Exam 1: NCLEX Style Study Questions

1. A mother of three is being seen for a screening assessment. While planning the initial part of the visit with this patient, the nurse
needs to ensure that:

1. The patient receives a refill for her thyroid medication.

2. The patient is instructed on preventive measures for hypertension.

3. Other family members are present during the interview.

4. Information about the patient’s lifestyle habits is gathered.

Rationale:

2. A nurse is assessing a female teenager. The nurse asks the young woman to bend over and touch her toes. The nurse assesses the
curvature of the spine as a means of detecting scoliosis. Assessing the curvature of the spine is an example of:

A. Health education
B. Primary prevention
C. Secondary prevention
D. Tertiary prevention

Rationale:

3. Health hxs can provide nurses with data needed for appropriate care. Nurses obtaining a health hx should:

1. Help the patient identify personal beliefs about health.

2. Assess vital signs.

3. Inquire about activities that can affect financial stability.

4. Explain patient rights and responsibilities.

Rationale:

4. Because a nurse seeks to create a patient-centered interview process, the nurse will:

1. Ask the patient, “Do you suffer from any arthralgias?”

2. Give the patient as little information as possible to avoid fear.

3. Ask the patient, “Can you please tell me more about your spells?”

4. Inform the patient, “You do not have to share anything with me that makes you uncomfortable.”

Rationale:
5. Preparation for an interview with a patient requires thoughtful consideration of the physical environment. As the physical space is
arranged:

1. Desks should not be used because they bestow too much “power” on the interviewer.

2. Desks are usable as long as they are not a barrier between interviewer and interviewee.

3. Interviewer eye level should be six inches lower than interviewee eye level.

4. Interviewer eye level should be six inches higher than interviewee eye level.

Rationale:

6. Collection of objective data from a patient with a swollen left elbow includes which piece of equipment?

1. Magnifier

2. Blood pressure cuff

3. Snellen chart

4. Goniometer

Rationale:

7. The nurse is working in a primary care clinic. She walks into the room, and the general inspection begins. What is not part of the
general inspection?

A. Patient’s facial expressions are consistent with verbalized emotions.

B. Patient is wearing clothes that are normally worn by Whites.
C. Patient is staring down at the floor through most of the interview.
D. Patient’s gait is strong and symmetrical.

Rationale:

8. The nurse collects patient data through assessment of vital signs. Many nurses will delegate the performance of temperature data
collection to unlicensed assistive personnel. As the nurse talks to the assistant, the nurse knows to teach that:

1. Tympanic thermometers touch the tympanic membrane.

2. Axillary temperatures are taken with the red probe on the electronic thermometer.

3. Axillary temperatures are usually most accurate because of the local blood supply.

4. Rectal thermometers are placed 2.5 cm to 3.8 cm into the rectum.

Rationale:
9. Staff development educators are responsible for assisting staff nurses in being adequately prepared to perform their duties as they
care for patients from many different cultures and backgrounds. As the educator works with a new nurse from the Philippines, the
educator will include:

1. Training on American food choices.

2. Assistance with competency in skin lesions on dark skin.

3. Practice in assessing patients’ personal beliefs and practices.

4. Information on immigration and privacy laws.

Rationale:

10. Initiation of intravenous access can be a painful experience for the patient. As the needle is inserted into skin, the patient is calm.
However, when the needle pierces the vein, the patient pulls the hand away. The time that the person endured the pain before
outwardly responding is known as:

1. Pain tolerance.

2. Pain intolerance.

3. Pain perception.

4. Pain threshold.

Rationale:

11. Assessment of circulation, motion, and sensation is done every 8 hours in a patient recovering from a laminectomy, three days
after surgery. The patient had the surgery for consistent low back pain. Now on day 3, the patient has a burning sensation on the
lateral edge of the right foot. This is best described as:

A. Cellulitis.
B. Nociceptive pain.
C. Fasciitis.
D. Neuropathic pain.

Rationale:

12. During the initial intake, the nurse asks the patient a series of questions. When asked how long he has been working in real estate,
the patient responds by saying, “I think 5 years. My dad was in real estate, but my mom worked in an office. I like offices because
they are usually organized and neat. My son is very messy, but he is good at guitar. Do you play any musical instruments?” The
nurse should document that the patient:

A. Appears concerned about son.

B. Suffers from manic disorder.
C. Demonstrates flight of ideas.
D. Is able to multitask but struggles with echolalia.

Rationale:
13. Patients needing dialysis treatments require careful monitoring of their dietary intake. The nurse works with the dietitian in an
effort to help patients manage intake to optimize dialysis treatment and overall outcomes. The best technique to accurately assess
dietary intake is:

1. 24-hour recall.

