ANSWERS
1. 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 hamstrings."
c. "This allows me to see how straight your spinal column is."
d. "I am assessing the flexion of your spine." correct answer c. "This allows me to
see how straight your spinal column is."
1. 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 correct answer c. By assessing the
cardinal fields of gaze
1. Which description of pain from the patient makes a nurse suspect the patient's
pain is originating from a muscle?
a. "Dull and Deep"
b. "Boring and Intense"
c. "Cramping"
d. "Sharp upon movement" correct answer c. "Cramping"
,1. Which patient's statement helps a nurse distinguish between chest pain
originating from pericarditis rather than from angina?
a. "This pain feels like there's an elephant sitting on my chest."
b. "Whenever this pain happens, it goes right away if I lie down."
c. "If I take a deep breath, the pain gets much worse."
d. "No, I have not done anything to strain chest muscles." correct answer c. "If I
take a deep breath, the pain gets much worse."
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 correct answer a. Depression
A 70-year-old man has a blood pressure of 150/90 mm Hg in a lying position,
130/80 mm Hg in a sitting position, and 100/60 mm Hg in a standing position.
How should the nurse evaluate these findings?
a. The blood pressure reading in the lying position is within normal limits.
b. This is a normal response due to changes in the patient's position.
c. The change in blood pressure reading is considered within normal limits for the
patient's age.
d. The change in blood pressure readings is called orthostatic hypotension.
correct answer d. The change in blood pressure readings is called orthostatic
hypotension.
,A 75-year-old man reports feeling dizzy at times. How should the nurse evaluate
his blood pressure?
a. Assess his blood pressure and pulse at the beginning and end of the
examination.
b. Have the patient walk around the room and assess his blood pressure after
activity.
c. Assess blood pressure and pulse in the supine, sitting, and standing positions.
d. Take the blood pressure on the right arm and then 5 minutes later take the
blood pressure on the left arm correct answer c. Assess blood pressure and pulse
in the supine, sitting, and standing positions.
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
correct answer d. A female interpreter who speaks Korean and English and is
available by phone
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. Tendonitis
, b. Osteoarthritis
c. Rheumatoid arthritis
d. Gout correct answer d. Gout
A nurse assessing a patient who had a cerebrovascular accident involving the
Broca area suspects expressive or non-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 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.
The patient is unable to comprehend speech and responds inappropriately to
conversation. correct answer a. The patient understands speech but is unable to
translate ideas into meaningful speech.
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 correct answer b. Ask the patient to
cough and repeat auscultation.
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?