand REF: 397| 431
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
40. The nurse correlates which patient complaint with suspected enlargement of the prostate
gland?
a. Constipation
b. Change in bowel patterns
c. Weak urine stream
d. Increased mucus in urine
ANSWER: C
A
B
C
D
Feedback
Enlargement of the prostate gland does not cause constipation.
This is a warning sign for colon cancer rather than a manifestation of an enlarged
prostate.
Enlargement of the prostate gland compresses the urethra causing a weak urinary
stream.
This may be an indication of a urinary tract infection rather than an enlarged
prostate.
DIF: Cognitive Level: Understand REF: 396| 423| 431
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
41. While giving a history, a patient reports having a weak urinary stream and feeling that his
bladder is not empty after urination. Based on these data, what finding does the nurse
anticipate upon examination?
a. An enlarged prostate gland palpated on the anterior wall of the rectum
b. An indirect hernia palpated through the inguinal ring when the patient coughs
c. The foreskin of the penis cannot be returned to position after retraction behind the
glans
d. A nodular prostate gland palpated on the posterior wall of the rectum
ANSWER: A
A
B
C
D
Feedback
The enlarged prostate compresses the urethra, causing difficulties with voiding.
A hernia would not interfere with voiding.
This is a description of paraphimosis.
The posterior prostate is palpated on the anterior surface of the rectum.
DIF: Cognitive Level: Apply REF: 396| 423| 431
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
42. A patient tells the nurse that he has been informed he has internal hemorrhoids and asks
whether there are different types of hemorrhoids. What is the nurse’s most appropriate
response?
a. “Internal hemorrhoids are usually seen outside the anus and appear blue.”
b. “Sometimes patients have other diseases, such as anal warts, that may be mistaken
for internal hemorrhoids.”
c. “Internal hemorrhoids are found higher in the rectum and usually can’t be felt
unless they are infected or prolapsed.”
d. “Both internal and external hemorrhoids arise from the same general area and
produce the same kinds of symptoms.”
ANSWER: C
A
B
C
D
Feedback
Internal hemorrhoids are found high in the rectum and may be felt if infected, but
are not seen during an anal examination.
Anal warts have a distinct appearance that is different from hemorrhoids.
This is a correct statement.
Internal hemorrhoids are found higher in the rectum, while external hemorrhoids
are found outside the external rectal sphincter.
DIF: Cognitive Level: Understand REF: 433
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
43. During a history, a patient reports rectal bleeding, a warning sign of colorectal cancer. The
nurse correlates which clinical finding with colorectal cancer?
a. Thick, blood-tinged mucus within the rectum
b. A pus-filled cavity in the anorectal area
c. An irregular mass with raised edges on the rectal wall
d. A small, smooth nodule protruding from the rectum
ANSWER: C
A
B
C
Feedback
This is not an indication of colorectal cancer.
This is an indication of an infection in the anal area.
This finding is indicative of colorectal cancer.
D
This may be a polyp protruding from the anus.
DIF: Cognitive Level: Understand REF: 397| 422| 434-435
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
MULTIPLE RESPONSE
1. Which comments by a male patient during a health history suggest erectile dysfunction?
Select all that apply.
a. “I have had type 1 diabetes mellitus since I was 8 years old.”
b. “I frequently have urinary tract infections.”
c. “I am taking medications to control my blood pressure.”
d. “I have an enlarged prostate gland.”
e. “I take a diuretic every morning.”
ANSWER: A, C, E
Correct: A chronic complication of diabetes can cause impotence. An adverse reaction of
some types of antihypertensive and diuretic medications can cause impotence.
Incorrect: Urinary tract infections are unrelated to impotence. Having an enlarged prostate
causes problems with urinating, but not with erections.
DIF: Cognitive Level: Analyze REF: 396
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
2. Which patients meet the criteria for Chlamydia screening? Select all that apply.
a. A 40-year-old woman who is sexually active and uses barrier protection
consistently
b. A 15-year-old female woman who is sexually active with one partner
c. A 22-year-old woman who is sexually active and uses barrier protection
inconsistently
d. A 23-year-old woman who has had four sexual partners in the last 3 months
e. A 34 year-old woman who uses barrier protection inconsistently with multiple
sexual partners
f. A 36-year-old pregnant woman making the first prenatal visit
ANSWER: B, C, D, E, F
Correct: These patients meet the criteria for screening for Chlamydia.
Incorrect: This patient does not meet criteria based on age and use of protection.
DIF: Cognitive Level: Analyze REF: 398
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Health Promotion Programs
3. Which questions are appropriate for a symptom analysis of a patient with benign prostatic
hyperplasia? Select all that apply.
a. “How often have you found that you stopped and started again several times when
you urinated?”
b. “How often have you had to urinate again less than 2 hours after you finished
urinating?”
c. “How often have you been incontinent of urine?”
d. “How often have you had constipation due to the enlarged prostate?”
e. “How often have you had to push or strain to begin urination?”
f. “How often have you had to get up during the night to urinate?”
ANSWER: A, B, E, F
Correct: These questions from the American Urological Association Symptom Index for
Benign Prostatic Hyperplasia are used to screen men for an enlarged prostate.
Incorrect: The urinary problem is difficulty in starting the urinary stream due to the prostate
gland compressing the urethra, thus incontinence is not a manifestation of an enlarged
prostate. Although the enlarged prostate is palpated through the rectum, it does not become
large enough to cause constipation.
DIF: Cognitive Level: Apply REF: 396-397
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
4. Which patients have risk factors for endometrial cancer? Select all that apply.
a. The patient who never had children.
b. The patient who has given birth to nine children.
c. The patient whose body mass index is 39.
d. The patient whose menopause began at age 60.
e. The patient whose father had colon cancer.
f. The patient who has had human papillomavirus (HPV) infections.
ANSWER: A, C, D, E
Correct: A family history of endometrial, breast, colon, or ovarian cancer is considered a risk
factor.
Incorrect: Nulliparity or infertility is a risk factor. HPV is a risk factor for cervical cancer
rather than endometrial cancer.
DIF: Cognitive Level: Analyze REF: 424
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Health Promotion Programs
Chapter 18: Developmental Assessment Throughout the Life Span
Test Bank
MULTIPLE CHOICE
1. Which statement best illustrates Erikson’s theory of development?
a. The main goal is to establish equilibrium between self and environment.
b. One progresses through stages that involve specific psychosocial tasks.
c. There are four distinct, sequential levels of cognitive development.
d. Cognitive development occurs from birth to around age 15.
ANSWER: B
A
B
C
D
Feedback
This statement is not consistent with Erikson’s theory of development.
This statement is consistent with Erikson’s theory of development.
This is more consistent with Piaget’s theory.
This is more consistent with Piaget’s theory.
DIF: Cognitive Level: Understand REF: 439-440
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Growth and Development
2. A nurse asks a 15-year-old boy to think of an explanation for a simple puzzle. When he is
unable to come up with any answer at all, the nurse recognizes that he may not yet have
successfully mastered which of Piaget’s levels of cognitive development?
a. Sensorimotor
b. Preoperational
c. Concrete operations
d. Formal operations
ANSWER: D
Feedback
A The sensorimotor stage develops in children between the ages of birth to 2 years,
when thoughts are dominated by physical manipulation of objects and events.
B The preoperational stage develops in children between the ages of 2 to 7 years,
when children function symbolically using language as a major tool.
C The concrete operations stage develops in children between the ages of 7 to 11
years, when mental reasoning processes assume logical approaches to solving
concrete problems.
D The formal operations level develops in children between the ages of 11 and 15
years, during which true logical thoughts and manipulation of abstract concepts
emerge.
DIF: Cognitive Level: Apply REF: 440
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Growth and Development
This study source was downloaded by 100000838401522 from CourseHero.com on 03-03-2022 08:55:23 GMT -06:00
https://www.coursehero.com/file/20908977/c18/
3. When performing a physical assessment on a 7-month-old infant, the nurse notes that the child
is able to smile responsively and unable to roll from the prone to the supine position. What is
the most appropriate action for this nurse?
a. Reassure the parents that the infant is “performing like an 8-month-old.”
b. Document the infant’s growth and development as “within normal limits.”
c. Continue to assess the infant for other signs of developmental delay.
d. Give the caretaker specific directions for specialized exercises.
ANSWER: C
A
B
C
D
Feedback
This would be an incorrect statement because this infant has delayed
development.
This would be an incorrect statement because this infant has delayed
development.
An infant should be able to roll from prone to supine at 4 months.
This infant needs to be referred for additional evaluation.
DIF: Cognitive Level: Analyze REF: 441-442
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Growth and Development
4. A 7-month-old infant weighs 11.6 lb compared with a birth weight of 7.1 lb and has a head
circumference of 19 inches. What does the nurse document about this infant?
a. Underweight and normal head circumference
b. Underweight and larger-than-normal head circumference
c. Overweight and smaller-than-normal head circumference
d. Normal weight and larger-than-normal head circumference
ANSWER: B
A
B
C
D
Feedback
This 7-month-old infant should weigh more than 14 lb and have a head
circumference of 16.5 to 17.5 inches.
This 7-month-old infant should weigh more than 14 lb and have a head
circumference of 16.5 to 17.5 inches. In general, infants double their birth weight
by 4 to 5 months of age. Expected head circumference for term newborns
averages from 13 to 14 inches (33 to 36 cm) and increases 0.5 inch (1.3 cm)
monthly for the first six months.
This 7-month-old infant should weigh more than 14 lb and have a head
circumference of 16.5 to 17.5 inches.
This 7-month-old infant should weigh more than 14 lb and have a head
circumference of 16.5 to 17.5 inches.
DIF: Cognitive Level: Apply REF: 441
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Growth and Development
5. A nurse notices that an infant tries to reach for a toy that the mother has hidden in her hand.
This illustrates that the child has developed an understanding of which concept?
a. Object permanence
This study source was downloaded by 100000838401522 from CourseHero.com on 03-03-2022 08:55:23 GMT -06:00
https://www.coursehero.com/file/20908977/c18/
b. Trust versus mistrust
c. Autonomy
d. Parallel play
ANSWER: A
A
B
C
D
Feedback
Object permanence, meaning that objects and people still exist when they are out
of sight.
This is Erikson’s developmental stage for infants when they develop trust
relationships with the mother or primary caregiver. Important criteria are the
quality and consistency of the mother-child relationship.
This is Erikson’s developmental stage for toddlers who yearn for independence;
however, they lack judgment to maintain their safety.
Parallel play is a social skill of a 2-year-old toddler.
DIF: Cognitive Level: Understand REF: 443
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Growth and Development
6. The parents of a toddler express concern that the child is not progressing the same way as
their other children did at that age. What is the most appropriate suggestion the nurse can give
the parents about monitoring the progress of the toddler?
a. Advising the parents to take the toddler to the clinic every 2 months for
reevaluation
b. Teaching the parents how to use the Denver II test to assess for gross motor
movement, language, fine motor movement, and personal-social skills
c. Suggesting that the child needs more time to reach the milestones and that
additional monitoring is not necessary
d. Informing the parents about the ages and stages questionnaire (ASQ), which
identifies developmental delays in children from 4 to 60 months
ANSWER: D
A
B
C
D
Feedback
This suggestion is time-consuming, expensive, and not practical.
The Denver II test requires special equipment and training, and is designed for
health care professionals.
The suggestion for the parents to take no action is not appropriate in this case.
This is the best suggestion for these parents at this time. The ASQ is designed for
parents to report data on their children.
DIF: Cognitive Level: Apply REF: 444
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Growth and Development
7. Which characteristics are expected during an assessment of a normal toddler?
a. Half of adult height achieved by age two, potbelly, and sway back.
b. Thirty-two erupted teeth by age 2, tripled birth weight by age 30 months.
c. Desire for autonomy coupled with sufficient judgment to ensure safety.
d. Head circumference greater than chest circumference, high frustration tolerance.
This study source was downloaded by 100000838401522 from CourseHero.com on 03-03-2022 08:55:23 GMT -06:00
https://www.coursehero.com/file/20908977/c18/
ANSWER: A
A
B
C
D
Feedback
These are characteristics of toddlers.
Toddlers have 20 teeth erupted and infants triple their birth weight.
The Erikson developmental stage for toddlers is autonomy versus shame and
doubt.
The first part is true for toddlers, but they do not have a high frustration tolerance.
DIF: Cognitive Level: Understand REF: 444
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Growth and Development
8. A nurse makes observations about a toddler’s motor development. Which behavior is an
example of fine motor behavior?
a. Sitting up in a chair
b. Walking while holding on to the edge of a table
c. Creeping up the stairs
d. Stacking blocks to make a tower
ANSWER: D
A
B
C
D
Feedback
Sitting up in a chair is an example of gross motor skills.
Walking while holding on to the edge of a table is an example of gross motor
skills.
Creeping up the stairs is an example of gross motor skills.
Stacking blocks to make a tower is an example of fine motor skills with hands
and fingers.
DIF: Cognitive Level: Understand REF: 445
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Growth and Development
9. A nurse is assessing a preschooler who is able to draw a three-part human figure, hop on one
foot, and recognize three colors. The nurse recognizes these characteristics as consistent for
what age?
a. 3 years old
b. 4 years old
c. 5 years old
d. 6 years old
ANSWER: C
A
B
C
D
Feedback
These characteristics are too advanced for 3-year-old children.
These characteristics are too advanced for 4-year-old children.
These are characteristics consistent with developmental expectations of 5-yearold
children.
These characteristics are below those expected for 6-year-old children who are in
This study source was downloaded by 100000838401522 from CourseHero.com on 03-03-2022 08:55:23 GMT -06:00
https://www.coursehero.com/file/20908977/c18/
first grade.
