West Coast University NURS 190
Physical Assessment (PA) Final Exam –
Latest Version A: Questions &
Answers with Rationales
1. The nurse is caring for a client who was admitted to the medical
unit. The nurse notes in the physical exam done by the physician that
the client has a positive Romberg. When meeting elimination needs
for this client, the nurse would perform which of the following
interventions?
A. Obtain an order for a catheter
B. Limit fluid intake
C. Obtain a bedside commode
D. Allow the client to walk independently
Answer: C. Obtain a bedside commode
Rationale: A positive Romberg test indicates loss of proprioception and
difficulty maintaining balance with eyes closed. This client is at increased
risk for falls. The nurse should provide a bedside commode to minimize the
distance the client must walk to eliminate, reducing fall risk. Allowing
independent walking (D) is unsafe, and catheterization (A) or fluid
restriction (B) are unnecessary interventions.
2. The nurse observes drainage from a client's ears after a head injury
and suspects a cerebral spinal fluid (CSF) leak. The nurse would
document which of the following descriptions of the drainage?
,A. Blood-tinged without sediment
B. Pink without sediment
C. Yellow without sediment
D. Clear, colorless
Answer: D. Clear, colorless
Rationale: CSF drainage from the ears (otorrhea) or nose (rhinorrhea)
following head trauma appears clear and colorless, like water. It may also
show a "halo sign" when tested on gauze. Blood-tinged, pink, or yellow
drainage would suggest other types of fluid (e.g., bloody drainage from
local trauma or purulent drainage from infection).
3. The nurse is performing a neurological assessment on a client and
needs to use stereognosis. Which of the following instructions would
the nurse provide for the client?
A. "Identify the number being traced in your hand with your eyes closed."
B. "Identify the object in your hand with your eyes closed."
C. "Tell me if you feel one or two objects touching you with your eyes
closed."
D. "Open and close your hand each time I tell you to."
Answer: B. "Identify the object in your hand with your eyes closed."
Rationale: Stereognosis is the ability to recognize objects by touch alone.
The nurse places a familiar object (e.g., key, coin) in the client's hand with
eyes closed and asks them to identify it. Option A describes graphesthesia
(tracing numbers), Option C describes two-point discrimination, and Option
D tests motor function.
,4. The nurse notes fanning of the toes when the sole of the foot is
stimulated during assessment of the plantar reflex. The nurse would
correctly chart which of the following?
A. Brudzinski sign
B. Nuchal rigidity
C. Hyperreflexia
D. Babinski response
Answer: D. Babinski response
Rationale: Fanning of the toes (dorsiflexion of the great toe and abduction
of the other toes) in response to stroking the sole of the foot is a positive
Babinski response. This is abnormal in adults and indicates upper motor
neuron dysfunction. Brudzinski sign (A) and nuchal rigidity (B) indicate
meningeal irritation, while hyperreflexia (C) is exaggerated deep tendon
reflexes.
5. The nurse is assessing a female client and notes facial hirsutism. The
client asks the nurse why this has happened to her. The nurse would
correctly respond with which of the following statements?
A. "Your diet is not nutritionally balanced."
B. "You need to take vitamins."
C. "There is not a known cause for this condition."
D. "You may have some hormone imbalances."
Answer: D. "You may have some hormone imbalances."
Rationale: Hirsutism—excessive hair growth in a male pattern in women—
is most commonly caused by hormonal imbalances, particularly increased
androgen levels. It can be associated with conditions such as polycystic
ovary syndrome (PCOS), adrenal disorders, or certain medications. Diet (A)
, and vitamins (B) are not the primary causes, and stating there is no known
cause (C) is incorrect.
6. The nurse is assessing the patellar reflex on a client and obtains no
reflex activity. The client is alert and oriented. The nurse should do
which of the following in this situation?
A. Look at the medication records for central nervous system depressants
B. Retest the reflex after having the client use distraction during the exam
C. Notify the physician immediately
D. Document the findings as normal
Answer: A. Look at the medication records for central nervous system
depressants
Rationale: Absent or diminished reflexes can be caused by CNS
depressants such as benzodiazepines, barbiturates, or opioids. Before
notifying the physician (C) or documenting as normal (D), the nurse should
first check for medication effects. Distraction (B) is used to enhance reflexes,
not assess absent ones.
7. The nurse is caring for a client that insists on having their food very
hot and very cold at each meal. The nurse correctly recognizes this as a
health belief in which of the following cultural groups?