2. Typical food intake.

3. Food frequency questionnaire.

4. Comprehensive diet history.

Rationale:

14. The doctor exits the room and then discusses with the nurse the signs of protein deficiency in the patient’s diet. These signs and
symptoms include:

1. Skin that is dry, scaling, and bruised.

2. Hypo-pigmented hair and abdominal edema.

3. Bone pain and arthralgia.

4. Diarrhea, oily skin, and stomatitis.

Rationale:

Exam 2 NCLEX Style Questions

1. Before caring for the patient, the nurse reviews the test results. A chest radiographic report shows that there is atelectasis in the
right base. During lung auscultation, what would the nurse expect to find?
A. Increased fremitus in the right base.
B. Diminished breath sounds.
C. Wheezing throughout.
D. Symmetrical chest expansion.

Rationale:

2. The nurse is caring for a patient who is suffering from chronic obstructive pulmonary disease. He coughs frequently and produces
a thick white sputum. During auscultation, the stethoscope should be placed:
A. Over the scapula to enhance adventitious lung sounds.
B. So that it is barely touching the skin to avoid auditory artifact.
C. Over the left lung fields first.
D. In one position long enough to hear an entire inhalation-exhalation set.

Rationale:
3. A patient has been admitted to the medical-surgical unit for exacerbation of congestive heart failure. The nurse notes bilateral +2
pitting edema and dry scaling skin. As the nurse assesses the dorsalis pedis pulse, the nurse is unable to detect it and notes that both
feet are warm. What is the best action for the nurse to take?
A. Call the physician immediately.
B. Assess skin turgor over the clavicle.
C. Use a Doppler and assess capillary refill.
D. Use a Doppler and assess for renal artery stenosis.

Rationale:

4. In the cardiac unit, a patient awaits surgery for mitral valve repair. As the nurse auscultates the patient’s heart, the nurse will
expect to hear a murmur that is:
A. Most pronounced at the base of the heart.
B. Most pronounced over the carotid arteries.
C. Heard best at the left sternal border.
D. Heard best over the left midclavicular line.

Rationale:

5. A nurse practitioner is performing a routine check-up on an adult male. As she begins the abdominal assessment, she knows to:
A. Begin with observation of the patient’s general behavior.
B. Begin with palpation if the patient is in pain.
C. Ask the patient if he has noted any vascular sounds in the abdomen before.
D. Ask the patient to straighten his legs for the abdominal examination.

Rationale:

6. When percussing the kidneys for tenderness, the nurse should:

A. Start tapping at the level of T1.
B. Tap in the costal angle.
C. Use the direct or indirect method of percussion.
D. Know whether the patient has a history of cholelithiasis.

Rationale:

Exam 3 NCLEX Qs chapters 9,10, 14, & 15

1 A patient has edema and redness of the skin surrounding the nail on his right index finger. Which data
elicited from his history best explains this condition?
1) He has a family history of liver disease.
2) There has been a scabies outbreak among his family members.
3) He has a new full-time position as a dishwasher at a local restaurant.
4) He had several warts removed from his hands 2 years ago.

2 When examining a 16-year-old male patient, the nurse notes multiple pustules and comedones on the face.
The nurse recognizes that increased activity of which cells or glands produce these manifestations?
1) Epidermal cells.
2) Eccrine glands.
3) Apocrine glands.
4) Sebaceous glands.
3 A patient with darkly pigmented skin has been admitted to the hospital with hepatitis. What is the best way
for the nurse to assess for jaundice in this patient?
1) Jaundice is best seen in the sclera.
2) In dark-skinned persons, jaundice results in a darkening of genitalia.
3) Jaundice is best determined by blanching the fingernails.
4) Jaundice cannot be assessed in patients with darkly pigmented skin.

4 A patient has multiple solid, red, raised lesions on her legs and groin that she describes as "itchy insect
bites." How does the nurse document these lesions?
1) Wheals.
2) Bullae.
3) Tumors.
4) Plaques.

5 The nurse observes multiple red circular lesions with central clearing that are scattered all over the
abdomen and thorax. How does the nurse document the shape and pattern of these lesions?
1) Gyrate and linear.
2) Annular and generalized.
3) Iris and discrete.
4) Oval and clustered

6 Which disorder is an example of a vascular lesion?

1) Dermatofibroma
2) Vitiligo
3) Sebaceous cyst
4) Port wine stain
7 A 60-year-old male patient states that he has a sore above his lip that has not healed and is getting bigger.
The nurse observes a red scaly patch with an ulcerated center and sharp margins. These findings are
commonly associated with which malignancy?
1) Kaposi's sarcoma.
2) Malignant melanoma.
3) Basal cell carcinoma.
4) Squamous cell carcinoma.