DIF: Cognitive Level: Understand REF: 447, Table 18-5
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Growth and Development
10. A parent tells the nurse about having difficulty disciplining a 5-year-old child. What
characteristic does the nurse teach this parent to improve the discipline of this child?
a. Children at this age are incapable of delaying gratification.
b. At age 5 years, children are not interested in attaining rights and privileges of
individuality.
c. Five-year-olds should demonstrate basic social skills and respond to others’
expectations.
d. At age 5 years, children use highly inappropriate methods of expressing frustration.
ANSWER: C
A
B
C
D
Feedback
This behavior describes a toddler.
This behavior is not consistent with a preschooler.
This describes expected developmental tasks of preschoolers.
This behavior is more consistent with a toddler.
DIF: Cognitive Level: Apply REF: 445-447
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Growth and Development
11. The mother of a 7-year-old boy takes him for a checkup at the local clinic. The nurse notes
that the child has gained 4.9 lb and has grown 2.5 inches in 1 year. Based on these findings,
what is the most appropriate action of this nurse?
a. Recommend that the child be placed on a low-fat, high-protein diet.
b. Counsel the mother to increase the amount of calcium in the child’s diet.
c. Ask the mother to return with the child next week for a more comprehensive
growth and development study.
d. Inform the mother that the child’s developmental rate is within the expected ranges
for his age.
ANSWER: D
A
B
C
D
Feedback
This child’s weight is within expected ranges.
This child’s height is within expected ranges.
This child’s weight and height are within expected ranges.
For school-age children, growth continues at a slow pace, with an average 5 lb
weight gain and 2 inch height increase per year.
DIF: Cognitive Level: Apply REF: 446
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Growth and Development
This study source was downloaded by 100000838401522 from CourseHero.com on 03-03-2022 08:55:23 GMT -06:00
https://www.coursehero.com/file/20908977/c18/
12. What suggestions does the nurse make to parents to support the development of their 8-yearold
child?
a. They buy the child a computer to foster a sense of self-worth.
b. The emphasis is placed on the importance of being a success at all costs.
c. The child is rewarded for cooperation and healthy competition with peers.
d. Social relationships outside the home are limited to one or two close friends.
ANSWER: C
A
B
C
D
Feedback
This action is not needed for the development of a child at this age.
This action is not needed for the development of a child at this age.
Cooperation and healthy competition are developmental tasks for school-age
children.
This action would interfere with extending abilities to relate to others, a
developmental task of this age group.
DIF: Cognitive Level: Apply REF: 446| 448
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Growth and Development
13. The parents of a 14-year-old boy express concern that their son’s behavior ranges from cleancut
and personable to “grungy” and sullen. They have tried talking with him about this and
have tried disciplining him, but he continues to show different sides, and they are confused.
What is the nurse’s assessment for the behavior of this teenager?
a. The teenager is dangerously labile.
b. This behavior is normal experimentation.
c. This boy is being rebelliously hostile.
d. This behavior may require hospitalization.
ANSWER: B
A
B
C
D
Feedback
The behaviors described fall within expected behavior for adolescents.
Adolescents may behave in new and different ways, much to the chagrin of their
parents, as they “try on” differing roles and values. Adolescents begin testing and
evaluating previously accepted notions about life, living, spirituality, relating, and
being.
The behaviors described fall within expected behavior for adolescents.
The behaviors described fall within expected behavior for adolescents.
DIF: Cognitive Level: Apply REF: 448, Box 18-5
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Growth and Development
14. During a counseling session, which statement by an adolescent indicates he is adjusting to
expected developmental tasks?
a. “I wish my parents would just leave me alone.”
b. “I’m hoping to go to college.”
c. “I don’t have any friends.”
d. “It’s terrible being taller than all my friends.”
This study source was downloaded by 100000838401522 from CourseHero.com on 03-03-2022 08:55:23 GMT -06:00
https://www.coursehero.com/file/20908977/c18/
ANSWER: B
A
B
C
D
Feedback
This comment does not demonstrate adjustment, although it is a problem some
adolescents face.
This indicates a developmental task of adolescence.
This comment does not demonstrate adjustment.
This comment does not demonstrate adjustment, although it is a problem some
adolescents face.
DIF: Cognitive Level: Apply REF: 448-449
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Growth and Development
15. Which behavior indicates successful achievement of the major developmental tasks of a
young adulthood?
a. Accepting physical changes
b. Achieving emotional independence
c. Mastering money management
d. Getting an appropriate education
ANSWER: D
A
B
C
D
Feedback
Accepting physical changes is a developmental task of adolescence.
Achieving emotional independence is a developmental task of adolescence.
Mastering money management is a developmental task of school-age children.
Getting an appropriate education is a developmental task of young adults.
DIF: Cognitive Level: Apply REF: 448-449
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Growth and Development
16. Which statement reflects a 21-year-old woman’s achievement of an expected developmental
task?
a. “I am planning to get married next year.”
b. “I don’t plan anything without asking my boyfriend first.”
c. “I don’t know which direction I’ll take after college.”
d. “I am living with my parents and may stay for a while.”
ANSWER: A
A
B
C
D
Feedback
This statement reflects an expected developmental task of a young adult.
This statement does not reflect an expected developmental task of a young adult.
This statement does not reflect an expected developmental task of a young adult.
This statement does not reflect an expected developmental task of a young adult.
DIF: Cognitive Level: Understand REF: 448-449
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Growth and Development
This study source was downloaded by 100000838401522 from CourseHero.com on 03-03-2022 08:55:23 GMT -06:00
https://www.coursehero.com/file/20908977/c18/
17. Interviewing patients in middle adulthood, the nurse recognizes which behavior as an
expected developmental task for this age group?
a. Finding meaning in life
b. Establishing autonomy as an individual
c. Increased self-understanding
d. Dissatisfaction with one’s interpersonal relationships
ANSWER: C
A
B
C
D
Feedback
This is a developmental task of older adults.
This is a developmental task of young adults.
This is a developmental task of middle adulthood.
This behavior would not be consistent with normal adaptation.
DIF: Cognitive Level: Apply REF: 449
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Growth and Development
18. During middle adulthood, which immunization may be recommended?
a. PPV (pneumococcal pneumonia vaccine)
b. Hepatitis B virus vaccine, third dose
c. Human papillomavirus (HPV)
d. Td (tetanus and diphtheria toxoids)
ANSWER: D
Feedback
A This immunization is given to adults older than 65.
B This immunization is given between birth and age 10.
C This immunization is given between ages 11 and 24.
D This is the only immunization recommended for this age group. Tetanus and
diphtheria toxoid is recommended every 10 years.
DIF: Cognitive Level: Understand REF: 451
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Growth and Development
19. A nurse recognizes that which patient has not yet successfully completed Erikson’s final
developmental stage?
a. A 78-year-old widower who has gone to the mental health clinic for counseling
after the recent death of his wife
b. A 60-year-old man who tells the nurse that he is feeling fine and really does not
need any help from anyone
c. An 81-year-old woman who states that she enjoys having her grandchildren visit
but is usually glad when it is time for them to go home
d. A 75-year-old woman who tells the nurse that she wishes her friends were alive and
she wishes she could change the choices she made over the years
ANSWER: D
This study source was downloaded by 100000838401522 from CourseHero.com on 03-03-2022 08:55:23 GMT -06:00
https://www.coursehero.com/file/20908977/c18/
A
B
C
D
Feedback
Dealing with the death of a spouse is a developmental task of this age group, and
this patient is seeking assistance to help him cope.
This man is meeting the developmental tasks for his age.
Enjoying grandchildren is a developmental task of this age group.
Erikson’s final stage is ego integrity versus despair, and this woman is voicing
despair and regret about previous decisions made in her life.
DIF: Cognitive Level: Analyze REF: 451-452
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Growth and Development
20. Which behavior illustrates a developmental task for a “young-old” older adult?
a. Adapting to living alone
b. Adjusting to loss of physical strength, illness, and emotional stress
c. Managing leisure time
d. Accepting possible institutional living arrangements
ANSWER: C
A
B
C
D
Feedback
This is a developmental task of those 85 years and older.
This is a developmental task of those older than 85 years of age.
This is a developmental task of the “young-old” adult (65 to 85 years of age).
This is a developmental task of those older than 85 years of age.
DIF: Cognitive Level: Understand REF: 452
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Growth and Development
This study source was downloaded by 100000838401522 from CourseHero.com on 03-03-2022 08:55:23 GMT -06:00
https://www.coursehero.com/file/20908977/c18/
Chapter 19: Assessment of the Infant, Child, and Adolescent
Test Bank
MULTIPLE CHOICE
1. An adolescent patient appears reluctant to discuss sensitive issues with her parents present.
What is the nurse’s most appropriate intervention?
a. Tell the patient that it is very important to be honest and specific.
b. Provide time when the adolescent is alone with the nurse.
c. Reassure the patient that anything said in the interview is considered confidential.
d. Ask the parents to answer the questions if the patient is not willing to answer.
ANSWER: B
A
B
C
D
Feedback
Although this statement is true, the adolescent should have time alone with the
nurse, if needed, to answer or ask personal questions.
As children reach adolescence, they should be given the option to provide
sensitive parts of the history without their parents present.
Although this statement is true, the adolescent should have time alone with the
nurse, if needed, to answer or ask personal questions.
This intervention is not appropriate when the patient is present and able to answer
questions. In addition, the parents may not know the information needed by the
nurse about the adolescent.
DIF: Cognitive Level: Apply REF: 456
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Psychosocial Integrity: Therapeutic Communication
2. What does the nurse teach to parents to prevent sudden infant death syndrome (SIDS)?
a. Place the baby on back to sleep.
b. Place the baby on side to sleep.
c. Not to feed the baby for 3 hours before sleep.
d. Place the baby on her stomach to sleep.
ANSWER: A
A
B
C
D
Feedback
The American Academy of Pediatrics recommends positioning infants on their
backs; the slogan to help people remember is “Back to Sleep.”
The side-lying position is not recommended for sleep because of the risk of
aspiration.
Not feeding the baby for 3 hours before sleep is not a prevention for SIDS.
The prone position is not recommended for sleep due to the risk of aspiration.
DIF: Cognitive Level: Apply REF: 458, Box 19-3
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion: Lifestyle Choices
3. In taking a history from an adolescent girl about diet and nutrition, a nurse specifically asks
which question?
a. “How frequently do you eat fast food or junk food?”
b. “Which carbonated drinks do you drink most often?”
c. “Do you have any food restrictions or diet routines?”
d. “What are your favorite fruits and vegetables?”
ANSWER: C
A
B
C
D
Feedback
Asking the frequency of fast food or junk food consumption does not give data
about what food is eaten.
Knowing the amount of carbonated drinks provides more useful data.
Adolescents should be asked specifically about their perception of their current
weight and behaviors associated with eating disorders, including food restrictions,
extreme diet/exercise routines, binging or purging, and the use of laxatives to
screen for eating disorders.
Knowing how frequently these foods are eaten provides more useful data.
DIF: Cognitive Level: Understand REF: 458
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Health and Wellness
4. A nurse is assessing a child who is able to dress herself, jump rope, identify colors, and follow
rules when playing games. These are expected developmental achievements of a child of what
age?
a. 3 years old
b. 4 years old
c. 5 years old
d. 6 years old
ANSWER: C
A
B
C
D
Feedback
These are developmental behaviors too advanced for a 3-year-old child.
These are developmental behaviors too advanced for a 4-year-old child.
These are developmental behaviors consistent with a 5-year-old child.
These developmental behaviors are typically achieved and surpassed by a 6-yearold
child.
DIF: Cognitive Level: Understand REF: 459
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Growth and Development
5. A 4-year-old child has had a tonsillectomy and the nurse is preparing to ask him about his
pain. Which technique is the most appropriate method for pain assessment for this patient?
a. Asking him if the pain hurts “a little or a lot”
b. Asking him to rate the pain on a scale of 0 to 10
c. Using the visual analog scale to rate the pain
d. Using the Wong/Baker FACES rating scale
ANSWER: D
A
B
C
D
Feedback
Using adjectives such as these is not reliable to assess pain in patients of any age.
This scale is appropriate for adolescents and adults, but a child cannot understand
the concept of using numbers to rate pain.
This type of scale is appropriate for adults, but a child cannot understand the
concept of using a straight line to rate pain.
This tool is appropriate for children who can point to the child’s face that best
represents how they are feeling.
DIF: Cognitive Level: Apply REF: 459| 461-462
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
6. Which assessment technique is appropriate to measure the 8-month-old’s vital signs during a
well-baby check?
a. Assess temperature using a rectal thermometer.
b. Observe the infant’s abdomen when counting respirations.
c. Take the infant from the parent’s arms to assess pulse.
d. Measure blood pressure in the leg.
ANSWER: B
A
B
C
D
Feedback
Rectal temperatures should be taken as a last resort because children tend to fear
intrusive procedures and because of the risk for rectal perforation. The
recommended sites for temperature measurement in newborns, infants, and
children to age 5 are the axillary or tympanic sites.
Infants usually breathe diaphragmatically, which requires observation of
abdominal movement.
For the older infant ( 6 months) and toddler, the nurse may find that having the
caregiver hold the baby or toddler decreases fear and distress, thus making it
easier for the nurse to conduct the examination.
This infant is too young for blood pressure measurement. The National High
Blood Pressure Education Program recommends that blood pressure be measured
in children from age 3 through adolescence as part of routine health care visits.
DIF: Cognitive Level: Apply REF: 463
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
7. An American Indian mother expresses concern about an irregularly shaped, dark area over her
neonate’s sacrum and buttocks. What is the nurse’s most appropriate response to this mother?
a. “This area will continue to grow until the infant is 10 to 15 months old.”
b. “This is a birth mark, which usually disappears by age 5 years.”
c. “This skin abnormality will require follow-up care.”
d. “This is a birth mark and they usually disappear by age 1 or 2 years.”
ANSWER: D
A
B
C
D
Feedback
This description refers to cavernous hemangioma that requires frequent
reassessment.
This description refers to a “stork bite” (telangiectasis).
