A 75-year-old client with a recent history of a cerebrovascular accident (CVA) presents with
right hemiparesis. The nurse tests the deep tendon reflexes on the right side and elicits a
brisk 4+ response. Which interpretation of this finding is accurate?
A. A normal reflex response.
B. Absent or sluggish response consistent with a lower motor neuron lesion.
C. Flaccid paralysis.
D. Hyperactive response consistent with an upper motor neuron disorder. - ANSWER Cor-
rect answer is D, brisk 4+ response is correlated with hyperactive response.
A. Presents with a hacking non-productive cough of 6 weeks duration.
B. Describe having a "body-wracking dry cough" of 6 weeks duration.
C. Expresses concern of "lung cancer" symptoms for last 6 weeks.
D. Young adult male presents with fears that he has "lung cancer" - ANSWER Correct an-
swer is B, as assessment process includes chief complaint which is how the patient describe
why he is here in the hospital or clinic and can't include diagnosis.
The nurse examines a client's abdomen. Which finding indicates an abnormal response
when palpating the spleen?
A. Pain notes when palpating McBurney's point.
B. Tip of spleen palpable when client is asked to forcefully exhale.
C. Rebound tenderness with compression over right upper quadrant. D. Firm mass palpated
at bottom of left rib cage. - ANSWER Correct answer is D. McBurney's point is related to
appendicitis and not spleen.
1
,In auscultating for the presence of a carotid artery bruit, the nurse places the bell of the
stethoscope at which location? - ANSWER *under mandible towards lymph nodes. trans-
verse to trachea
A male client arrives at the clinic for follow-up health assessment after recent antibiotic
treatment for pneumonia without hospitalization. Which technique should the nurse imple-
ment to assess for adventitious lung sounds?
A. Use the bell of the stethoscope to listen to the lung fields over lower lobes. B. Have the
client lay flat while listening to the anterior surface of the chest.
C. Press the stethoscope's diaphragm firmly on the skin over each lung field.
D. Shave all chest hair that may distort sounds heard through the diaphragm. - ANSWER
Correct answer is C. The nurse should listen to all lungs fields during assessment and move
from side to side during auscultation.
A client with streptococcus pharyngitis reports high fever, difficulty swallowing and a muffled
voice. Which complication should the nurse suspect?
A. Foreign body obstruction.
B. Laryngeal polyps.
C. Peritonsillar abscess.
D. Nasal polyps - ANSWER Correct answer is C. Since infections are associated with ab-
scesses and pus.
The nurse is obtaining a health history for a client prior to a scheduled cholecystectomy.
While interviewing the client, which assessment technique should the nurse use when ask-
ing about the client's use of illegal drugs and alcohol?
A. Obtain a drug using screen to verify legitimacy of client's stated history.
B. Allow the client to decline answering social questions.
C. Ask specifically about alcohol, marijuana, cocaine, her
D. Use the term illegal or illicit to describe street drug. - ANSWER Correct answer is C.
When interviewing the patient, questions should be clear and specific.
2
, The nurse applies pressure over an area of the lower abdomen where the client reports
pain. The client denies pain upon palpation, but reports pain when the pressure is released.
What action should the nurse implement?
A. Offer to administer a laxative prescribed for PRN use.
B. Obtain a prescription to catheterize the client's bladder.
C. Instruct the client in distraction and relation techniques.
D. Notify the healthcare provider of the rebound tenderness. - ANSWER Correct answer
is D. As this could be a sign of appendicitis.
The nurse is assessing an ulcer on a client's lower extremity, which is likely the result of ei-
ther venous or arterial insufficiency. Which assessment technique should the nurse use to
differentiate the pathophysiology causing the ulcer?
A. Measure the degree of join range of motion in the extremity.
B. Compare the skin turgor of the client's upper and lower leg.
C. Observe the specific location and appearance of the ulceration.
D. Note any change in the color of the ulcer when the leg is moved - ANSWER Correct an-
swer is C. Location and appearance of the ulcer would give us the type (venous vs arterial)
The nurse is assessing a healthy adult male during an annual physical examination. The nurse
auscultates the client's abdomen and hears gurgling sound every ten seconds. What action
should the nurse take in response to this finding?
A. Document this normal bowel sound activity in the record.
B. Encourage increased consumption of fiber in the diet.
C. Observe the next bowel movement for signs of bleeding.
D. Report the hyperactivity to the healthcare provider. - ANSWER Correct answer is A.
Normal Bowel sound consist of clicks and gurgles and 5-30 per minute. An occasional borbo-
rygmus (Loud prolonged gurgle) may be hear.
The nurse is conducting a physical assessment of a young adult. Which information provides
the best indication of the individual's nutritional status?