8 A 48-year-old woman asks the nurse how to best protect herself from excessive sun exposure while at the
beach. Which response would be most appropriate?
1) "Limit your time in the sun to 5 minutes every hour.
2) "Wear a wet suit that covers your arms and legs."
3) "Apply a waterproof sunscreen (SPF 15 or higher) to exposed skin surfaces; reapply at least every 2 hours."
4) "Apply sunscreen with a minimum SPF 50 to all skin surfaces before leaving for the beach; this will provide all-
day coverage."
9 The nurse is performing a skin assessment on a patient in pain. Which skin layer contains sensory fibers
that react to touch, pain, and temperature?
1) The epidermis
2) The dermis
3) The hypodermis
4) The subcutaneous tissue

10 The nurse knows that the functions of the skin include: Select all that apply:
1) Sensory input
2) Protection
3) Production of Vitamin D
4) Temperature regulation
5) Production of Vitamin C
6) Sensory output

11 The nurse is performing a skin assessment and finds that the patient has milia. In which age group would
this be an expected finding?
1) Newborn
2) Young children
3) Adolescents
4) Older adults

12 A patient is concerned because the dermatologist diagnosed macules all over the skin. The patient asks the
nurse what could be causing this? The nurse's best response is:
1) "Macules need to be watched closely for signs of skin cancer."
2) "Macules are warts and should be removed."
3) "Macules are freckles are considered normal on the skin."
4) "You have an infection and will need an antibiotic."

13 The nurse is assessing an African-American patient for cyanosis. Cyanosis in dark pigmented skin appears
as a(n):
1) Yellowish-green skin
2) Deeper tone of brown or purple
3) Ashen gray color to the skin
4) Cluster of dark spots over the skin surface

14 The nurse is assessing a patient for nail clubbing. Where should the nurse focus the exam?
1) The width of the nail base
2) The color of the nail
3) The thickness of the nail
4) The angle of the nail base
15 A patient comes to the clinic for a skin check. Which finding by the nurse indicates a need to further
investigate a lesion?
1) The lesion is dark brown.
2) The lesion has been present for 20 years.
3) The lesion bleeds easily when it is touched.
4) The lesion is slightly raised and circumscribed.

16 The nurse is performing a skin check on a patient. In which age group is seborrheic keratosis an expected
finding?
1) Newborns
2) Young children
3) Adolescents
4) Older adults

17 The nurse is teaching a parent about risk factors associated with the skin for their school-age child. What
would the nurse include as the most common cause of skin lesions for this age group?
1) Communicable disease and bacterial infection
2) Changes in skin turgor and skin tone
3) Maturation of melanocytes, causing changes in skin color
4) Skin inflammation from sebaceous gland activity

18 The nurse is assessing a patient's skin turgor. Skin turgor is assessed by:
1) Auscultating the skin to note the presence of motility sounds
2) Pressing on the skin and observing the depression
3) Stretching the skin and observing for a degree of flexibility
4) Pinching the skin and watching the skin return to place

Chapter 10

1. A patient describes a recent onset of frequent and severe unilateral headaches that last about 1 hour. Based
on these symptoms, the nurse suspects which type of headache?
1. Cluster headaches
2. Migraine headaches
3. Tension headache
4. Sinus headache

2. During a physical examination, the nurse is unable to feel the patient's thyroid gland with palpation. What
is the appropriate action of the nurse at this time?
1. Recognize that this is an expected finding.
2. Auscultate the thyroid area.
3. Percuss the anterior neck for thyroid span.
4. Refer the patient for follow-up with an endocrinologist.
3. A 24-year-old female patient has a 2-day history of clear nasal drainage. Based on these data, which
question is the most logical for the nurse to ask?
1. "Is there a foul odor coming from your nose?"
2. "Have you recently had nosebleeds?"
3. "Do you snore when sleeping?"
4. "Do you have allergies?"

4. A 32-year-old woman has a 4-day history of sore throat and difficulty swallowing. The nurse observes
tonsils covered with yellow patches. The tonsils are so large that they fill the entire oropharynx and appear
to be touching. How does the nurse document these findings?
1. "Tonsils yellow and swollen."
2. "Enlarged tonsils 4+ with yellow exudate."
3. "Strep infection to tonsils with 3+ swelling."
4. "1+ edema of tonsils with pus."

5. A nurse is obtaining a health history from a 52-year-old male patient with a red lesion at the base of the
tongue. What additional data does the nurse specifically collect about this patient?
1. Alcohol and tobacco use
2. The date of his last dental examination
3. The presence of dentures
4. A history of pyorrhea

5. While talking with a patient, the nurse suspects that he has hearing loss. Which examination technique is
most accurate for assessing hearing loss?
1. Whispered voice test
2. Rinne test
3. Weber's test
4. Audiometry test
6. Which data from the health history of a 42-year-old man should be evaluated further as a possible risk for
hearing loss?
1. "I watch tv in the evenings with my wife and children."
2. "When i was younger, i wore an earring."
3. "My primary hobby is carpentry work."
4. "I have been an accountant for 16 years for an insurance agency."