This is an inappropriate response.
This description refers to a Mongolian spot.
DIF: Cognitive Level: Apply REF: 466
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific
Assessments
8. How does a nurse document a large, flat bluish capillary area on a neonate’s cheek?
a. Mongolian spot
b. Stork bite (telangiectasis)
c. Port-wine stain (nevus flammeus)
d. Strawberry hemangioma
ANSWER: C
A
B
C
D
Feedback
A Mongolian spot appears as an irregularly shaped, darkened, flat area over the
sacrum and buttocks.
A stork bite (telangiectasis) is a common vascular birthmark that appears as a
small red or pink spot often seen on the back of the neck.
Port-wine stains appear as large, flat, bluish purple capillary areas. They are
frequently found on the face along the distribution of the fifth cranial nerve
(trigeminal).
A strawberry hemangioma appears as a slightly raised, reddened area with a sharp
demarcation line that may be 2 to 3 cm in diameter.
DIF: Cognitive Level: Apply REF: 466
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific
Assessments
9. How does a nurse collect baseline measurements of a 6-month-old infant?
a. Measure the chest circumference around the lower ribs.
b. Ask the parent how much the infant’s weight has changed since birth.
c. Measure the head just above the ears and eyebrows.
d. Ask the parent to hold the infant while the nurse measures the length.
ANSWER: C
A
B
Feedback
The nurse measures chest circumference, but the tape measure is placed around
the nipples rather than the ribs.
An infant platform scale covered with a paper drape is used for weighing
newborns, infants, and small children.
C
D
The nurse measures head circumference using this procedure until about 2 years
old.
An infant’s height is measured while the infant is lying supine.
DIF: Cognitive Level: Apply REF: 467-468
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
10. How does a nurse assess the head circumference of an infant?
a. Places a ruler behind the infant’s head, noting the head width.
b. Uses a plastic headband placed around the infant’s head from crown to chin.
c. Places a measuring tape around the head above the eyebrows and occipital
prominence.
d. Uses a measuring tape to find the distance between the ears and eyes and between
the eyes and occiput.
ANSWER: C
A
B
C
D
Feedback
This is an incorrect technique.
This is an incorrect technique.
This is the correct technique for measuring head circumference.
This is an incorrect technique.
DIF: Cognitive Level: Understand REF: 467
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
11. During a well-baby check for several 4-month-old infants, a nurse recognizes that which
infant needs further assessment of an abnormal finding?
a. The infant who is unable to sit independently
b. The infant whose head circumference and chest circumference are equal
c. The infant whose weight has doubled since birth
d. The infant whose length falls in the 90th percentile on growth charts
ANSWER: B
Feedback
A This is not an expected motor skill for a 4-month-old; it is expected at 6 months
of age.
B At four months of age, the head circumference should be larger than the chest
circumference.
C This is a normal finding; infants generally double their birth weight by age 4 to 5
months.
D This is not an abnormal finding, especially if weight is normal; the height of the
parents should also be considered.
DIF: Cognitive Level: Analyze REF: 467-468
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Growth and Development
12. Which finding indicates to a nurse that a neonate has a cephalhematoma?
a. Well-defined edematous area over one cranial bone
b. Molding of the cranium that causes generalized cerebral edema
c. Diffuse edema over two or more cranial bones
d. Anterior fontanelle that is deeply depressed
ANSWER: A
A
B
C
D
Feedback
This is a subperiosteal hematoma under the scalp that occurs secondary to birth
trauma. The area, which appears as a soft, well-defined swelling over the cranial
bone, generally is reabsorbed within the first month of life.
Molding is secondary to the head passing through the birth canal and generally
lasts less than a week.
Cephalhematoma occurs over one cranial bone rather than several, and is welldefined
rather than diffuse.
Anterior fontanelles are soft but not depressed.
DIF: Cognitive Level: Understand REF: 468
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
13. During assessment of an infant, the nurse notes that when the infant cries, the fontanelles
bulge slightly. What is the most appropriate action for the nurse at this time?
a. Note in the record that the child is microcephalic.
b. Assess the fontanelles again when the child is not crying.
c. Check the child for signs of malnutrition and dehydration.
d. Use transillumination for further assessment of the skull.
ANSWER: B
A
B
C
D
Feedback
Microcephaly occurs when the head circumference is less than expected, which is
not the finding here.
The fontanelles frequently bulge when an infant is crying. The nurse will palpate
the anterior and posterior fontanelles for fullness while the infant is in an upright
position and calm.
An elevated fontanelle when the infant is calm may indicate overhydration or
fluid volume excess.
Transillumination is not needed in this case.
DIF: Cognitive Level: Apply REF: 468
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Growth and Development
14. A mother who sees her newborn just after vaginal delivery is distraught because the child’s
head is elongated. Which response is most appropriate by the nurse?
a. “This is due to a small area of bleeding that will go away in 1 to 2 months.”
b. “This may indicate a congenital deformity; the pediatrician will evaluate this.”
c. “This will require surgery to prevent hydrocephalus from developing.”
d. “This is not unusual after a vaginal delivery and will go away in about a week.”
ANSWER: D
A
B
C
D
Feedback
This response refers to cephalohematoma, which is not described here.
The newborn has molding that will resolve in a week.
The newborn has molding that will resolve in a week.
This is molding, which occurs when cranial bones override each other. Molding is
secondary to the head passing through the birth canal and generally lasts less than
a week.
DIF: Cognitive Level: Apply REF: 468
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific
Assessments
15. A nurse shines the light from the ophthalmoscope into the eyes of a newborn and observes a
bright, round, red-orange glow seen through both pupils. How does the nurse document this
finding?
a. An expected red reflex
b. Eyelid capillary hemangiomas
c. Bilateral conjunctivitis
d. Ophthalmia neonatorum
ANSWER: A
A
B
C
D
Feedback
The red reflex appears as a bright, round, red-orange glow seen through both
pupils.
Eyelid capillary hemangiomas are abnormalities that appear on the eyelid, but
disappear spontaneously.
Redness, lesions, nodules, discharge, or crusting of conjunctiva indicate
conjunctivitis.
Ophthalmia neonatorum is an eye disorder that produces purulent conjunctivitis
and keratitis.
DIF: Cognitive Level: Apply REF: 468
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific
Assessments
16. What finding does a nurse expect when assessing a one-month old’s eyes and vision?
a. The newborn distinguishes most colors
b. Tears when the newborn cries
c. The newborn following a bright toy or light
d. The newborn’s blink reflex is present
ANSWER: C
A
B
C
D
Feedback
Testing for color vision occurs between ages 4 and 8 years.
There are no tears until about 2 to 3 months of age.
This is an accurate statement.
The blink reflex is present in normal newborns and infants before one month.
DIF: Cognitive Level: Understand REF: 469
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Growth and Development
17. Which finding rules out defects in the cornea, lens, and vitreous chamber of an infant?
a. Bilateral red reflex
b. Symmetric corneal light reflex
c. Bilateral blink reflex
d. Symmetric eye movements
ANSWER: A
A
B
C
D
Feedback
Presence of the red reflex eliminates the presence of most serious defects of the
cornea, aqueous chamber, lens, and vitreous chamber.
Symmetric corneal light reflex tests for symmetric eye muscle function and
eliminates the presence of strabismus.
Bilateral blink reflex tests the function of cranial nerve V (trigeminal).
Symmetry of extraocular muscles tests cranial nerves III (oculomotor), IV
(trochlear), and VI (abducens).
DIF: Cognitive Level: Understand REF: 468-469
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific
Assessments
18. In assessing the eyes of a 4-month-old infant, a nurse shines a penlight in the infant’s eyes and
notices that the light reflection is not in the same location in each eye. What is the nurse’s
most appropriate response to this finding?
a. Perform the cover-uncover test.
b. Document it as an expected finding at this age.
c. Document abnormal function of cranial nerves IV (trochlear) and VI (abducens).
d. Refer the infant to an ophthalmologist.
ANSWER: B
A
B
C
D
Feedback
Performing the cover-uncover test is not indicated unless there is asymmetric
light reflex after 6 months of age.
Transient strabismus is common during the first few months of life due to a lack
of binocular vision. If it continues after 6 months of age; however, a referral to an
ophthalmologist is needed.
The data do not support this interpretation.
Referral is not needed unless the finding is present after the infant is 6 months
old.
DIF: Cognitive Level: Apply REF: 469
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific
Assessments
19. What technique does a nurse use to inspect the ear canal of a 1-year-old child?
a. Uses a light source without a speculum to minimize any trauma to the ear canal
b. Places the child in an upright position with the head flexed slightly downward
c. Applies gentle traction to the lower portion of the ear and pulls upward and
laterally
d. Uses an assistant to hold the child’s arms down and keep the child’s head turned to
one side
ANSWER: D
A
B
C
D
Feedback
A nurse uses the largest speculum that fits comfortably into the child’s ear canal.
Because the nurse must have both hands free to hold the ear and maneuver the
otoscope, another individual must act as a “holder.” The child’s head is turned to
one side.
The correct technique is to grasp the lower portion of the pinna and apply gentle
traction down and slightly backward (as opposed to pulling the pinna up and back
for the adult). This maneuver straightens the canal of the ear.
Instruct the holder to secure the infant’s arms at the sides with one hand, and turn
and hold the infant’s head to one side with the other hand.
DIF: Cognitive Level: Apply REF: 469
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
20. In inspecting the eyes and ears of an infant, the nurse documents which finding as normal?
a. The external ear is in direct line with the outer margin of the eyelid.
b. The ear lobe is within 10° of alignment with the outer margin of the eyelid.
c. A lateral upward slant of the eyes aligns them with the helix of the ear.
d. The inner margin of the eye is directly aligned with the helix of the ear.
ANSWER: A
A
B
C
D
Feedback
This is the expected alignment of the ears and eyes of an infant.
This is not an expected finding.
This finding occurs in infants with Down syndrome.
This is not an expected finding.
DIF: Cognitive Level: Understand REF: 470
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific
Assessments
21. Which behavior would be most indicative of hearing impairment in a 1-year-old child?
a. Failure to respond to mother’s voice
b. Crying when a loud noise occurs unexpectedly
c. Saying only single-syllable words
d. Disinterest in playing with musical toys
ANSWER: A
A
B
C
D
Feedback
By age 4 to 6 months, an infant should turn the head toward the source of the
sound and should respond to the parent’s voice.
This behavior indicates an ability to hear loud noises.
This is an expected finding for a child this age.
Although an infant by age 4 to 6 months should respond to music toys, a
disinterest does not indicate a hearing problem.
DIF: Cognitive Level: Understand REF: 470
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
22. Which finding during inspection of the mouth of a 1-month-old infant requires further
investigation?
a. A small loose tooth in the lower jaw
b. Tongue overlapping the floor of the mouth
c. Whitish epithelial cells on the roof of the mouth
d. White patches on the tongue that scrape off easily
ANSWER: B
A
B
C
D
Feedback
This is not an abnormal finding; occasionally, a natal loose tooth may be found.
The infant’s tongue should be appropriate to the size of the mouth and fit well
into the floor of the mouth.
These small, white epithelial cells on the palate or gums are called Bohn nodules
or Epstein pearls and are an expected finding.
Whitish patches seen along the mucosa that scrape off easily are milk deposits.
White patches that scrape off but leave a red area that may bleed indicate
candidiasis lesions.
DIF: Cognitive Level: Apply REF: 471
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
23. In performing a respiratory assessment of a 1-month-old infant, the nurse recognizes which
finding as abnormal?
a. Sneezing
b. Coughing
c. Abdominal breathing
d. Predominantly nose breathing
ANSWER: B
A
B
C
D
Feedback
Sneezing is a common finding for an infant and is therapeutic because it helps to
clear the nose.
Coughing at this age is considered abnormal and indicates a problem.
Infants use abdominal breathing rather than diaphragmatic breathing.
Infants are obligate nose breathers until about 3 months old.
DIF: Cognitive Level: Understand REF: 472
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
24. The nurse suspects respiratory distress in a newborn infant who exhibits which manifestation?
a. Respiratory rate of 36 breaths/min
b. Sternal retractions
c. Nasal breathing
d. Irregular breathing pattern
ANSWER: B
A
B
C
D
Feedback
Respiratory rate of 36 per minute in the newborn and infant is within the expected
range of 30 to 60 breaths/min.
Several respiratory findings indicate that an infant is in respiratory distress,
including stridor, grunting, sternal or supraclavicular retractions, and nasal
flaring.
Infants are obligate nose breathers until about 3 months old.
The respiratory pattern in the newborn may be irregular, having a Cheyne-Stokes
type of pattern.
DIF: Cognitive Level: Understand REF: 471-472
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
25. When assessing an infant, the nurse recognizes which finding requires immediate attention?
a. Cheyne-Stokes type of respiratory pattern
b. 1:1 anteroposterior to lateral chest diameter
c. Stridor and nasal flaring
d. Bronchovesicular lung sounds in the periphery
ANSWER: C
A
B
Feedback
The respiratory pattern in the newborn may be irregular, having a Cheyne-Stokes
type of pattern.
Unlike the adult, the infant has a round thorax with an equal anteroposterior and
lateral diameter.
C
D
Stridor and nasal flaring warrants immediate medical attention. Stridor is a highpitched,
piercing sound that is primarily heard in a distressed infant during
inspiration.
The predominant breath sound heard in the peripheral lung fields of infants is
bronchovesicular.
DIF: Cognitive Level: Analyze REF: 472
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
26. Which statement by a mother makes the nurse assess the infant girl for cardiovascular
problems?
a. “She has gained 2 lb since our last visit.”
b. “She naps twice a day for almost 2 hours each time.”
c. “She gets so tired and out of breath when she takes her bottle.”
d. “She gets fussy after I feed her and seems to have lots of gas.”
ANSWER: C
A
B
C
D
Feedback
This is an expected weight gain for an infant.
