NUR 216 COMPLETE SET FINAL EXAM WITH CORRECT ANSWERS 2025

The left pupil of a patient fails to accommodate. This finding may reflect an abnormality in which cranial nerve (CN)? a. CN III b. CN V c. CN VIII d. CN X - -a. This is correct. CN III, the oculomotor nerve, is responsible for accommodation. Failure of a pupil to accommodate reflects an abnormality in CN III. b. This is incorrect. CN V, the trigeminal nerve, controls the corneal reflex, chewing, and biting. c. This is incorrect. CN VIII, the acoustic nerve, plays a role in hearing and the sense of balance. d. This is incorrect. CN X, the vagus nerve, affects heart rate, peristalsis, swallowing, and the gag reflex. A client has noticed a decrease in taste sensation. Which cranial nerve (CN) is most likely involved? a. CN V and CN VII b. CN VII and CN IX c. CN V and CN VIII d. CN VI and CN X - -a. This is incorrect. While CN VII does supply sensations for taste, cranial nerve V supplies sensation to the eyes, face, and mouth. b. This is correct. Cranial nerves VII and IX supply sensation to the tongue. c. This is incorrect. CN V supplies sensory and motor movement to the eyes, scalp, teeth, face, and jaw, and CN VIII provides sensations to the ear. d. This is incorrect. CN VI provides motor movement to the eyes, while CN X supplies sensations to the pharynx and larynx; motor activity of swallowing and vocal cords; sensory in cardiac, respiratory, and blood pressure reflexes; peristalsis; and digestive secretions. Which skin assessment finding would cause the nurse to suspect dehydration in a middle-aged patient admitted to the hospital with traveler's diarrhea? a. Edema b. Erythema c. Pallor NUR216 NUR216 d. Tenting - -This is incorrect. Edema, an excessive amount of fluid in the tissues, may be a sign of heart failure, kidney disease, peripheral vascular disease, or low albumin levels. This is incorrect. Erythema is a red, pink skin color that may indicate inflammation, fever or increased blood flow. This is incorrect. Pallor, abnormal loss of skin color, may be a sign of anemia or blood loss. This is correct. Tenting, skin that takes several seconds to return to normal after lifting up a skinfold, may be a sign of dehydration. Which situation indicates that the nurse is conducting a focused assessment? a. The nurse performs a head-to-toe assessment that includes every body system. b. The nurse performs the Romberg test on a patient who reports problems with balance. c. The nurse evaluates the patient during every interaction to determine nursing care needs. d. The nurse evaluates the patient's overall health status. - -a. This is incorrect. Performing a head-to-toe assessment, including every body system, is a comprehensive assessment, not a focused assessment. b. This is correct. The patient reported problems with balance and the nurse conducted the Romberg test; this indicates a focused assessment. c. This is incorrect. Evaluating the patient at every interaction is an ongoing assessment, not a focused assessment. d. This is incorrect. Evaluating the overall health status is a comprehensive assessment, not a focused assessment. A nurse is at bedside to perform a brief physical examination. Which action best describes the procedure used to assess capillary refill? a. Briefly press the tip of the nail with firm, steady pressure; then release and observe for changes in color. b. Press firmly with your fingertip for 5 seconds over a bony area, release pressure, and observe the skin for the reaction. c. Tap on the skin with short strokes using middle fingers. d. Lift a fold of skin, and allow it to return to its normal position. - -a. This is correct. To assess capillary refill, the nurse should briefly press the tip of the nail with firm, steady pressure, then release and observe for changes in skin color. b. This is incorrect. The nurse should press firmly with fingertip for 5 seconds over a bony area, then release the finger and observe the skin for the reaction to grade edema. c. This is incorrect. Tapping the skin describes the procedure for performing percussion. d. This is incorrect. Lifting a fold of skin demonstrates the procedure for checking skin turgor and monitoring for tenting. Which assessment should the nurse perform if the patient has a palpable thyroid gland? NUR216 NUR216 a. Illuminate the thyroid gland for the presence of fluid. b. Auscultate the thyroid gland for bruits. c. Percuss the thyroid gland for mass size. d. Measure the thyroid gland to assess change. - -a. This is incorrect. It is not necessary to illuminate the thyroid gland. b. This is correct. Normally, the thyroid gland is smooth, firm, and nontender. It is often nonpalpable. If the thyroid gland is palpable, the nurse should auscultate it for bruits. c. This is incorrect. The thyroid gland should not be percussed; it is palpated. d. This is incorrect. The thyroid gland is not