7. The nurse examines a patient's auditory canal and tympanic membrane with an otoscope. Which finding is
considered abnormal?
1. Presence of cerumen
2. Yellow or amber color to the tympanic membrane
3. Presence of a cone of light
4. Shiny, translucent tympanic membrane
8. During the history the patient indicates that her eyes have been red and itching. Which additional question
does the nurse ask?
1 "Have you ever had a detached retina?"
2 "Have you had the pressure in your eyes checked?
3 "Do you have seasonal allergies?"
4 "Do you also have double vision?"

9. How does the nurse assess a patient's consensual reaction?

1. By touching the cornea with a small piece of sterile cotton and observing the change in the pupil size
2. By observing the patient's pupil size when she or he looks at an object 2 to 3 feet away and then looks at an object
6 to 8 inches away
3. By shining a light into the patient's right eye and observing the pupillary reaction of the left eye
4. By covering one eye with a card and observing the pupillary reaction when the card is removed

10. What are the characteristics of lymph nodes in patients who have an acute infection?
1. They are enlarged and tender.
2. They are round, rubbery, and mobile.
3. They are hard, fixed, and painless.
4. They are soft, mobile, and painless.

11. Which technique is used for palpating lymph nodes?

1. Apply firm pressure over the nodes with the pads of the fingers.
2. Apply gentle pressure over the nodes with the tips of the fingers.
3. Apply firm pressure anterior to the nodes with the tips of the fingers.
4. Apply gentle pressure over the nodes with the pads of the fingers.

12. A patient is complaining of difficulty hearing. Which structure of the ear stimulates the acoustic nerve?
1. The tympanic membrane
2. The ossicle
3. The organ of corti
4. The tragus
13. The nurse is assessing a patient's mandible. The area between the sternocleidomastoid muscles and the
mandible is anatomically known as the:
1. Anterior neck
2. Thyroid
3. Anterior triangle
4. Cervical lymph nodes of the neck

14. The nurse is assessing a patient's optic disc. What instrument would be best for this assessment?
1. The optic disc is viewed with an ophthalmoscope.
2. The optic disc is viewed with a stethoscope.
3. The optic disc is viewed with an otoscope.
4. The optic disc is viewed by the naked eye.

15. The nurse is aware that the greatest physical variation of ears in individuals of different races is:
1. The size of the ear
2. Hearing acuity
3. Consistency and color of cerumen
4. The length of the auditory canal

16. The nurse suspects that a female patient is having trouble with the thyroid when the patient answers yes to
which question?
1. "how much alcohol do you drink?"
2. "have you noticed a change in your level of energy?"
3. "do you have headaches?"
4. "are you currently menstruating?"

17. The nurse is treating a patient for a nosebleed. The patient complains of frequent nosebleeds. What could
be a possible cause of the nosebleeds?
1. Excessive cilia
2. Tobacco use
3. Snorting cocaine
4. Hypotension

18. The nurse is assessing a patient for confrontation. The confrontation test assesses:
1. Visual acuity
2. Peripheral vision
3. Extraocular muscle movement
4. Red reflex

19. The student nurse is learning how to use the ophthalmoscope. When performing an ophthalmoscope
examination, examine the patient's right:
1. Eye with your right eye and the patient's left eye with your left eye
2. Eye with your left eye, and the patient's left eye with your right eye
3. And left eyes with your dominant eye
4. And left eyes with your non-dominant eye

20. The nurse is documenting in the chart. For documentation purposes, which term is used to describe a head
that is of average size and shape?
1. Normocephalic
2. Microcephalic
3. Macrocephalic
4. Hydrocephalic

21. The nurse is asking the patient to stick out his tongue and move it back and forth. Which cranial nerve is
the nurse testing?
1. Hypoglossal nerve (cn xii)
2. Vagus nerve (cn x)
3. Facial nerve (cn vii)
4. Olfactory nerve (cn i)
Chapter 11

1. A nurse suspects a viral infection or upper respiratory allergies when the patient describes the sputum as
being which color?
1) White
2) Clear
3) Yellow
4) Pink tinged

2. During inspection of the respiratory system the nurse documents which finding as abnormal?
1) Skin color consistent with patient's ethnicity
2) 1:2 ratio of anteroposterior to lateral diameter
3) Anterior costal angle is 85 degrees
4) Patient leaning forward with arms braced against the knees

3. A patient has an infection of the terminal bronchioles and alveoli that involves the right lower lobe of the
lung. Which abnormal findings are expected?
1) Dyspnea with diminished breath sounds bilaterally
2) Asymmetric chest expansion on the right side
3) Fever and tachypnea with crackles over the right lower lobe
4) Prolonged expiration with an occasional wheeze in the right lower lobe

4. On auscultation of a patient's lungs, the nurse hears a low-pitched, coarse, loud, and low snoring sound.
Which term does the nurse use to document this finding?
1) Rhonchi
2) Wheeze
3) Crackles
4) Pleural friction rub
5. Which question gives the nurse further information about the patient's complaint of chest pain?
1) "Have you had your influenza immunization this year?"
2) "Are there environmental conditions that may affect your breathing at home?"
3) "How would you describe the chest pain?"
4) "Has the chest pain been interrupting your sleep?"