This is an expected sleep pattern for an infant.
Heart problems are indicated when caregivers report the child stops eating to
catch her breath.
This finding may be related to the food eaten, rather than a cardiovascular
problem.
DIF: Cognitive Level: Analyze REF: 472
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
27. During the assessment of a newborn within hours after birth, a nurse determines which finding
as abnormal?
a. Capillary refill time of less than 1 second
b. Apical pulse felt at the second intercostal space
c. Splitting of heart sounds
d. Cyanosis of the hands and feet
ANSWER: B
A
B
C
D
Feedback
This is a normal finding; capillary refill in infants is rapid—less than 1 second.
This finding is abnormal because the apical pulse of the newborn normally is felt
in the fourth or fifth intercostal space.
Splitting of heart sounds is common in infants until about 48 hours after birth
because of the transition from fetal circulation to systemic and pulmonic
circulation.
Acrocyanosis (cyanosis of hands and feet) without central cyanosis is of little
concern and usually disappears within hours to days after birth.
DIF: Cognitive Level: Analyze REF: 472
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
28. On assessment of an infant’s abdomen, the nurse notes which finding as normal?
a. Easily palpable spleen
b. Flat to slightly concave abdominal contour
c. Lower liver border 2 inches below the costal margin
d. Small protrusion between the rectus muscles when crying
ANSWER: D
A
B
C
D
Feedback
The spleen is generally not palpable, although the tip may be felt in the left upper
quadrant (far left costal margin).
Inspecting the abdomen of a healthy infant finds a symmetric, soft, and round
abdomen with a slight protrusion.
The edge of the infant’s liver should be 1 to 2 cm below the right rib cage (costal
margin).
Diastasis swelling and a gap between the rectus muscles may be noted as an
expect finding during crying.
DIF: Cognitive Level: Understand REF: 472
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific
Assessments
29. The nurse documents which finding as normal after performing the Barlow-Ortolani
maneuver on an infant?
a. The clavicles are immobile and without crepitus.
b. Each shoulder remains in a “hunched up” position.
c. No clicking is noted when the hips are abducted and adducted.
d. Both feet are held in the varus position when stroked on the soles.
ANSWER: C
A
B
C
D
Feedback
Normal findings include stable and smooth clavicles, without crepitus.
The Barlow-Ortolani maneuver assesses hip location.
The Barlow-Ortolani maneuver assesses hip location, and the movement should
feel smooth and produce no clicking.
The feet should be flexible and not fixed. Normally, the hindfoot aligns with the
lower leg and the forefoot turns inward slightly.
DIF: Cognitive Level: Understand REF: 473
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific
Assessments
30. Which technique does a nurse use to assess hip location of a newborn?
a. With newborn’s knees flexed, the nurse adducts the legs, then abducts them,
moving the knees apart and down to touch the table.
b. With the newborn supine, the nurse flexes and extends the hips, and then passively
moves each leg through internal and external rotation.
c. The nurse holds the newborn in a vertical position with the feet flat on the table and
palpates each hip for location.
d. With the newborn supine, the nurse measures the length of each leg from the
trochanter to the lateral malleolus (ankle).
ANSWER: A
A
B
C
D
Feedback
This describes the Barlow-Ortolani maneuver to assess hip location and
determine dislocation.
This describes an incorrect technique.
This describes an incorrect technique.
This describes an incorrect technique.
DIF: Cognitive Level: Apply REF: 473
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
31. A nurse assessing a 3-month-old infant suspects hydrocephalus based on which finding?
a. Soft anterior fontanelle
b. Lack of head control while sitting
c. Increasing head circumference
d. Marked asymmetry of the head
ANSWER: C
A
B
C
D
Feedback
This is an expected finding. Bulging fontanelle is a manifestation of
hydrocephalus.
By 4 months old, most infants demonstrate head control by holding the head erect
and midline when in an upright position.
The abnormal accumulation of cerebrospinal fluid increases the head
circumference because the sutures of the skull are not ossified and the anterior
fontanelle is not closed.
Marked asymmetry of the head may indicate craniosynostosis, a premature
ossification of one or more of the cranial sutures.
DIF: Cognitive Level: Understand REF: 475
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
32. To assess the reflexes of a 5-month-old infant lying supine, the nurse turns the infant’s head to
the left side so that the chin is over the shoulder. What is the expected response for this reflex?
a. Left arm and leg abduct and the right arm and leg adduct.
b. Left arm and leg extend and the right arm and leg flex.
c. Infant turns the chin from the left to the right side.
d. Infant begins a sucking motion with the lips and tongue.
ANSWER: B
Feedback
A The arms and legs flex and extend, rather than abduct and adduct.
B This is the expected response for the tonic neck reflex that appears from birth to 6
weeks old and disappears at 4 to 6 months old.
C This is not an expected finding for any infant reflexes.
D This is a description of the sucking reflex.
DIF: Cognitive Level: Apply REF: 474
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Growth and Development
33. A nurse tests a reflex on a 9-month-old infant’s right foot by stroking the surface of the
infant’s foot, moving from the sole laterally up and across to the great toe. What is the
expected response?
a. Flexion of the right toes
b. Extension of the right ankle
c. Dorsiflexion of the right foot
d. Fanning of the toes of the right foot
ANSWER: D
A
B
C
D
Feedback
This is not an expected response from any reflex.
This is not an expected response from any reflex.
This is part of the clonus reflex test.
This is the expected response for the Babinski reflex.
DIF: Cognitive Level: Apply REF: 474-475
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Growth and Development
34. In assessing a neonate, the nurse notices that one testicle has not descended into the scrotal
sac. What is the most appropriate response for the nurse as a result of this finding?
a. Document the findings and refer this neonate for further examination for an
undescended testicle.
b. Place a finger over the upper inguinal ring and gently push downward to try to push
the testicle into the scrotum.
c. Use a light source to transilluminate the affected scrotal sack to determine if fluid is
preventing the descent of the testicle.
d. Insert the fifth finger into the inguinal ring to palpate for a hernia that may have
prevented the testicle from descending.
ANSWER: B
Feedback
A
B
C
D
This response is premature without determining if the testicle can be manually
descended into the scrotum.
If the testicle can be pushed into the scrotum, it is considered descended even
though it retracts into the inguinal canal.
Transillumination is used to detect a hydrocele, which is a common finding in
infants but not related to an undescended testicle.
This response is not appropriate.
DIF: Cognitive Level: Analyze REF: 476
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific
Assessments
35. After obtaining a history from the parents and inspecting the skin, the nurse determines which
child needs further evaluation?
a. The child who has a 1-cm red spot on the back of the neck, a fever of 100° F, and
clear nasal drainage.
b. The child who has a 2-cm slightly-raised, reddened area with a sharp demarcation
line on the back of the neck.
c. The child has a 2-cm abrasion on the right knee, a 3-cm abrasion on the left knee,
and scrapes on both palms.
d. The child who has several flat, bluish discolorations of the skin on the abdomen
and back from 2 to 6 cm.
ANSWER: D
A
B
C
D
Feedback
This child has a stork bite birthmark on the back of the neck and an upper
respiratory allergy or viral infection.
This is a strawberry hemangioma, a birthmark that disappears by 5 years of age.
This child probably fell down while running, skinned both knees, and tried to
break the fall with the hands.
Bruising in unusual areas (such as upper arms, back, buttocks, and abdomen) or
multiple bruises found at different stages of healing should be further investigated
to determine if there is abuse.
DIF: Cognitive Level: Analyze REF: 477
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
36. Which tool is most appropriate for testing the vision of a 5-year-old child?
a. Denver II test
b. Snellen E chart
c. Allen picture cards
d. Snellen standard chart
ANSWER: B
A
Feedback
Vision can be assessed when performing developmental tests such as the Denver
B
C
D
II, but the Snellen E provides more objective data.
Use the Snellen E chart for children 3 to 6 years of age (see Chapter 11). Have
children point their fingers in the direction of the “arms” of the E.
Use the Allen picture cards to screen for visual acuity in 2.5- to 3-year-old
children.
The Snellen standard chart is used for adolescents and adults; it is too difficult to
use for children.
DIF: Cognitive Level: Understand REF: 478
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
37. When examining lymph nodes in a 7-year-old child, the nurse records which finding as
abnormal?
a. “Shotty” nodes in the cervical areas
b. Palpable submandibular nodes
c. Nodes that are tender 1 week after a tetanus vaccination
d. Tender, fixed nodes greater than 1 cm
ANSWER: D
A
B
C
D
Feedback
The term “shotty” may be used to describe small, firm, and mobile nodes, usually
occurring as a normal variation in children.
Cervical and submandibular nodal enlargements are frequent in older children.
Enlarged, tender nodes may occur after immunizations or upper respiratory
infection.
Abnormal findings are tender, fixed nodes greater than 1 cm.
DIF: Cognitive Level: Analyze REF: 479-480
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
38. After assessment of each child, the nurse determines which child needs to be referred for
further evaluation?
a. A 4-year-old child with a predominantly nasal breathing pattern
b. A 6-year-old child with a 1:2 anteroposterior-to-transverse-chest ratio
c. A 7-year-old child with a predominantly thoracic breathing pattern
d. A 9-year-old child with bronchovesicular breath sounds in peripheral lungs
ANSWER: D
A
B
C
Feedback
At this age, children have a nasal and abdominal breathing pattern and do not
develop a thoracic breathing pattern until 6 or 7 years of age.
By age 5 or 6, the rounded thorax of the child approximates the 1:2 ratio of
anteroposterior to lateral diameter of the adult.
By age 6 or 7, the child’s breathing pattern should change from primarily nasal
and abdominal to thoracic in girls and abdominal in boys.
D
Although bronchovesicular breath sounds in peripheral lung areas are expected in
a young child, vesicular sounds are expected at this age.
DIF: Cognitive Level: Analyze REF: 480
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
39. A nurse refers which child for further assessment?
a. A 2-year-old who has a jugular venous hum after playing
b. A 4-year-old who has a resting heart rate of 100
c. A 5-year-old who positions herself in a squat after running a few feet
d. A 7-year-old who has a strong femoral pulse readily detected on palpation
ANSWER: C
A
B
C
D
Feedback
An expected finding in children is a venous hum in the jugular vein.
This is an expected resting heart rate for a child; the expected range for a toddler
is from 80 to 110 and for a school-age child from 60 to 110 beats/min.
Squatting may be a compensatory position for a child with a heart defect.
This is an expected finding.
DIF: Cognitive Level: Analyze REF: 481
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
40. How does a nurse respond to parents of a 5-year-old who are worried that their child has a
protruding abdomen?
a. Assesses the child to differentiate a normal “potbelly” from a hernia
b. Suggests that the parents administer an appropriate dose of a laxative at bedtime
c. Refers the parents to a nutritionist to develop an appropriate weight-loss diet for the
child
d. Informs the parents that a protruding abdomen is always an abnormal finding in
this age group
ANSWER: A
A
B
C
D
Feedback
Toddlers normally exhibit a rounded (potbelly) abdomen while both standing and
lying down.
The nurse needs to collect more data before making this recommendation.
The nurse needs to collect more data before making this recommendation.
This is an inappropriate statement based on the description of this child.
DIF: Cognitive Level: Apply REF: 481
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Growth and Development
41. During a musculoskeletal assessment of a school-age child, a nurse documents which finding
as expected?
a. A positive Trendelenburg sign on one side
b. Lumbar lordosis, especially in African American children
c. Varus rotation when the knees are greater than 1 inch apart
d. Valgus rotation of less than 1 inch with the knees touching
ANSWER: D
A
B
C
D
Feedback
Trendelenburg sign (or gait) tests for hip dysplasia and the function of the gluteus
medius muscle.
Lordosis is seen more frequently in African American children but should not be
seen in children older than 6 years of age.
Varus rotation (medial malleolus touching with knees greater than 1 inch [2.5 cm]
apart) requires further evaluation for tibial torsion; it may be normal through 18
to 24 months of age.
Valgus rotation (medial malleolus greater than 1 inch [2.5 cm] apart with knees
touching) is normal in 2- to 3.5-year-old children and may be present up to 12
years old.
DIF: Cognitive Level: Understand REF: 482
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific
Assessments
42. While examining the genitalia of a 6-year-old girl, a nurse notices which finding as expected?
a. Clear mucoid vaginal discharge
b. Prepuce and clitoris are prominent
c. Flat labia majora with thin labia minora
d. Sparse pubic hair over the inner thighs
ANSWER: C
A
B
C
D
Feedback
Vaginal discharge is an abnormal finding at this age.
Normally at this age the clitoris is relatively small.
Until approximately age 7, the labia majora are flat, the labia minora are thin.
Evidence of pubic hair may be seen by the time the child reaches pubescence,
usually between ages 8 and 11.
DIF: Cognitive Level: Understand REF: 485
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific
Assessments
43. The nurse places an 8-year-old boy in which position for examination of his genitalia?
a. Supine with legs extended to either side
b. Lying on his left side with knees bent
c. Reclining with knees flexed
d. Standing with legs spread apart
ANSWER: C
A
B
C
D
Feedback
The examination is easiest to perform if the child is sitting.
The examination is easiest to perform if the child is sitting.
The examination is easiest to perform if the child is sitting in either a slightly
reclining position with his knees flexed or heels near the buttock or sitting with
his knees spread and ankles crossed.
The examination is easiest to perform if the child is sitting.
DIF: Cognitive Level: Understand REF: 485
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
44. Which disorder, if any, does a nurse screen for when examining a healthy adolescent?
a. Muscle weakness
b. Limited joint range of motion
c. Curvature of the spine
d. No screening is needed when the adolescent is healthy
ANSWER: C
A
B
C
D
Feedback
Screening for muscle weakness in a well adolescent is not indicated.
Screening for limited range of motion in a well adolescent is not indicated.