A. Chinese Americans
B. Native Americans
C. Cuban Americans
D. Jewish Americans
Answer: A. Chinese Americans
Rationale: In Traditional Chinese Medicine (TCM), health is maintained
through balance of "hot" and "cold" forces (yin and yang). Many Chinese
Physical Assessment (PA) Final Exam –
Latest Version A: Questions &
Answers with Rationales
1. The nurse is caring for a client who was admitted to the medical
unit. The nurse notes in the physical exam done by the physician that
the client has a positive Romberg. When meeting elimination needs
for this client, the nurse would perform which of the following
interventions?
A. Obtain an order for a catheter
B. Limit fluid intake
C. Obtain a bedside commode
D. Allow the client to walk independently
Answer: C. Obtain a bedside commode
Rationale: A positive Romberg test indicates loss of proprioception and
difficulty maintaining balance with eyes closed. This client is at increased
risk for falls. The nurse should provide a bedside commode to minimize the
distance the client must walk to eliminate, reducing fall risk. Allowing
independent walking (D) is unsafe, and catheterization (A) or fluid
restriction (B) are unnecessary interventions.
2. The nurse observes drainage from a client's ears after a head injury
and suspects a cerebral spinal fluid (CSF) leak. The nurse would
document which of the following descriptions of the drainage?
,A. Blood-tinged without sediment
B. Pink without sediment
C. Yellow without sediment
D. Clear, colorless
Answer: D. Clear, colorless
Rationale: CSF drainage from the ears (otorrhea) or nose (rhinorrhea)
following head trauma appears clear and colorless, like water. It may also
show a "halo sign" when tested on gauze. Blood-tinged, pink, or yellow
drainage would suggest other types of fluid (e.g., bloody drainage from
local trauma or purulent drainage from infection).
3. The nurse is performing a neurological assessment on a client and
needs to use stereognosis. Which of the following instructions would
the nurse provide for the client?
A. "Identify the number being traced in your hand with your eyes closed."
B. "Identify the object in your hand with your eyes closed."
C. "Tell me if you feel one or two objects touching you with your eyes
closed."
D. "Open and close your hand each time I tell you to."
Answer: B. "Identify the object in your hand with your eyes closed."
Rationale: Stereognosis is the ability to recognize objects by touch alone.
The nurse places a familiar object (e.g., key, coin) in the client's hand with
eyes closed and asks them to identify it. Option A describes graphesthesia
(tracing numbers), Option C describes two-point discrimination, and Option
D tests motor function.
,4. The nurse notes fanning of the toes when the sole of the foot is
stimulated during assessment of the plantar reflex. The nurse would
correctly chart which of the following?
A. Brudzinski sign
B. Nuchal rigidity
C. Hyperreflexia
D. Babinski response
Answer: D. Babinski response
Rationale: Fanning of the toes (dorsiflexion of the great toe and abduction
of the other toes) in response to stroking the sole of the foot is a positive
Babinski response. This is abnormal in adults and indicates upper motor
neuron dysfunction. Brudzinski sign (A) and nuchal rigidity (B) indicate
meningeal irritation, while hyperreflexia (C) is exaggerated deep tendon
reflexes.
5. The nurse is assessing a female client and notes facial hirsutism. The
client asks the nurse why this has happened to her. The nurse would
correctly respond with which of the following statements?
A. "Your diet is not nutritionally balanced."
B. "You need to take vitamins."
C. "There is not a known cause for this condition."
D. "You may have some hormone imbalances."
Answer: D. "You may have some hormone imbalances."
Rationale: Hirsutism—excessive hair growth in a male pattern in women—
is most commonly caused by hormonal imbalances, particularly increased
androgen levels. It can be associated with conditions such as polycystic
ovary syndrome (PCOS), adrenal disorders, or certain medications. Diet (A)
, and vitamins (B) are not the primary causes, and stating there is no known
cause (C) is incorrect.
6. The nurse is assessing the patellar reflex on a client and obtains no
reflex activity. The client is alert and oriented. The nurse should do
which of the following in this situation?
A. Look at the medication records for central nervous system depressants
B. Retest the reflex after having the client use distraction during the exam
C. Notify the physician immediately
D. Document the findings as normal
Answer: A. Look at the medication records for central nervous system
depressants
Rationale: Absent or diminished reflexes can be caused by CNS
depressants such as benzodiazepines, barbiturates, or opioids. Before
notifying the physician (C) or documenting as normal (D), the nurse should
first check for medication effects. Distraction (B) is used to enhance reflexes,
not assess absent ones.
7. The nurse is caring for a client that insists on having their food very
hot and very cold at each meal. The nurse correctly recognizes this as a
health belief in which of the following cultural groups?
A. Chinese Americans
B. Native Americans
C. Cuban Americans
D. Jewish Americans
Answer: A. Chinese Americans
Rationale: In Traditional Chinese Medicine (TCM), health is maintained
through balance of "hot" and "cold" forces (yin and yang). Many Chinese