6. Which finding does the nurse expect when performing tactile fremitus?
1) A vibration of sounds that are equal bilaterally
2) A change in muscle tone when the patient inhales and exhales, indicating weakness
3) The symmetric rise of the thorax as the patient speaks, indicating equal expansion
4) Coughing triggered by patient speech, indicating bronchial irritation

7. How does the nurse palpate the chest for tenderness, bulges, and symmetry?
1) Uses the fist of the dominant hand to gently tap the anterior, lateral, and posterior chest, comparing one side with
another
2) Uses the ulnar surface of one hand to palpate the anterior, posterior, and lateral chest, comparing one side with
another
3) With the tips of the fingers, palpates the skin over the chest and the alignment of vertebrae
4) With the palmar surface of fingers of both hands, feels the consistency of the skin over the chest and the alignment
of vertebrae

8. Which breath sounds are expected over the posterior chest of an adult?
1) Vesicular
2) Bronchovesicular
3) Bronchial
4) Bronchoalveolar

9. Narrowing of the bronchi creates which adventitious sound?

1) Wheeze
2) Crackles
3) Rhonchi
4) Pleural friction rub

10. Which finding may indicate abnormal thoracic expansion?

1) A 4-cm diaphragmatic excursion
2) A 1:2 ratio anteroposterior to lateral diameter
3) An S-shaped curvature of the spine
4) A costal angle of 85 degrees

11. The student nurse is reviewing the pathophysiology of inspiration. The primary muscles of inspiration are
the diaphragm and the ____________?
1) Pectoral muscles
2) External intercostal muscles
3) Abdominal muscles
4) Scalene muscles

12. A patient complains to the nurse of coughing up green phlegm and is having difficulty breathing at rest.
The nurse suspects:
1) A viral infection
2) Tuberculosis
3) Pulmonary edema
4) Bacterial pneumonia

13. The nurse assesses a patient who has a costal angle greater than 90 degrees. What is the most likely cause of
this finding?
1) Chronic obstructive pulmonary disease
2) Pneumothorax
3) Infant respiratory distress syndrome
4) Atelectasis
14. The nurse auscultates prolonged expiration with expiratory wheezing and diminished breath sounds while
assessing a patient. What does the nurse suspect?
1) Tuberculosis
2) Pneumonia
3) Croup
4) Asthma

15. The nurse is palpating a patient's chest wall. What can be accomplished with palpation of the chest?
1) Approximation of lung size
2) Determination of oxygenation
3) Assessment of equal chest expansion
4) Identification of lung sounds

16. The nurse percusses a patient's chest and feels dullness. The nurse suspects which diagnosis?
1) Emphysema
2) Pneumonia
3) Bronchiectasis
4) Chronic obstructive pulmonary disease (COPD)

17. A nurse hears inspiratory and expiratory wheezes bilaterally. What is the meaning of this finding?
1) Consolidation in alveoli
2) Narrowed airways
3) Sputum in the bronchi
4) Fluid in the alveoli

18. A nurse hears bronchovesicular sounds in the posterior chest on either side of the spine. This finding
indicates:
1) A normal finding
2) Pneumonia
3) Lung cancer
4) Pleural effusion

19. The examiner notes a diaphragmatic excursion of 4 cm on the right side and 8 cm on the left side. What do
these findings mean?
1) The patient may have a pleura effusion.
2) The patient may have a pneumothorax.
3) Asymmetric findings are common in well-conditioned adults.
4) This is a normal finding because the right lung is larger than the left lung.

20. During an assessment, the nurse knows that expected assessment findings in the normal adult lung include
the presence of what? Select all that apply:
1) Adventitious sounds and limited chest expansion
2) Increased tactile fremitus and dull percussion tones
3) Muffled voice sounds and symmetric tactile fremitus
4) Absent voice sounds and hyperresonant perfusion tones
5) Symmetric chest
6) Resonant percussion tones
7) Expansion muffled voice sounds

Chapter 12

1. The nurse is listening to the patient's heart at the left sternal border (LSB) at the second intraclavicular
space (ICS). Which area is being auscultated?
1 Erb's point
2 Mitral area
3 Aortic area
4 Pulmonic area

2. A patient complains of pain in the calf when walking. Which question should the nurse ask for further
data?
1 "Does your calf also swell when this pain occurs?"
2 "Does the pain go away when you stop walking?"
3 "Do you become short of breath when you're walking?"
4 "Do you feel dizzy when the pain occurs?"