Adolescents are screened for scoliosis, kyphosis, and lordosis. Postural kyphosis
is almost always accompanied by a compensatory lordosis, an abnormally
concave lumbar curvature.
Adolescents are screened for scoliosis.
DIF: Cognitive Level: Understand REF: 486-487
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Growth and Development
45. During a physical examination, a 12-year-old girl expresses concern to the nurse that her
breasts are different sizes. Which response is most appropriate for the nurse?
a. “This happens normally to many girls your age. Full breast development takes an
average of 3 years.”
b. “I can talk with your mother about a referral to a physician who can perform further
examination and tests.”
c. “Have you started your menstrual period yet, because breast development is
irregular until menstruation begins?”
d. “This is called ‘precocious breast development’ and your breasts will become more
equal just before your growth spurt starts.”
ANSWER: A
A
Feedback
The right and left breasts may develop at different rates. It is important to reassure
the patient that this is common and, in time, the development may equalize. Full
B
C
D
development of the breast takes an average of 3 years (range 1.5 to 6 years).
Breasts may develop at different rates.
Menarche begins when the breasts reach Tanner stages 3 or 4, which is
approximately age 12.
Precocious breast development is the development of breasts before 8 years old.
DIF: Cognitive Level: Apply REF: 487
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Growth and Development
Chapter 20: Assessment of the Pregnant Patient
Test Bank
MULTIPLE CHOICE
1. A patient who is 30 weeks pregnant tells the nurse, “I have had low blood pressure all my life,
and now it is 136/74. What’s wrong with me?” What is the most appropriate response by this
nurse?
a. “A woman’s blood pressure usually drops several points during pregnancy, but
yours hasn’t.”
b. “The blood pressure increases because your blood volume increases to supply you
and the baby with enough blood.”
c. “Yes, this is a significant change from your baseline, and I advise you to see your
obstetrician at your earliest convenience.”
d. “If you spend more time lying down, I think your blood pressure should return to
normal in a few days.”
ANSWER: B
A
B
C
D
Feedback
The blood pressure may decrease slightly in the second trimester and then return
to the usual level during the third trimester. With an increase in blood volume, the
patient may experience an increase in blood pressure above baseline.
Blood volume increases by 1500 mL to meet the needs of an enlarged uterus and
fetal tissue, causing increased cardiac workload (increased heart rate and blood
pressure).
This referral is unnecessary.
With an increase in blood volume, the patient may experience an increase in
blood pressure above baseline.
DIF: Cognitive Level: Apply REF: 496
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific
Assessments
2. A nurse instructs the patient about which expected skin changes during pregnancy?
a. Nipples becoming thicker
b. Hands and feet becoming pale and cool
c. Blotchy, brown pigmentation of the abdomen
d. Stretch marks on the expanding abdomen
ANSWER: D
A
B
C
D
Feedback
Nipples and areolae become more prominent and deeply pigmented.
Blood volume increases and edema often develops in the feet.
The blotchy, brown pigmentation occurs on the face and is called chloasma, or
the mask of pregnancy.
The increasing size of the abdomen contributes to striae gravidarum (stretch
marks) over the abdomen.
DIF: Cognitive Level: Understand REF: 496| 505
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body
Systems
3. How does a nurse determine the Goodell sign?
a. Assesses the softening of the lower uterine segment
b. Palpates for softening of the cervix
c. Assesses the breasts for fullness and tenderness
d. Inspects the cervix for a bluish coloration
ANSWER: B
A
B
C
D
Feedback
Assesses the softening of the lower uterine segment is a description of Hegar
sign.
Palpates for softening of the cervix is a description of Goodell sign.
Assesses the breasts for fullness and tenderness is a presumptive sign of
pregnancy rather than a probable sign.
Inspects the cervix for a bluish coloration is a description of Chadwick sign.
DIF: Cognitive Level: Understand REF: 496, Table 20-1
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Ante/Intra/Postpartum and
Newborn Care
4. The nurse recognizes which clinical manifestation as a positive sign of pregnancy?
a. Cessation of menstruation
b. Visualization of the fetus by ultrasound
c. Nausea and increased abdominal girth
d. Positive pregnancy test (hCG)
ANSWER: B
A
B
C
D
Feedback
Cessation of menstruation is a presumptive sign of pregnancy.
This is a positive sign of pregnancy.
Nausea and increased abdominal girth are presumptive signs of pregnancy.
Positive pregnancy test (hCG) is a probable sign of pregnancy.
DIF: Cognitive Level: Understand REF: 496, Table 20-1
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Ante/Intra/Postpartum and
Newborn Care
5. Using Nägele’s rule, what is the estimated delivery date of a patient whose last menstrual
period started on December 1?
a. August 1
b. August 10
c. September 4
d. September 8
ANSWER: D
Feedback
A Subtract 3 months rather than 4, and add 7 days.
B Subtract 3 months rather than 4, and add 7 days rather than 9.
C After subtracting 3 months, add 7 days instead of 3.
D September 8 is determined by using the first day of the last menstrual period,
subtracting 3 months, and adding 7 days.
DIF: Cognitive Level: Apply REF: 497
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Ante/Intra/Postpartum and
Newborn Care
6. What is the meaning of “G5, T1, P0, A3, L1” found in a patient’s history?
a. One birth at term
b. Three living children
c. Five grown children
d. One delivery not at term
ANSWER: A
A
B
C
D
Feedback
These data report that this patient has had five pregnancies, one term birth, no
preterm births, three abortions, and one living child.
This patient has had three abortions.
This patient has had five pregnancies.
This patient has had no preterm births.
DIF: Cognitive Level: Apply REF: 497
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Ante/Intra/Postpartum and
Newborn Care
7. A pregnant woman who drinks alcoholic beverages while pregnant increases the risk for
which disorder?
a. Low infant birth weight
b. Birth defects
c. Abruptio placentae
d. Gestational diabetes mellitus
ANSWER: B
A
B
C
D
Feedback
Low infant birth weight is not directly caused by alcohol intake.
Alcohol is a teratogen; no safe level of alcohol ingestion has been identified for
pregnant women.
Maternal hypertension is the risk factor for abruptio placentae.
Gestational diabetes mellitus is not caused by alcohol intake.
DIF: Cognitive Level: Understand REF: 498
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential
8. A nurse refers which pregnant patient for additional assessment?
a. A woman at 36 weeks of gestation who has 30% effacement of the cervix
b. A woman at 19 weeks of gestation who has noticed fetal movement every day this
week
c. A woman at 20 weeks of gestation who has gained 4 lb in the last 2 weeks
d. A woman at 28 weeks of gestation who has a systolic blood pressure of 40 mg Hg
over baseline
ANSWER: D
A
B
C
D
Feedback
This is an expected finding at this point in the third trimester.
This is an expected finding.
This is an expected weight gain.
This finding may indicate pregnancy-induced hypertension, characterized by
systolic blood pressure of at least 30 mm Hg above baseline.
DIF: Cognitive Level: Analyze REF: 500
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body
Systems
9. A patient’s prepregnant weight was 131 lb, within the desirable range for her height. What is
the expected weight for this pregnant patient?
a. 131 lb at 1 week postpartum
b. 140 lb at the end of the first trimester
c. 145 lb at the end of the second trimester
d. 176 lb at the beginning of the third trimester
ANSWER: C
A
B
C
D
Feedback
There are no specific weight guidelines for after birth, but it is unlikely that she
would be at her prepregnant weight 1 week after delivery.
The expected range for the first trimester is weight gain of 3 to 5 lb; the patient
gained 9 lb.
This 14-lb weight gain is within expected ranges (12 to 15 lb [5.5 to 6.8 kg]) for
the second trimester.
This 45-lb weight gain is 10 lb more than desired; the expected range for the third
trimester is 12 to 15 lb greater than the second trimester, which would be 163 to
166 lb.
DIF: Cognitive Level: Apply REF: 501
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Ante/Intra/Postpartum and
Newborn Care
10. A pregnant patient presents to the clinic with a 3 lb/wk weight gain for 2 successive weeks.
The nurse is most concerned that this patient is demonstrating signs of which condition?
a. Gestational diabetes mellitus
b. Preeclampsia
c. Placenta enlargement
d. Multiple gestations
ANSWER: B
A
B
C
D
Feedback
A rapid increase in weight could indicate gestational diabetes, but a gain of this
much in 2 successive weeks warrants considering preeclampsia.
If a woman gains more than 2 lb (0.9 kg) in any 1 week, preeclampsia should be
suspected.
Rapid weight gain is not associated with placental enlargement.
A rapid increase in weight could indicate multiple gestation, but a gain of this
much in 2 successive weeks warrants considering preeclampsia.
DIF: Cognitive Level: Analyze REF: 501
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Ante/Intra/Postpartum and
Newborn Care
11. A pregnant woman’s weight before becoming pregnant was 137 lb. What weight is expected
for this woman during her second trimester?
a. 149 lb
b. 151 lb
c. 155 lb
d. 164 lb
ANSWER: C
A
B
C
D
Feedback
This weight is obtained when you forget to include the 3 to 5 lb for the first
trimester.
The prepregnant weight was 137 lb. Add 3 to 5 lb for the first trimester, making
the ranges from 140 to 142 lb. The second trimester is 12 to 15 lb in addition to
the first trimester weight. This 140 to 142 lb + 12 to 15 lb = a range from 152 to
157 lb.
The prepregnant weight was 137 lb. Add 3 to 5 lb for the first trimester, making
the ranges from 140 to 142 lb. The second trimester is 12 to 15 lb in addition to
the first trimester weight. This 140 to 142 lb + 12 to 15 lb = a range from 152 to
157 lb.
This is the weight for the third trimester when an additional 12 to 15 lb can be
added.
DIF: Cognitive Level: Apply REF: 501
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Ante/Intra/Postpartum and
Newborn Care
12. A nurse documents as abnormal which finding of a pregnant patient?
a. Facial swelling in a woman who is 20 weeks pregnant
b. 1+ pitting ankle edema in a woman who is 26 weeks pregnant
c. Pinkish-red blotches of the hands in a woman at 32 weeks gestation
d. Blotchy, brownish pigmentation of the face in a woman at 36 weeks gestation
ANSWER: A
A
B
C
D
Feedback
Excessive edema (particularly if noted in the hands and face in addition to the
lower extremities) is considered pathologic and may be an indication of
pregnancy induced hypertension.
Some edema is expected during pregnancy and 1+ is a modest amount of edema.
Pinkish-red blotches or diffuse mottling of the hands due to an increase in
estrogen is termed palmar erythema and is considered an expected finding.
Blotchy, brownish pigmentation of the face—chloasma, or the mask of pregnancy
—is an expected finding.
DIF: Cognitive Level: Apply REF: 502
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body
Systems
13. In prioritizing patient care, the nurse would give immediate attention to the pregnant patient
with which clinical manifestation?
a. Darkened eyelids
b. Seeing spots
c. Excessive eye dryness
d. Pale conjunctiva
ANSWER: B
A
B
C
D
Feedback
Darkened eyelids may occur normally and is not a reason for concern.
Chromatopsia may be noted, characterized by unusual color perception, seeing
spots, or blindness in the lateral visual field, and requires immediate follow-up.
Excessive eye dryness occurs normally in pregnancy and can be treated with
artificial tears.
Pale conjunctiva may indicate anemia, which needs to be treated, but it is not an
urgent problem.
DIF: Cognitive Level: Analyze REF: 502
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:
Establishing Priorities
14. The nurse documents which clinical finding as an expected change associated with advancing
pregnancy?
a. Slight persistent ankle edema
b. Hypoplasia of the thyroid gland
c. Increased diaphragmatic excursion
d. Heart murmur after 20 weeks of gestation
ANSWER: D
A
B
C
D
Feedback
Ankle edema may occur, but normally is not persistent.
This is not an expected finding in pregnancy.
The diaphragm is pushed up by the growing fetus, which decreases the
diaphragmatic excursion, rather than increasing it.
Murmurs, splitting of S 1 and S 2 , and the presence of S 3 may be heard after the
twentieth week of gestation.
DIF: Cognitive Level: Understand REF: 503
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Ante/Intra/Postpartum and
Newborn Care
15. A patient at 20 weeks of gestation is concerned about a discharge from her nipples. What is
the nurse’s appropriate response to this patient?
a. “That is expected. It is milk production that begins at the onset of pregnancy.”
b. “A nipple discharge is unusual. I advise you to consult your obstetrician.”
c. “I suggest you decrease your fluid intake for several days to see if this makes a
difference.”
d. “After the first trimester a thin, yellow fluid called colostrum may be secreted from
the nipples.”
ANSWER: D
A
B
C
D
Feedback
Colostrum cannot be expressed until after the first trimester.
This finding is not unusual.
This action is not necessary because this is an expected finding.
This is a correct statement by the nurse.
DIF: Cognitive Level: Understand REF: 504
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Ante/Intra/Postpartum and
Newborn Care
16. A woman who is 16 weeks pregnant with her first child is concerned because she has not felt
the fetus move. What is the most appropriate explanation for a nurse to give this patient?
a. Movement of a fetus in the first pregnancy often does not occur until the twentyfourth
week of pregnancy.
b. A referral to an obstetrician should be made for further evaluation of this finding.
c. Movement of the fetus is not expected until the nineteenth week of pregnancy.
d. Movement of the fetus is related to fundal height; the greater the fundal height, the
sooner the fetal movement.
ANSWER: C
Feedback
A
B
C
D
Fetal movement is felt by the nineteenth week and movement observed by
approximately the twenty-eighth week.
A referral is not warranted in this case.
This patient will likely not feel fetal movement for another 3 weeks.
Fetal movement is related to gestational age rather than fundal height.
DIF: Cognitive Level: Understand REF: 506
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Ante/Intra/Postpartum and
Newborn Care
17. In measuring fundal height, the nurse documents which finding as abnormal?
a. 29 cm at week 30
b. 28 cm at week 26
c. 34 cm at week 38
d. 26 cm at week 24
ANSWER: C
Feedback
A From the twentieth to thirty-sixth week of gestation, the expected pattern of
uterine growth is an increase in fundal height of about 1 cm per week.
