Questions and Answers
1. When assessing a 2–3-year-old child, what is most important?
A. Start with examining the ears and mouth
• B. Assess least invasive to most invasive
C. Make sure child lies on exam table
D. Parent should not be in the room
Rationale: Children at this age are fearful; starting with less invasive techniques builds
trust and cooperation.
2. The nurse notes an audible, crunching/grating sound on the client’s knee while
climbing stairs. What is the best term?
A. Crepitus
B. Crackles
C. Friction rub
D. Murmur
Rationale: Crepitus refers to bone or joint grinding, often linked to arthritis.
3. The nurse is preparing to conduct a health history. How should this be explained
to the patient?
• A. “I will ask questions about your past and present health. This helps create a
database for diagnosis.”
B. “It is only for research purposes.”
C. “It replaces the physical exam.”
D. “It is optional and not necessary.”
Rationale: Health history provides subjective data that complements objective findings.
4. Which finding is considered abnormal in an adult?
A. BP 118/76 mmHg
B. HR 72 bpm
• C. Respiratory rate 28/min
D. Temp 98.6°F
Rationale: Normal adult respiratory rate is 12–20/min; 28 indicates tachypnea.
5. The nurse hears S3 in an adult patient. This sound is associated with:
A. Normal finding in adults
• B. Heart failure
C. Hypertension
D. Aortic stenosis
Rationale: S3 is abnormal in adults, often linked to ventricular overload/heart failure.
6. Which breath sound is high-pitched, musical, and heard primarily during
expiration?
A. Crackles
, • B. Wheezes
C. Rhonchi
D. Pleural rub
Rationale: Wheezes indicate narrowed airways, common in asthma or COPD.
7. A patient is unable to smile or puff cheeks. Which cranial nerve is affected?
A. CN V
• B. CN VII (Facial)
C. CN IX
D. CN XII
Rationale: CN VII controls facial muscles for expression.
8. A bluish discoloration of the skin is termed:
A. Pallor
• B. Cyanosis
C. Jaundice
D. Erythema
Rationale: Cyanosis indicates hypoxemia or poor circulation.
9. The nurse auscultates bowel sounds. Normal sounds are:
A. Absent
B. Hypoactive
• C. High-pitched gurgling, 5–30/min
D. Continuous rumbling
Rationale: Normal bowel sounds are irregular, high-pitched, and frequent.
10. The nurse teaches testicular self-exam. Best time is:
A. Before exercise
• B. During/after warm shower
C. Before bedtime
D. After meals
Rationale: Warmth relaxes scrotal sac, making lumps easier to detect.
11. The nurse asks patient to spell “world” backward. This assesses:
A. Orientation
• B. Attention/concentration
C. Memory recall
D. Judgment
Rationale: Spelling backward tests concentration and attention span.
12. The nurse notes tympanic membrane is pearly gray, translucent. This is:
• A. Normal finding
B. Otitis media
C. Perforation
D. Cerumen impaction