3. Which patient has the greatest risk for hypertension?

1 An Asian man who is 5 ft 5 in (165 cm) tall, weighs 125 lbs (56.7 kg), and complains of a headache over his
forehead and eyes
2 A Cheyenne Indian woman who complains of a gnawing, burning epigastric pain radiating to her neck and jaw
3 An African American man who has type 2 diabetes mellitus, exercises once a month, and drinks two-to-three
alcoholic drinks a night with dinner
4 A Caucasian woman who has a family history of heart disease and complains of pain in her chest when she takes a
deep breath
4. When a patient complains of chest pain, which question is pertinent to ask to gain additional data?
1 "What were you doing when the pain first occurred?"
2 "What does the pain feel like?"
3 "Do you have episodes of shortness of breath?"
4 "Has anyone in your family ever had a similar pain?"

5. How does a nurse determine jugular vein pulsations?

1 Elevates the head of the bed about 90 degrees and looks for the jugular vein pulsation parallel to the
sternocleidomastoid muscle as the head of the bed is slowly lowered
2 Looks for jugular vein pulsations at the jaw line as the patient turns from supine to a side-lying position
3 Elevates the head of the bed until the external jugular vein pulsation is seen above the clavicle
4 Positions the patient supine and asks him or her to cough; looks for jugular vein pulsations during the cough

6. Where does a nurse palpate to assess the posterior tibial pulse?

1 Behind the knee in the popliteal fossa
2 The inner aspect of the ankle below and slightly behind the medial malleolus
3 Over the dorsum of the foot between the extension tendons of the first and second toes
4 The outer side of the ankle below and slightly behind the lateral malleolus

7. On auscultation of the heart, the nurse recognizes which expected finding?

1 A low-pitched blowing sound is heard over the abdominal aorta.
2 A high-pitched vibration is heard over the base of the heart.
3 The S1 heart sound is louder at the apex of the heart.
4 The S3 heart sound sounds like "Ken-tucky."

8. What is the most accurate technique for detecting a deep vein thrombosis at the bedside?
1 Dorsiflex the calf and note if the patient complains of pain.
2 Elevate one leg above the level of the heart to determine if the veins empty.
3 Palpate the pulses distal to the areas of the suspected thrombosis.
4 Measure the thigh circumference to detect an increase from the baseline.

9. Each patient has had consistent blood pressure readings during the last three clinic visits. Which patient
has a blood pressure consistent with expected findings?
1 Mr. P, whose blood pressure has been 110/78
2 Ms. J, whose blood pressure has been 140/90
3 Mr. Q, whose blood pressure has been 130/76
4 Ms. Y, whose blood pressure has been 120/80

10. While inspecting the legs of a male patient, the nurse notes that the skin is shiny and taut with little hair
growth. Which additional data would the nurse find to indicate that this patient has peripheral arterial
disease?
1 Pitting edema of one or both feet or legs
2 Increased circumference in the thighs bilaterally
3 Pale, cool legs with diminished-to-absent dorsal pulses
4 Pain when legs are dependent that is relieved when legs are elevated

11. The nurse is listening to a patient's heart and hears an S2 sound. The S2 heart sound is caused by the:
1. Opening of the aortic and pulmonic valves
2. Opening of the mitral and tricuspid valves
3. Closing of the aortic and pulmonic valves
4. Closing of the mitral and tricuspid valves

12. The nurse assesses a pulse at 3+ amplitude. Which word best describes a pulse with 3+ amplitude?
1. Diminished
2. Normal
3. Full volume
4. Bounding

13. Patient reports having intermittent chest pain. What is the most appropriate question to ask next?
1. "Do you work in a stressful environment?"
2. "Have you told your physician about the chest pain?"
3. "What other symptoms do you have when the chest pain occurs?"
4. "Do you have high cholesterol levels?"

14. The nurse is percussing the heart. Percussion of the heart could be performed to:
1. Estimate the heart's size and borders
2. Determine fluid levels in the heart
3. Locate the presence of a murmur
4. Identify congenital heart defects

15. A patient complains of chest pain. Which report made by a patient would suggest to the nurse that the
chest pain is cardiac in origin?
1. "My chest hurts every time I cough."
2. "My chest feels really tight and heavy."
3. "I have sharp pains in my chest when I eat raw vegetables."
4. "I fess on some ice yesterday. Today, my chest hurts when I breathe."