A. Status of current appetite.
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right hemiparesis. The nurse tests the deep tendon reflexes on the right side and elicits a
brisk 4+ response. Which interpretation of this finding is accurate?
A. A normal reflex response.
B. Absent or sluggish response consistent with a lower motor neuron lesion.
C. Flaccid paralysis.
D. Hyperactive response consistent with an upper motor neuron disorder. - ANSWER Cor-
rect answer is D, brisk 4+ response is correlated with hyperactive response.
A. Presents with a hacking non-productive cough of 6 weeks duration.
B. Describe having a "body-wracking dry cough" of 6 weeks duration.
C. Expresses concern of "lung cancer" symptoms for last 6 weeks.
D. Young adult male presents with fears that he has "lung cancer" - ANSWER Correct an-
swer is B, as assessment process includes chief complaint which is how the patient describe
why he is here in the hospital or clinic and can't include diagnosis.
The nurse examines a client's abdomen. Which finding indicates an abnormal response
when palpating the spleen?
A. Pain notes when palpating McBurney's point.
B. Tip of spleen palpable when client is asked to forcefully exhale.
C. Rebound tenderness with compression over right upper quadrant. D. Firm mass palpated
at bottom of left rib cage. - ANSWER Correct answer is D. McBurney's point is related to
appendicitis and not spleen.
1
,In auscultating for the presence of a carotid artery bruit, the nurse places the bell of the
stethoscope at which location? - ANSWER *under mandible towards lymph nodes. trans-
verse to trachea
A male client arrives at the clinic for follow-up health assessment after recent antibiotic
treatment for pneumonia without hospitalization. Which technique should the nurse imple-
ment to assess for adventitious lung sounds?
A. Use the bell of the stethoscope to listen to the lung fields over lower lobes. B. Have the
client lay flat while listening to the anterior surface of the chest.
C. Press the stethoscope's diaphragm firmly on the skin over each lung field.
D. Shave all chest hair that may distort sounds heard through the diaphragm. - ANSWER
Correct answer is C. The nurse should listen to all lungs fields during assessment and move
from side to side during auscultation.
A client with streptococcus pharyngitis reports high fever, difficulty swallowing and a muffled
voice. Which complication should the nurse suspect?
A. Foreign body obstruction.
B. Laryngeal polyps.
C. Peritonsillar abscess.
D. Nasal polyps - ANSWER Correct answer is C. Since infections are associated with ab-
scesses and pus.
The nurse is obtaining a health history for a client prior to a scheduled cholecystectomy.
While interviewing the client, which assessment technique should the nurse use when ask-
ing about the client's use of illegal drugs and alcohol?
A. Obtain a drug using screen to verify legitimacy of client's stated history.
B. Allow the client to decline answering social questions.
C. Ask specifically about alcohol, marijuana, cocaine, her
D. Use the term illegal or illicit to describe street drug. - ANSWER Correct answer is C.
When interviewing the patient, questions should be clear and specific.
2
, The nurse applies pressure over an area of the lower abdomen where the client reports
pain. The client denies pain upon palpation, but reports pain when the pressure is released.
What action should the nurse implement?
A. Offer to administer a laxative prescribed for PRN use.
B. Obtain a prescription to catheterize the client's bladder.
C. Instruct the client in distraction and relation techniques.
D. Notify the healthcare provider of the rebound tenderness. - ANSWER Correct answer
is D. As this could be a sign of appendicitis.
The nurse is assessing an ulcer on a client's lower extremity, which is likely the result of ei-
ther venous or arterial insufficiency. Which assessment technique should the nurse use to
differentiate the pathophysiology causing the ulcer?
A. Measure the degree of join range of motion in the extremity.
B. Compare the skin turgor of the client's upper and lower leg.
C. Observe the specific location and appearance of the ulceration.
D. Note any change in the color of the ulcer when the leg is moved - ANSWER Correct an-
swer is C. Location and appearance of the ulcer would give us the type (venous vs arterial)
The nurse is assessing a healthy adult male during an annual physical examination. The nurse
auscultates the client's abdomen and hears gurgling sound every ten seconds. What action
should the nurse take in response to this finding?
A. Document this normal bowel sound activity in the record.
B. Encourage increased consumption of fiber in the diet.
C. Observe the next bowel movement for signs of bleeding.
D. Report the hyperactivity to the healthcare provider. - ANSWER Correct answer is A.
Normal Bowel sound consist of clicks and gurgles and 5-30 per minute. An occasional borbo-
rygmus (Loud prolonged gurgle) may be hear.
The nurse is conducting a physical assessment of a young adult. Which information provides
the best indication of the individual's nutritional status?
A. Status of current appetite.
3