B Measurement of fundal height is an estimate and may vary among examiners by 1
C
to 2 cm.
This is a 4 cm difference; any discrepancy greater than 2 cm between fundal
height and the estimate of gestational age (based on the last menstrual period)
should be evaluated further.
D Measurement of fundal height is an estimate and may vary among examiners by 1
to 2 cm.
DIF: Cognitive Level: Apply REF: 506
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Ante/Intra/Postpartum and
Newborn Care
18. A nurse assesses fetal heart rates when patients are examined in the maternity clinic. The
nurse determines which fetus needs further assessment?
a. The fetus with a heart rate of 150 beats/min
b. The fetus with a heart rate of 140 beats/min
c. The fetus with a heart rate of 130 beats/min
d. The fetus with a heart rate of 110 beats/min
ANSWER: D
A
B
C
D
Feedback
This heart rate is within the expected range of 120 to 160 beats/min.
This heart rate is within the expected range of 120 to 160 beats/min.
This heart rate is within the expected range of 120 to 160 beats/min.
This fetal heart rate is too slow and needs further assessment. The expected range
is from 120 to 160 beats/min.
DIF: Cognitive Level: Apply REF: 507
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:
Establishing Priorities
19. To perform Leopold maneuvers, the nurse uses which assessment technique?
a. Percussing over the symphysis pubis
b. Auscultating all four abdominal quadrants
c. Palpating the fundus
d. Measuring from symphysis pubis to the umbilicus
ANSWER: C
A
B
C
D
Feedback
This technique may be used to determine a full bladder.
This technique determines presence of peristalsis.
This is the procedure for Leopold maneuvers to determine presentation.
This technique is used to determine the size of the fetus.
DIF: Cognitive Level: Understand REF: 508-509
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
20. The nurse correlates which clinical manifestation with the diagnosis of polyhydramnios?
a. Difficulty palpating fetal parts
b. Increased fetal movement
c. Weight gain of less than estimated by gestational age
d. Increase of 2 cm in fundal height in 1 week
ANSWER: A
A
B
C
D
Feedback
Inability to palpate the fetal position could be associated with polyhydramnios, an
excessive quantity of amniotic fluid.
This is not a manifestation of excessive amniotic fluid.
This is not a manifestation of excessive amniotic fluid.
This is not a manifestation of excessive amniotic fluid.
DIF: Cognitive Level: Understand REF: 513
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body
Systems
21. In reviewing the results of physical examination of a 25-year-old pregnant patient, a nurse
recognizes which finding as expected?
a. Small, round, oval cervix
b. Pale, symmetrical cervix
c. Smooth, bluish-colored cervix
d. Slit-shaped, pink cervix
ANSWER: C
A
B
C
D
Feedback
This describes a nulliparous cervix, but the patient referred to is pregnant, which
would cause a bluish-colored cervix.
The patient referred to is pregnant, which would cause a bluish-colored cervix.
By the second month of pregnancy, the cervix, vagina, and vulva take on a bluish
color (Chadwick sign) due to increased vascularity.
The patient referred to is pregnant, which would cause a bluish-colored cervix.
DIF: Cognitive Level: Apply REF: 508
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific
Assessments
22. How does a nurse describe abruptio placentae when teaching a class to pregnant women?
a. A premature separation of the implanted placenta before birth of the fetus
b. An accumulation of amniotic fluid associated with decreased fetal movement
c. An attachment of the placenta in the lower uterine segment near the cervical os
d. Related to premature rupture of membranes with purulent vaginal discharge
ANSWER: A
A
B
C
D
Feedback
A premature separation of the implanted placenta before birth of the fetus is a
description of abruptio placentae.
This is an incorrect description.
This is a description of placenta previa.
Abruptio placentae is premature separation of the implanted placenta rather than a
premature rupture of membranes; there is no purulent vaginal discharge.
DIF: Cognitive Level: Understand REF: 512
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body
Systems
23. Which complication of pregnancy does a nurse suspect when the patient reports painless
vaginal bleeding at 32 weeks of gestation?
a. Placenta previa
b. Eclampsia
c. Abruptio placentae
d. Premature rupture of membranes
ANSWER: A
A
B
C
D
Feedback
Placenta previa has painless vaginal bleeding as a manifestation.
Eclampsia does not have painless vaginal bleeding as a manifestation.
Abruptio placentae does not have painless vaginal bleeding as a manifestation.
Premature rupture of membranes does not have painless vaginal bleeding as a
manifestation.
DIF: Cognitive Level: Understand REF: 512-513
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body
Systems
24. In assessing a patient for modifiable risk factors, the nurse correlates which finding with a
high-risk pregnancy?
a. 15-year-old mother
b. Low socioeconomic status
c. Previous birth of infant with isoimmunization
d. Weight less than 100 lb
ANSWER: D
A
B
C
D
Feedback
Age cannot be modified.
Low socioeconomic status cannot be modified easily.
Previous birth of infant with isoimmunization cannot be modified.
This risk factor can be modified by diet.
DIF: Cognitive Level: Understand REF: 512
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Ante/Intra/Postpartum and
Newborn Care
MULTIPLE RESPONSE
1. Which physiologic changes are associated with pregnancy? Select all that apply.
a. Increase in brittleness of fingernails
b. 1500 mL increase in blood volume
c. Periodic shortness of breath later in pregnancy
d. Edematous and bleeding gums
e. Painless vaginal bleeding
f. Waddling gait
ANSWER: B, C, D, F
Correct: Blood volume increases by 1500 mL to meet the need of an enlarged uterus and fetal
tissue, causing increased cardiac workload (increased heart rate). Uterine enlargement pushes
up on the diaphragm, causing periodic shortness of breath. Increased estrogen increases
vascularity and tissue proliferation of gums, resulting in edematous and bleeding gums. The
increased size of the uterus and growing fetus results in the center of gravity moving forward,
resulting in a waddling gait.
Incorrect: Increased nail growth is reported by some individuals. Painless vaginal bleeding
indicates a problem with the pregnancy, such as placenta previa.
DIF: Cognitive Level: Understand REF: 496
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Ante/Intra/Postpartum and
Newborn Care
2. What does a nurse teach pregnant patients about the effects of smoking while pregnant? Select
all that apply.
a. Fluid retention increases.
b. Prematurity risk increases.
c. Low infant birth weight risk increases.
d. Anemia develops.
e. Vitamin C deficiency develops.
f. Craving of starch, baking soda, or clay develops.
ANSWER: B, C, E
Correct: These three are due to the effects of smoking while pregnant.
Incorrect: Fluid retention increases may occur during pregnancy, but it is not caused by
smoking. Anemia may occur during pregnancy, but it is not caused by smoking. Craving of
starch, baking soda, or clay may occur during pregnancy, but it is not caused by smoking.
DIF: Cognitive Level: Understand REF: 498
TOP: Nursing Process: Assessment
MSC: NCLEX: Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
3. What manifestations does a nurse anticipate when assessing a patient with preeclampsia?
Select all that apply.
a. Systolic blood pressure greater than 140 mm Hg
b. Increase in systolic blood pressure of 20 mm Hg over baseline
c. Diastolic blood pressure greater than 90 mm Hg
d. Increase in diastolic blood pressure of 15 mm Hg over baseline
e. 2 lb increase in weight in 1 week
f. 9 lb increase in weight in 1 month
ANSWER: A, C, D, F
Correct: Preeclampsia is precipitated by pregnancy-induced hypertension indicated by
systolic blood pressure of 140 mm Hg or higher, diastolic blood pressure more than 90 mm
Hg, and an increase of more than 15 mm Hg of diastolic blood pressure from baseline. A 9-lb
weight gain in this time period contributes to hypertension.
Incorrect: Increase in systolic blood pressure of 20 mm Hg over baseline is an increase of
more than 30 mm Hg of systolic blood pressure from baseline. Two-pound increase in weight
in 1 week is an expected weight gain during pregnancy.
DIF: Cognitive Level: Understand REF: 513
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body
Systems
COMPLETION
1. If a patient’s last menstrual period was May 13, her estimated date of birth is .
ANSWER:
February 20
May 13 minus 3 months = February 13 plus 7 days = February 20.
DIF: Cognitive Level: Apply REF: 497
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Ante/Intra/Postpartum and
Newborn Care
2. A pregnant patient’s weight before pregnancy was 148 lb. Her expected weight during the first
trimester is to lb.
ANSWER:
151
153
151, 153
3- to 5-lb weight gain is expected during the first trimester resulting in a total of 151 to 153 lb.
DIF: Cognitive Level: Apply REF: 501
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Ante/Intra/Postpartum and
Newborn Care
3. A pregnant patient’s weight before pregnancy was 163 lb. The nurse expects the patient to
weigh to lb during the second trimester.
ANSWER:
178; 183
178, 178
A 3- to 5-lb weight gain is expected during the first trimester, making the weight 166 to 168.
The second trimester is 12 to 15 lb in addition to the first trimester weight. Thus 166 + 12 lb =
178 lb at the low end and 168 + 15 lb = 183 at the high end.
DIF: Cognitive Level: Apply REF: 501
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Ante/Intra/Postpartum and
Newborn Care
Chapter 21: Assessment of the Older Adult
Test Bank
MULTIPLE CHOICE
1. A 75-year old patient tells the nurse, “I just do not enjoy eating as much as I used to because
the food does not have much taste or smell.” Which statement by the nurse is most
appropriate?
a. “You should make an appointment with your health care provider.”
b. “Try eating small, frequent meals.”
c. “The senses of smell and taste decrease as we age.”
d. “Maybe you should use saline drops in your nose.”
ANSWER: C
A
B
C
D
Feedback
This action is not warranted in this case; these changes are expected with aging.
This is practical advice, but will not alter the change in smell and taste.
A decreased sense of smell is caused by a decrease in the number of sensory cells
in the nasal lining. Taste perception may also diminish due to gradual atrophy of
the tongue and a decrease in the number of papillae and taste buds.
This is practical advice, but will not alter the change in smell and taste.
DIF: Cognitive Level: Apply REF: 516
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Aging Process
2. During inspection of the mouth of an older adult, a nurse notices which finding as an expected
change associated with aging?
a. Exposed root surfaces of teeth
b. Aphthous ulcers of the mucosa
c. Collection of debris at the gingival margins
d. Leukoplakia of the dorsal and ventral tongue
ANSWER: A
A
B
C
D
Feedback
Root surfaces of the teeth are exposed to caries formation because of gingival
recession.
Ulcers are not an expected finding.
Collection of debris at the gingival margins is not an expected finding.
This is not an expected finding; leukoplakia is a white patch or plaque that cannot
be scraped off and often represents a premalignant lesion.
DIF: Cognitive Level: Understand REF: 516
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Aging Process
3. Which assessment finding of older adult patients indicates expected respiratory function?
a. Increased elasticity of the alveoli
b. Flaccidity of the chest wall
c. Reduced inspiratory and expiratory effort
d. Decreased anteroposterior diameter
ANSWER: C
A
B
C
D
Feedback
With aging, alveoli become less elastic and more fibrous.
With aging, the chest wall may become stiffer, possibly because of calcification at
rib articulation points, resulting in decreased chest wall compliance.
Diminished strength of the respiratory muscles results in reduced maximal
inspiratory and expiratory force.
The anteroposterior diameter increases with aging due to kyphoscoliosis.
DIF: Cognitive Level: Understand REF: 516
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Aging Process
4. During an office visit, a 78-year-old woman is upset because her height is “2 inches less than
it was when I was 40!” How does the nurse explain this change to the patient?
a. “Reduced height may occur as you age due to shortening of the vertebrae.”
b. “You may be experiencing this height change due to arthritis.”
c. “You need to improve your posture by performing stretching exercises.”
d. “This is a rare occurrence and warrants having a bone density test.”
ANSWER: A
A
B
C
D
Feedback
Decreased bone formation reduces height in most older adults, which may cause
shortening of the vertebrae and thinning of the vertebral disks.
Decreased bone formation reduces height in most older adults and is not due to
arthritis.
This is appropriate advice, but is not related the patient’s height.
This is an expected occurrence and does not warrant concern.
DIF: Cognitive Level: Apply REF: 516
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Aging Process
5. In collecting a history from an older adult, which information does the nurse consider least
essential for a patient of this age?
a. Past health history
b. Genogram
c. Functional abilities
d. Mental health
ANSWER: B
A
B
Feedback
Past health history is important to document the patient’s chronic illnesses.
A genogram is not routinely used to document the family history for an older
C
D
adult. The health status and cause of death of the patient’s parents and siblings
lose value as the patient ages.
Assessing functional abilities provides data about how well the patient performs
activities of daily living.
Mental health data are essential to collect about all patients regardless of age.
DIF: Cognitive Level: Understand REF: 517
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Aging Process
6. In assessing the mood of older adult patients, a nurse documents which finding as abnormal?
a. Sadness and grief after returning from the funeral of a long-time friend
b. Depression that interferes with the ability to perform activities of daily living
c. Frustration about rearranging the day’s schedule to attend a grandson’s birthday
party
d. Crying about the unexpected death of a pet that had been with the family 12 years
ANSWER: B
A
B
C
D
Feedback
Emotional experiences of sadness, grief, response to loss, and temporary “blue”
moods are normal responses in older adults.
Persistent depression that interferes significantly with the ability to function is not
an expected finding.
This is a normal response for any adult.
Emotional experiences of sadness, grief, response to loss, and temporary “blue”
moods are normal responses in older adults.
DIF: Cognitive Level: Apply REF: 518
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
7. When assessing the pain level of an older adult, a nurse considers which factor?
a. Neural transmission of pain is increased as a part of the aging process.
b. Older adult patients are not reliable in their descriptions of pain and how it affects
them.
c. Physiologic indicators of pain that are unique to older adults are tachycardia and
hypotension.
d. The older adult may believe that pain is a factor of aging and not worth mentioning.