16. A patient has 3+ pitting edema in her feet and ankles. The nurse suspects:
1. The patient has a heart murmur
2. The patient has excess fluid in the interstitial space
3. The patient is having a myocardial infarction
4. The patient has elevated cholesterol levels

17. A patient reports shortness of breath with a gradual onset. The nurse suspects:
1. Heart failure
2. Dysrhythmia
3. Deep vein thrombosis
4. Myocardial infarction

18. A patient reports leg and foot pain with activity that resolves with rest. With what type of problem is this
consistent?
1. Arterial insufficiency
2. Leg edema
3. Venous thrombosis
4. Hypertension

19. The nurse is assessing a patient's dorsalis pedis pulse. What is the primary reason for this assessment?
1. The patient's heart rate
2. Perfusion to the foot
3. Sensation to the foot
4. Reflexes within the foot

20. The nurse is palpating a patient's pericardium. What may be detected by palpating the pericardium?
1. An inflammation of the heart
2. An increased heart size
3. An increase in cardiac output
4. A thrill
Chapter 13

1 What question does a nurse ask a patient with a history of pancreatitis who is complaining of abdominal
pain?
1. Which foods aggravate the pain?
2. Have you recently traveled outside the United States?
3. Have you noticed a change in your bowel habits?
4. How severe is the pain on a scale of 0 to 10?

2 The nurse is interviewing a patient with a history of flank pain, fever, chills, and pain radiating to the
groin. Which examination technique is most appropriate for this patient?
1. Percussion of the costovertebral angle
2. Deep palpation of the abdomen
3. Testing for rebound tenderness
4. Auscultation of all quadrants of the abdomen

3 A patient reports a gnawing, burning pain in the mid-epigastric area that is aggravated by bending over or
lying down. Which additional question does the nurse ask for the symptom analysis?
1. "Do you have a family history of this type of pain?"
2. "How long ago did you eat?"
3. "Do you have any symptoms such as nausea with this pain?"
4. "Have you noticed any yellow coloring in your eyes or on your skin?"
4 The nurse palpates the abdomen to gather data about which organs, located in the RUQ?
1. Liver and gallbladder
2. Stomach and spleen
3. Uterus, if enlarged, and right ovary
4. Right ureter and ascending colon

5 A nurse performing an abdominal examination on a 37-year-old woman would document which finding as
abnormal?
1. Non-palpable spleen or kidneys
2. Bowel sounds every 15 seconds in the lower quadrants
3. Bulges observed when coughing
4. Silver-white striae and a faint vascular network

6 A 50-year-old patient asks how he can reduce his risk of colon cancer. What is the most appropriate
response by the nurse?
1. "A diet high in animal protein reduces the risk."
2. "Regular exercise to reduce body fat helps prevent colon cancer."
3. "Taking antacids for heartburn can help prevent colon cancer."
4. "Taking vitamin C daily helps reduce the risk."
7 Which is an expected finding of an abdominal examination of an adult?
1. Dull percussion tones over the bladder
2. Venus hum over the epigastrium on auscultation
3. High-pitched gurgles every 5 to 15 seconds on auscultation
4. Swishing sounds over the abdominal aorta on auscultation

8 Which technique does the nurse use to palpate a patient's abdomen?

1. Asks the patient to breath slowly though the mouth
2. Uses the heel of the hand to perform deep palpation
3. Uses the left hand to lift the rib cage away from the abdominal organs
4. Depresses the abdomen 1 to 2 inches for light palpation

9 When assessing a patient's abdomen, the nurse uses assessment techniques in which order?
1. Inspection, palpation, percussion, and auscultation
2. Inspection, auscultation, palpation, and percussion
3. Auscultation, inspection, percussion, and palpation
4. Palpation, auscultation, inspection, and percussion

10 The nurse suspects that the patient has appendicitis. Which assessment techniques can the nurse use to
confirm his or her suspicion?
1. Gently perform fist percussion over the right costovertebral angle
2. Ask the patient to place her hand on the abdomen while the nurse taps one side of the abdomen and palpates the
other side
3. Palpate the left lower quadrant at a 90-degree angle and quickly release his or her hand
4. With the patient lying supine and flexing her right knee and hip, tap on the sole of the patient's right foot

11 The nurse is preparing to perform an abdominal assessment. In which position should the patient be placed
for abdominal assessment?
1. Sitting upright on the examination table
2. In a high-Fowler's position
3. Supine
4. In a left lateral position

12 In what patient would pulsation w/in epigastric area be seen as a normal finding during inspection?
1. A very thin patient
2. An obese patient
3. A patient with ascites
4. An elderly patient

13 The nurse is performing an abdominal assessment. What assessment techniques should be included in the
assessment? Select all that apply:
1. Inspection
2. Percussion
3. Palpation
4. Illumination
5. Auscultation
6. Mirror check

14 The nurse is percussing a patient's abdomen and hears tympany. Which anatomic features explain the
finding of tympany with stomach percussion?
1. The stomach is hollow.
2. The stomach is flask-shaped.
3. The stomach secretes digestive enzymes.
4. The stomach is a muscular organ.

