Review Questions and Answers
Patient Assessment
1. When assessing a 2–3-year-old child, which approach is most appropriate?
A. Begin with invasive procedures
• B. Start with non-threatening areas (e.g., heart, lungs)
C. Ask the child to lie still immediately
D. Perform head-to-toe in strict order
Rationale: Toddlers are fearful; starting with non-threatening areas builds trust.
Vital Signs
2. Which finding indicates orthostatic hypotension?
A. BP rises when standing
• B. BP drops ≥20 mmHg systolic or ≥10 mmHg diastolic when standing
C. HR decreases with position change
D. No change in BP
Rationale: Orthostatic hypotension is defined by a significant BP drop upon standing.
Cultural Competence
3. A patient refuses blood transfusion due to religious beliefs. The nurse should:
A. Persuade the patient to accept
• B. Respect the patient’s decision and explore alternatives
C. Document refusal and proceed anyway
D. Call security
Rationale: Respecting cultural and religious values is central to patient-centered care.
Neurological Assessment
4. Which finding is abnormal in an adult neurological exam?
A. Pupils equal and reactive
• B. Babinski reflex present
C. Symmetrical strength in extremities
D. Alert and oriented ×3
Rationale: Babinski reflex should disappear after infancy; persistence indicates
pathology.
Respiratory Assessment
5. Crackles heard in the lungs are most associated with:
A. Asthma
• B. Pneumonia or heart failure
C. COPD
D. Normal aging
Rationale: Crackles indicate fluid in alveoli, common in pneumonia or CHF.
6. Skin Assessment
, Which finding requires immediate follow-up?
A. Freckles on the arms
B. Symmetrical moles
• C. Irregular, asymmetric mole with color variation
D. Birthmark on the thigh
Rationale: ABCDE rule (Asymmetry, Border, Color, Diameter, Evolution) indicates
possible melanoma.
7. Cardiac Assessment
A nurse hears an S3 heart sound in an adult. This is most associated with:
A. Normal aging
• B. Heart failure
C. Hypertension
D. Aortic stenosis
Rationale: S3 in adults suggests fluid overload/CHF.
8. Pain Assessment
Which tool is best for assessing pain in a non-verbal patient?
A. Numeric scale
• B. FLACC scale
C. Wong-Baker FACES
D. Verbal descriptor scale
Rationale: FLACC (Face, Legs, Activity, Cry, CONSOL ability) is validated for non-
verbal patients.
9. Respiratory Assessment
Which finding indicates hypoxia?
A. Pink mucous membranes
• B. Cyanosis of lips and nail beds
C. Warm skin
D. Normal capillary refill
Rationale: Cyanosis is a late sign of hypoxia.
10. Abdominal Assessment
Correct sequence for abdominal exam:
A. Palpation → Percussion → Auscultation → Inspection
• B. Inspection → Auscultation → Percussion → Palpation
C. Auscultation → Palpation → Percussion → Inspection
D. Percussion → Inspection → Palpation → Auscultation
Rationale: Auscultation precedes palpation to avoid altering bowel sounds.
11. Mental Status Exam
Which finding is abnormal?
A. Alert and oriented ×3
• B. Disoriented to time and place
C. Appropriate affect