ANSWER: D
A
B
C
D
Feedback
Neural transmission is the same for older and younger adults.
Becoming older does not diminish one’s ability to describe pain.
The physiologic indicators are the same for older and younger adults.
Some older adults may perceive pain as an expected aspect of aging that they
must endure.
DIF: Cognitive Level: Apply REF: 519
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Aging Process
8. A nurse is assessing the pain of an 86-year-old man who had hip surgery recently. The patient
has been slightly confused since his surgery, but he responds to simple questions. What is the
best way to assess this patient’s pain?
a. Ask him to rate his pain on a scale of 0 to 10.
b. Ask him to rate his pain using a list of descriptive adjectives.
c. Ask him to rate his pain using a vertical numeric scale.
d. Observe his behavior and measure his vital signs.
ANSWER: C
A
B
C
D
Feedback
This scale is appropriate for adolescents and adults, but older adults are assessed
more accurately with a scale that they can see.
This method is not effective for assessing pain because adjectives have different
meanings to different people. It is best to use a scale or pictures of faces.
Pain assessment in older adults is significantly improved by using a vertical
numeric scale or pain faces.
Patient behavior and vital signs are not accurate ways to assess a patient’s
perception of pain.
DIF: Cognitive Level: Apply REF: 519
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Aging Process
9. What finding does a nurse look for when assessing the skin of an older adult with solar
lentigo?
a. Yellowish, thin papules with a central depression
b. Pigmented, raised, wartlike lesions on the face or trunk
c. Small, soft, pigmented tags of skin on the face and neck
d. Irregular, flat, deeply pigmented macules on sun-exposed areas
ANSWER: D
A
B
C
D
Feedback
Yellowish, thin papules with a central depression is a description of sebaceous
hyperplasia.
Pigmented, raised, wart-like lesions on the face or trunk is a description of
seborrheic keratosis.
Small, soft, pigmented tags of skin on the face and neck is a description of
acrochordon (skin tags).
Irregular, flat, deeply pigmented macules on sun-exposed areas is a description of
solar lentigo.
DIF: Cognitive Level: Apply REF: 522
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Aging Process
10. When assessing the skin of an older adult, a nurse notices pigmented, raised warty-appearing
lesions on the trunk. How does a nurse document this finding?
a. Solar lentigo
b. Basal cell skin cancer
c. Seborrheic keratosis
d. Sebaceous hyperplasia
ANSWER: C
A
B
C
D
Feedback
Solar lentigo appears as irregularly shaped, flat, deeply pigmented macules that
may appear on body surface areas with repeated exposure to the sun.
Basal cell carcinoma appears as a nodular pigmented lesion with a depressed
center and rolled borders found on sun-exposed areas.
Seborrheic keratosis is described as pigmented, raised warty-appearing lesions on
the trunk.
Sebaceous hyperplasia appears as yellowish, flattened papules that have central
depressions.
DIF: Cognitive Level: Understand REF: 523
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Aging Process
11. In assessing the nails of an older adult, which finding does a nurse expect to find?
a. Transverse ridges
b. Thick, brittle, and yellow nails
c. Thin, brittle nails
d. Lateral edges turned upward
ANSWER: B
A
B
C
D
Feedback
These changes occur when the patient has had nail trauma.
Thick, brittle, and yellow nails are expected changes in the nails of older adults.
These changes occur when the patient has anemia.
This change, called spoon nail, occurs when the patient has anemia.
DIF: Cognitive Level: Understand REF: 523
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Aging Process
12. In assessing the external eyes of an older adult, a nurse documents which finding as
abnormal?
a. Gray-white circle where the cornea and the sclera merge
b. Brown spots near the limbus in both eyes
c. Lack of luster of the eye and dry bulbar conjunctiva
d. Lower lid drops away from the globe
ANSWER: D
Feedback
A
B
C
D
This is a description of arcus senilis.
This is a description of a normal variation.
This occurs because the lacrimal apparatus may function poorly, producing fewer
tears.
This is a description of ectropion, an abnormal finding.
DIF: Cognitive Level: Apply REF: 523-524
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
13. What is the best color for nurses to select when designing educational materials for older
adults?
a. Blue
b. Yellow
c. Violet
d. Green
ANSWER: B
A
B
C
D
Feedback
Color perception of blue, violet, and green may be impaired for older adults.
Color perception of blue, violet, and green may be impaired for older adults.
Color perception of blue, violet, and green may be impaired for older adults.
Color perception of blue, violet, and green may be impaired for older adults.
DIF: Cognitive Level: Understand REF: 523
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Aging Process
14. A 75-year-old man reports he stopped playing cards with his friends because their voices
sounded mumbled. How does the nurse explain the cause of this change?
a. Sudden low-frequency hearing loss
b. Accumulation of earwax in the outer ear
c. Damage to the middle ear from ear infections
d. Gradual high-frequency hearing loss
ANSWER: D
A
B
C
D
Feedback
This does not describe presbycusis and is not an expected change with aging.
This does not describe presbycusis and is not an expected change with aging.
This does not describe presbycusis and is not an expected change with aging.
This is a description of presbycusis, a sensorineural hearing loss, and an expected
change with aging.
DIF: Cognitive Level: Apply REF: 524
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Aging Process
15. Which finding on cardiovascular assessment of an older adult patient warrants further
evaluation?
a. Occasional ectopic beats heard on auscultation of the heart
b. Murmur heard over the mitral valve
c. Systolic pressure of 156 in the right arm and 188 in the left arm
d. Persistent S 4 sound in a patient with a history of decreased ventricular function
ANSWER: C
A
B
C
D
Feedback
Occasional ectopic beats are common and may or may not be significant.
Sclerosis of the mitral and aortic valves may cause murmurs.
These systolic pressures are above normal and require further evaluation.
The S 4 heart sound is common in older adults and may be associated with
decreased left ventricular compliance.
DIF: Cognitive Level: Apply REF: 521-522
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
16. The nurse notes which finding as expected during a history and examination of an older adult
patient’s abdomen?
a. Hyperactive bowel sounds in all quadrants
b. Decreased fatty deposits over the abdomen
c. Marked concavity of the abdominal contour
d. Soft abdomen on palpation in all quadrants
ANSWER: D
A
B
C
D
Feedback
The opposite is true; decreased peristalsis causes hypoactive bowel sounds.
The opposite is true; older adults may have increased fat deposits over the
abdominal area.
The opposite is true due to the increased fat deposits over the abdominal area.
The abdomen of older adults may feel soft due to decreased abdominal muscle
tone.
DIF: Cognitive Level: Understand REF: 525
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Aging Process
17. Which approach does a nurse use to assess neck range of motion of an older adult patient?
a. Have the patient perform each neck movement separately.
b. Defer range of motion examination if the patient has kyphosis.
c. Ask the patient to turn the head against the resistance of the nurse’s hand.
d. Ask the patient to rotate the head starting with forward flexion and moving
clockwise.
ANSWER: A
Feedback
A
B
C
D
The nurse should assess range of motion of the neck with one movement at a
time, rather than a full rotation of the neck, to avoid causing dizziness on
movement.
Assessing range of motion is important data to gather to determine how limited
the range is due to the kyphosis.
This technique tests muscle strength rather than range of motion.
This technique tests muscle strength rather than range of motion.
DIF: Cognitive Level: Apply REF: 525
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
18. A nurse asks an older adult patient to rise from an arm chair without using the arms, stand
with eyes closed, and turn around in a circle. What is the nurse assessing in this patient?
a. Ability to follow instructions
b. Muscle strength
c. Balance
d. Hearing
ANSWER: C
A
B
C
D
Feedback
Although following instruction is required for this balance assessment, it is not
the primary purpose of the assessment.
Muscle strength is tested by having the patient push or pull against resistance.
These are three of the activities of the Tinetti Balance and Gait Assessment Tool.
Although hearing is required for this balance assessment, it is not the primary
purpose of the assessment.
DIF: Cognitive Level: Analyze REF: 525-526
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
19. An older adult patient reports being able to see her granddaughter play basketball out of the
sides of her eyes, but not in the center of her eyes. Based on this information, what vision
disorder does the nurse suspect?
a. Presbyopia
b. Macular degeneration
c. Pseudoptosis
d. Entropion
ANSWER: B
A
B
C
Feedback
Presbyopia is a decrease in near vision that usually occurs after age 40 and is
treated with corrective lenses.
Gradual loss of central vision may be caused by macular degeneration due to
changes in the retina.
Pseudoptosis is a relaxed upper eyelid.
D
Entropion is a disorder of the eyelid, in which the lower lid turns inward.
DIF: Cognitive Level: Understand REF: 524| 528
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
20. The nurse examining the breasts of an older adult woman recognizes which finding as
normal?
a. Firm and rounded breasts of equal size and shape
b. Relatively large size and number of mammary ducts
c. Loose elasticity and puckering of the suspensory ligaments
d. Flattened breasts with a slightly granular texture on palpation
ANSWER: D
A
B
C
D
Feedback
The breasts in postmenopausal women may appear flattened.
This is not a finding in older women.
The suspensory ligaments in older woman are relaxed, but not puckering.
The breasts in postmenopausal women may appear flattened and elongated or
pendulous secondary to a relaxation of the suspensory ligaments.
DIF: Cognitive Level: Understand REF: 525
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Aging Process
MULTIPLE RESPONSE
1. What expected physiologic changes of aging put older adults at risk for respiratory infections?
Select all that apply.
a. Breath sounds are bronchovesicular in the peripheral lung.
b. Alveoli are less elastic.
c. Weak intercostal muscles reduce effective coughing.
d. Fewer cilia make mucociliary clearance less effective.
e. Curvature of the spine limits chest wall expansion.
f. Cough reflex is impaired due to deceased sensitivity of receptors.
ANSWER: B, C, D, E
Correct: These are all expected findings of healthy older adults that impair their ability to
breathe deeply and cough to prevent or recover from a respiratory infection.
Incorrect: Breath sounds are the same as for younger adults—vesicular in the peripheral
lungs. Cough reflex is not changed in the older adult.
DIF: Cognitive Level: Analyze REF: 516| 524
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Aging Process
2. What risk factors for falls does a nurse teach a group of older adults? Select all that apply.
a. Being a woman
b. Taking more than six medications
c. Having hypertension
d. Having cataracts
e. Muscle strength 3/5 bilaterally
f. Incontinence
ANSWER: B, D, E, F
Correct: Adverse effects of medications can contribute to falls. Cataracts impair vision,
which is a risk factor for falls. Poor muscle strength is a risk factor for falls. Incontinence of
urine or stool increases risk for falls.
Incorrect: Men have a higher risk for falls than women. Hypertension itself does not
contribute to falls. Dizziness does contribute to falls.
DIF: Cognitive Level: Analyze REF: 528
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: Potential for
Alteration in Body Systems
Chapter 22: Conducting a Head-to-Toe Examination
Test Bank
MULTIPLE CHOICE
1. When does the health assessment begin?
a. When the nurse first meets the patient
b. When the patient tells the nurse his name and age
c. When the nurse asks the patient the first health-related question
d. When the patient consents to have a health assessment performed
ANSWER: A
A
B
C
D
Feedback
When the nurse and patient first meet, the nurse begins collecting data about the
patient.
Before this, the nurse began collecting data about the patient, such as gait,
posture, and hygiene.
Before this, the nurse began collecting data about the patient, such as gait,
posture, and hygiene.
Before this, the nurse began collecting data about the patient such as gait, posture,
and hygiene.
DIF: Cognitive Level: Understand REF: 531
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
2. Which assessments are routine examination techniques of the upper extremities?
a. Palpating the epitrochlear lymph nodes for size and tenderness
b. Palpating the arms for skin characteristics, symmetry, tenderness, and deformities
c. Testing the range of motion and muscle strength comparing one arm with the other
d. Testing triceps, biceps, and brachioradialis deep tendon reflexes bilaterally
ANSWER: B
A
B
C
D
Feedback
Lymph nodes are not palpated unless indicated.
Palpation of upper extremities is performed in a routine head-to-toe examination.
These data are not routinely assessed unless indicated.
These data are not routinely assessed unless indicated.
DIF: Cognitive Level: Understand REF: 533
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
MULTIPLE RESPONSE
This study source was downloaded by 100000838401522 from CourseHero.com on 03-03-2022 08:58:43 GMT -06:00
https://www.coursehero.com/file/20908986/c22/
1. Which data does a nurse collect during the general survey when meeting a patient for the first
time? Select all that apply.
a. Gait
b. Muscle strength
c. Heart sounds
d. Hearing and speech abilities
e. Mood or affect
f. Position of the trachea
ANSWER: A, D, E
Correct: These data are observed during the general survey as the patient enters the
examination area and greets the nurse.
Incorrect: Although the nurse could detect firmness in a patient’s handshake, muscle strength
testing is performed during the examination if indicated, not during the general survey. Data
about heart sounds are collected during auscultation of the chest. Position of the trachea is
determined by palpating the trachea during the examination.
DIF: Cognitive Level: Apply REF: 532
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
2. Which techniques does a nurse use routinely to collect data when assessing a patient’s
posterior thorax? Select all that apply.
a. Inspection of the thorax for symmetry of shoulders
b. Percussion the costovertebral angle bilaterally
c. Inspection of respiratory movement for symmetry, depth, and rhythm of respiration
d. Percussion of the posterior and lateral thorax for resonance
e. Palpation of vertebrae for alignment and tenderness
f. Inspection of thorax for muscular development and scapular alignment
ANSWER: A, C, E, F
Correct: These techniques are performed in a routine head-to-toe assessment of the posterior
thorax.
Incorrect: Percussion of the costovertebral angle bilaterally is not performed unless indicated.
For example, when the patient has a kidney disorder. Percussion of the posterior and lateral
thorax for resonance is not performed unless indicated.