15 The student nurse is studying the liver. The primary function of the liver is to:
1. Metabolize nutrients
2. Store vitamin C
3. Produce red blood cells for circulation
4. Absorb most nutrients

16 The nurse auscultates the abdomen to gain information regarding:

1. The metabolic activity of the liver
2. The production of erythrocytes by the spleen
3. The peristaltic activity of the intestinal tract
4. The perfusion of the mesentery

17 The nurse notes a black umbilicus on a 5-day-old infant. What does this finding indicate?
1. The infant may have a feeding problem.
2. The umbilicus is infected.
3. The infant has hepatitis.
4. This is a normal finding.
18 The nurse is assessing a patient's abdomen and suspects ascites. Which technique is used to confirm the
presence of abdominal ascites?
1. Auscultation of fluid movement within the abdominal cavity
2. Palpation of rebound tenderness
3. Palpation of pitting edema of the abdomen
4. Percussion of dullness over dependent areas of the abdomen

19 Nurse includes questions over chest pain as part of an abdominal hx b/c myocardial pain can be:
1. Associated with ulcer disease
2. Caused by esophageal herniation or rupture
3. Perceived as esophageal and stomach pain
4. Related to congenital abdominal defects

20 The nurse should auscultate the abdomen for at least ____ before documenting an absence of bowel sounds.
1. 5 to 15 seconds
2. 30 seconds
3. Several minutes
4. 1 hour
Chapter 14
1 Which patient's description of pain is consistent with injury to a bone?
1 "Deep, dull, and boring"
2 "Cramping even when not moving"
3 "Intermittent, sharp, and radiating"
4 "Numbness and tingling with movement"

2 How are expected findings for the musculoskeletal system determined during an examination?
1 Compare the patient's function with others in the same age-group.
2 Compare the patient's function with others of the same gender.
3 Compare the patient's function with others in the same racial group.
4 Compare the patient's left side with the right side.

3 While testing a patient's bicep muscle strength, the nurse applies resistance and asks the patient to perform
which motion?
1 Extension of the arm
2 Flexion of the arm
3 Adduction of the arm
4 Abduction of the arm

4 The nurse testing the patient's muscle strength finds that the patient has complete range of motion with
gravity. Using Table 14-3, how would this finding be documented?
1 Poor or 2/5
2 Fair or 3/5
3 Good or 4/5
4 Normal or 5/5
5 While assessing the range of motion of the patient's knee, the nurse expects the patient to be able to
perform which movements?
1 Flexion, extension, and hyperextension
2 Circumduction, internal rotation, and external rotation
3 Adduction, abduction, and rotation
4 Flexion, pronation, and supination

6 During an assessment of a young adult, the nurse notes that the patient's shoulders are uneven. Which
further examination would the nurse perform for further data?
1 Ask the patient to rotate each shoulder to assess for shoulder range of motion.
2 Ask the patient to push against the nurse's hands with his or her forearm to test muscle strength.
3 Ask the patient to shrug his or her shoulders while the nurse pushes them down to test the muscle strength.
4 Ask the patient to bend forward at the waist while the nurse checks the alignment of the patient's vertebrae.

7 The nurse is comparing the right and left legs of a patient and notices that they are asymmetric. Which
additional data does the nurse collect at this time?
1 Passively moves each leg through range of motion and compares the findings
2 Observes the patient's gait and legs as he or she walks across the room
3 Measures the length of each leg and compares the findings
4 Palpates the joints and muscles of each leg and compares the findings
8 A patient complains of her jaw popping when chewing. Which examination techniques are appropriate for
the nurse to use with this patient?
1 Inspecting the musculature of the face and neck for symmetry
2 Observing the range of motion of and palpating each temporomandibular joint for movement, sounds, and
tenderness
3 Asking the patient to move her chin to her chest, hyperextend her head, and move her head from the right side to the
left side
4 Asking the patient to open her mouth as widely as possible and inspecting the lower jaw for redness, edema, or
broken teeth

9 When a nurse asks a patient to place the right arm behind the head, the nurse is testing for which range of
motion?
1. Flexion of the elbow
2. Hyperextension of the shoulder
3. Internal rotation and adduction of the shoulder
4. External rotation and abduction of the shoulder

10 With the patient in a supine position, how does a nurse test the external rotation of the patient’s right hip?
1. Asking the patient to move the right left laterally with the right knee straight
2. Asking the patient to flex the right knee and turn medially toward the left side [inward]
3. Asking the patient to place the right heel on the left patella
4. Asking the patient to raise the right led straight up and perpendicular to the body