DIF: Cognitive Level: Apply REF: 534
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
3. Which techniques does a nurse use routinely to collect data when assessing a patient’s anterior
thorax? Select all that apply.
a. Palpation of the thorax for fremitus
b. Inspection of the skin for color, intactness, lesions, and scars
c. Auscultation of breath sounds bilaterally
d. Auscultation of heart sounds for rate, rhythm, frequency, and S 1 and S 2
e. Palpation the anterior chest wall for thoracic expansion
f. Inspection of respiratory movement for symmetry and ease of respiration
This study source was downloaded by 100000838401522 from CourseHero.com on 03-03-2022 08:58:43 GMT -06:00
https://www.coursehero.com/file/20908986/c22/
ANSWER: B, C, D, F
Correct: These techniques are performed in a routine head-to-toe assessment of the anterior
thorax.
Incorrect: Palpation of the thorax for fremitus and palpation of the anterior chest wall for
thoracic expansion are not performed unless indicated.
DIF: Cognitive Level: Apply REF: 534
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
4. Which techniques does a nurse use routinely to collect data when assessing the abdomen of a
patient? Select all that apply.
a. Testing for presence of abdominal reflexes
b. Inspecting skin for contour, scars, lesions, vascularity, and bulges
c. Percussing in all quadrants for tone
d. Lightly palpating for tenderness, guarding, and masses
e. Auscultating for bowel sounds, bruits, and venous hums
f. Deeply palpating for tenderness, guarding, and masses
ANSWER: B, D, E
Correct: These techniques are performed in a routine head-to-toe assessment of the abdomen.
Incorrect: Testing for abdominal reflexes for presence, percussing in all quadrants for tone,
and deeply palpating for tenderness, guarding, and masses are not performed unless indicated.
DIF: Cognitive Level: Apply REF: 535
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
5. Which techniques does a nurse routinely use to collect data when assessing the lower
extremities of a patient? Select all that apply.
a. Inspecting of legs, ankles, and feet for skin characteristics and hair distribution
b. Assessing for knee stability with the drawer test, McMurray test, or Apley test
c. Palpating lower legs and feet for temperature, pulses, and tenderness
d. Assessing for nerve root compression with straight leg raises
e. Palpating hips for stability and tenderness
f. Testing for patellar and Achilles deep tendon reflexes bilaterally
ANSWER: A, C
Correct: These techniques are performed in a routine head-to-toe assessment of the lower
extremities.
Incorrect: Assessing for knee stability with the drawer test, McMurray test, or Apley test is
not performed unless indicated by knee instability. Assessing for nerve root compression with
straight leg raises is not performed unless indicated. Palpating hips for stability and tenderness
is not performed unless the patient has unstable hips. Testing for patellar and Achilles deep
tendon reflexes bilaterally is not performed unless indicated.
DIF: Cognitive Level: Apply REF: 535-536
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
This study source was downloaded by 100000838401522 from CourseHero.com on 03-03-2022 08:58:43 GMT -06:00
https://www.coursehero.com/file/20908986/c22/
Assessment
This study source was downloaded by 100000838401522 from CourseHero.com on 03-03-2022 08:58:43 GMT -06:00
https://www.coursehero.com/file/20908986/c22/
Chapter 23: Documenting the Head-to-Toe Health Assessment
Test Bank
MULTIPLE CHOICE
1. Which documentation by a nurse is most descriptive?
a. Heart sounds normal.
b. Few ectopic beats heard during auscultation.
c. S 1 murmur is heard at second right sternal border.
d. Pulse within normal limits.
ANSWER: C
A
B
C
D
Feedback
This information is not specific without a description of what is considered
“within normal limits” for hair color, texture, length, etc.
This description is not specific because the number of permanent teeth is not
detailed.
This is the most descriptive data, specifying what is heard and the location.
This description would be more descriptive if the pain scale were used to indicate
the level of tenderness and if the location on the abdomen were documented.
DIF: Cognitive Level: Apply REF: 540
TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Management of Care
2. The nurse documents which data under the category of present health status?
a. Heart sounds normal.
b. Few ectopic beats heard during auscultation.
c. Apical pulse palpated at 5th left intercostal space, midclavicular line
d. Pulse within normal limits.
ANSWER: D
A
B
C
D
Feedback
This information is not specific without a description of what is considered
“within normal limits” for heart sounds
This description is not specific
This is the most descriptive data, specifying what is heard and the location.
This description would be more descriptive such as which pulse and the rate
DIF: Cognitive Level: Apply REF: 538
TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Management of Care
3. Which data do nurses document under the category of past health history?
a. Chronic diseases
b. Immunizations received
c. Allergies to medications or food
d. Causes of death of the patient’s parents
ANSWER: B
.
.
A
B
C
D
Feedback
Chronic diseases are documented under the present health status category.
Immunizations are documented under the past health history category.
Allergies to medications or food are documented under the present health status
category.
Causes of death of parents are documented under the family history category.
DIF: Cognitive Level: Apply REF: 538
TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Management of Care
4. A patient reports she has shortness of breath and peripheral edema. Under which category
does the nurse document these data?
a. Review of systems
b. Present health status
c. Past health history
d. Functional ability
ANSWER: A
A
B
C
D
Feedback
In the review systems part of the history, the nurse asks patients whether they
have had symptoms from specific body systems. Patients either deny or admit to
having the symptoms.
The present health status category contains data on chronic diseases, medications,
and allergies.
The past health history category contains data on childhood diseases, surgeries
and hospitalizations, and immunizations.
The functional ability category contains data on patient’s activities, including
maintaining a home and working full-time.
DIF: Cognitive Level: Understand REF: 539
TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Management of Care
5. What data do nurses document under the category general survey?
a. Mental health
b. Functional ability
c. Diet and nutrition
d. Orientation
ANSWER: D
A
B
C
D
Feedback
Mental health is described under the heading of personal and psychosocial
history.
Functional ability data are collected during the history.
Diet and nutrition data are collected during the history.
The general survey is the beginning of the examination when the nurse is
collecting data about the patient.
DIF: Cognitive Level: Understand REF: 540
.
.
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Management of Care
MULTIPLE RESPONSE
1. Which data do nurses document under the category of personal and psychosocial health
history? Select all that apply.
a. Allergies to medications or food
b. Diet and foods eaten on a regular basis
c. Type of employment
d. Address and date of birth
e. Activities that promote health
f. Use of tobacco and alcohol
ANSWER: B, E, F
Correct: These data are documented under the heading of personal and psychosocial health.
Incorrect: Allergies to medications or food is documented under the present health status
category. Type of employment is documented under the heading of biographic data. Address
and date of birth are documented under the heading of biographic data.
DIF: Cognitive Level: Apply REF: 539
TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Management of Care
.
.
Chapter 24: Adapting Health Assessment to the Hospitalized Patient
Test Bank
MULTIPLE CHOICE
1. Development of which complication is considered a never event?
a. Fever
b. Atelectasis
c. Pressure ulcer
d. Thrombophlebitis
ANSWER: C
A
B
C
D
Feedback
Fever is a common occurrence in ill patients that may indicate inflammation or
infection.
Atelectasis is collapse of alveoli that may occur due to the patient’s
hypoventilation, such as after surgery.
Pressure ulcer is termed a never event because it refers to preventable, medical
errors that should never occur.
Thrombophlebitis is inflammation of veins that may occur due to immobility.
DIF: Cognitive Level: Understand REF: 545
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
2. For which patient does the nurse make assessment of the oral mucous membrane a priority?
a. The patient who has an arteriovenous (AV) fistula
b. The patient who has a gastrostomy tube
c. The patient who uses a Ventimask
d. The patient who has a colostomy
ANSWER: B
A
B
C
D
Feedback
The AV fistula is required by patients who need hemodialysis for kidney failure.
They are able to drink fluids by mouth.
Which patient can drink fluids by mouth is the distinguishing fact. This patient
has this gastrostomy tube because he or she has difficulty swallowing. Thus this
patient may not have fluids by mouth, which increases the risk for dry mucous
membranes and makes the assessment most important compared with the other
listed patients.
The Ventimask fits over the nose and mouth to deliver oxygen. This patient is
able to drink fluids by mouth.
This patient has had part or all of the colon removed, but this patient is able to
drink fluids by mouth.
DIF: Cognitive Level: Apply REF: 550
TOP: Nursing Process: Assessment
.
https://www.coursehero.com/file/20908983/c24/
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
3. How does a nurse assess perfusion to the foot when a patient has a cast from the left middle
calf to the toes?
a. Palpate the popliteal pulse of the left leg.
b. Palpate the posterior tibial pulse of the left leg.
c. Assess movement and sensation of the left toes.
d. Assess the capillary refill of the left toes.
ANSWER: D
A
B
C
D
Feedback
This pulse is above the foot and does not indicate perfusion of the foot.
The pulse is not palpable because it is covered by the cast.
This assessment is important for this patient but assesses neurologic function
rather than perfusion.
The presence of capillary refill in less than 2 seconds indicates perfusion of the
left foot when the dorsalis pedis pulse cannot be palpated.
DIF: Cognitive Level: Understand REF: 553
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
4. A nurse uses the Glasgow Coma Scale to assess which patient?
a. The patient who has a new onset of quadriplegia
b. The patient who has tonic-clonic seizures
c. The patient who requires stimuli for responses
d. The patient who has dementia
ANSWER: C
A
B
C
D
Feedback
Although this patient is paralyzed, he or she is conscious. The Glasgow Coma
Scale would not yield useful data about this patient.
Although this patient may be unconscious during seizures, consciousness will
return. The Glasgow Coma Scale would not yield useful data about this patient.
The Glasgow Coma Scale is applicable only to patients who are unconscious,
meaning they do not respond unless stimulated in some way from touch to pain.
This patient is not unconscious. The Glasgow Coma Scale would not yield useful
data about this patient.
DIF: Cognitive Level: Apply REF: 555-556
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
5. During the assessment, the nurse determines that the patient’s Glasgow Coma Scale score is
15. What is the meaning of this number for this patient?
a. This patient is fully conscious.
.
https://www.coursehero.com/file/20908983/c24/
b. This patient has movement but does not open the eyes or speak.
c. This patient is unable to respond to any stimuli.
d. This patient opens the eyes but does not speak or move.
ANSWER: A
A
B
C
D
Feedback
A score of 15 is the expected value for the Glasgow Coma Scale.
This patient would score a 9 on the Glasgow Coma Scale.
This patient would score a 3 on the Glasgow Coma Scale.
This patient would score a 4 on the Glasgow Coma Scale.
DIF: Cognitive Level: Understand REF: 556
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific
Assessments
6. When performing a neurologic assessment of a male patient, a nurse discovers that shouting
and shaking are necessary to arouse the patient enough to assess his neurologic status. After
the patient answers questions about who he is and squeezes the nurse’s hand as requested, he
returns to “sleep.” How does the nurse document this patient’s level of consciousness?
a. Lethargic
b. Obtunded
c. Stuporous
d. Semicomatose
ANSWER: B
A
B
C
D
Feedback
Lethargic patients can be aroused by saying their names and touching them.
Obtunded patients require shouting and vigorous shaking to arouse them; they
carry out requests while awake, but return to “sleep” when stimuli stops.
Stuporous patients require painful stimuli to respond and the response usually is a
withdrawal from the source of pain.
Semicomatose patients require painful stimuli and respond with abnormal flexion
or extension.
DIF: Cognitive Level: Understand REF: 555
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
MULTIPLE RESPONSE
1. What data do nurses collect when assessing a patient’s wound? Select all that apply.
a. Skin turgor
b. Width, length, and depth
c. Presence of pulsations
d. Wound color
e. Presence of edema
f. Drainage color
ANSWER: B, D, E, F
Correct: These data are collected when assessing a wound.
Incorrect: Skin turgor is assessed in intact skin rather than wounds. Presence of pulsations is
not indicated when assessing a wound.
DIF: Cognitive Level: Understand REF: 546
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
2. Which patient using respiratory equipment requires skin assessment? Select all that apply.
a. A patient using a nasal cannula
b. A patient with a tracheostomy
c. A patient using an incentive spirometer
d. A patient using a Ventimask
e. A patient with an IV
ANSWER: A, B, D
Correct: Patients using a nasal cannula need inspection of the nares and behind the helix of
the ears. Patients with a tracheostomy need inspection of skin around the stoma where the
tracheostomy tube enters the trachea. Patients using a Ventimask need inspection of skin
where the mask comes in contact with the face and behind the helix of the ears. Patients with
IVs need inspection of the skin to verify the catheter is secured and to assess for redness or
edema.
Incorrect: Using an incentive spirometer requires the patient to take deep breaths, thus a skin
assessment is not indicated.
DIF: Cognitive Level: Understand REF: 547-548
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
3. Which tube interferes with hearing lung sounds during auscultation? Select all that apply.
a. Gastrostomy tube
b. Chest tube
c. Nasogastric tube
d. Tracheostomy tube
e. Oral endotracheal tube
ANSWER: B, C
Correct: When attached to suction, chest and nasogastric tubes can create sounds that may
mimic lung sounds.
Incorrect: Gastrostomy tube is in the stomach and not attached to suction that might create a
false sound similar to lung sounds. Tracheostomy tube is not attached to suction that might
create a false sound similar to lung sounds. Oral endotracheal tubes are not attached to suction
that might create a false sound similar to lung sounds.
DIF: Cognitive Level: Understand REF: 548| 551
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
Test Bank for Health Assessment for
Nursing Practice 7th Edition by Wilson
This is a bank of tests (study questions) to help you
prepare for the tests.
To clarify, this is a test bank, not a textbook.
You have immediate access to download your test
bank. No
delays, loading is fast and instant immediately after
Purchase!
You will receive a full bank of tests; in other words, all
chapters will be there.
Test banks are presented in PDF format; therefore,
no special software is required to open them