measured. Bronchovesicular breath sounds are best heard over which area? a. Midline over the trachea just below the larynx b. Fifth intercostal space, in the midclavicular line c. First and second intercostal spaces next to the sternum d. At the base of the lungs near the diaphragm - -a. This is incorrect. Bronchial (not bronchovesicular) breath sounds are heard over the trachea. b. This is incorrect. The fifth intercostal space midclavicular line is known as the point of maximal impulse for the heart. c. This is correct. Bronchovesicular breath sounds are best heard over the first and second intercostal spaces adjacent to the sternum on the anterior chest. d. This is incorrect. Base of the lungs is not the best place to hear bronchovesicular breath sounds. A nurse is at the bedside to perform a brief physical examination. The nurse notes high pitched breath sounds. Which of the following is a high-pitched breath sound produced by airway narrowing? a. Rales b. Crackles c. Rhonchi d. Wheezing - -a. This is incorrect. Even though rales are high-pitched, they are not produced by narrowing airways. Rales, also called crackles, are crackling, bubbling sounds that indicate emphysema or pneumonia. b. This is incorrect. Even though crackles are high-pitched, crackles are not produced by narrowing airways. Crackles are crackling, bubbling sounds that indicate emphysema or pneumonia. c. This is incorrect. Rhonchi are low-pitched snoring or rumbling sounds that result from mucous secretions in the large airways. d. This is correct. Wheezing is a high-pitched sound produced by narrowing of an airway. The admission assessment form indicates that the patient has pedal pulses that are rated 1 in amplitude. This documentation indicates that the patient's pulses are: a. Bounding. NUR216 NUR216 b. Normal. c. Full. d. Diminished. - -a. This is incorrect. A pulse amplitude of 4 indicates a bounding pulse. b. This is incorrect. Pulses documented as a 2 indicate a normal pulse. c. This is incorrect. A pulse documented as a 3 indicates a full pulse. d. This is correct. Pulses documented as 1 are diminished and barely palpable (weak). The nurse asks the patient to spread their fingers and then bring them together again. Which type of movement is the nurse testing when asking the patient to bring the fingers together? a. Abduction b. Adduction c. Flexion d. Extension - -a. This is incorrect. Asking the patient to spread fingers tests abduction. b. This is correct. Asking the patient to bring fingers together assesses adduction. c. This is incorrect. Asking the patient to make a fist tests flexion. d. This is incorrect. Asking the patient to extend the hand tests extension. Which question helps assess immediate memory? a. "How did you get to the hospital today?" b. "Can you repeat the numbers 2, 7, 9 for me?" c. "Do you remember the three items I mentioned earlier?" d. "What is your birth date, including the year?" - -a. This is incorrect. The nurse can assess recent (not immediate) memory by asking the patient how they got to the hospital. b. This is correct. The nurse can assess immediate memory by asking the patient to repeat a series of three numbers and gradually increasing the length of the series until the patient cannot repeat the series correctly. c. This is incorrect. The nurse can assess recent (not immediate) memory by asking the patient to repeat three items from what the nurse had mentioned earlier in the examination. d. This is incorrect. The nurse can assess remote (not immediate) memory by asking the patient their birth date or the date of a significant historical event. Based on developmental stage, how should the nurse modify the comprehensive physical examination of an older adult? a. Work rapidly to finish as quickly as possible. b. Sequence the examination to limit position changes. c. Demonstrate equipment before using it. d. Omit portions of the examination that may be tiring. - -a. This is incorrect. The nurse should work efficiently; however, speed is not the goal, and the nurse should observe the patient's energy level and stop for periods of rest as needed. NUR216 NUR216 b. This is correct. Because older adults may tire easily and because they may have stiff muscles and arthritic joints, the nurse should arrange the sequence of the examination to limit position changes. c. This is incorrect. It is appropriate to demonstrate equipment for school-age children but is not usually necessary for older adults, who have probably experienced other physical examinations. d. This is incorrect. Because this is a comprehensive examination, it is not appropriate to omit portions of it because they may be tiring. As discussed, the patient should rest and then the nurse should return to the examination. The nurse is planning a breast examination class for a group of women at a community health fair. In planning the class, what is most important for the nurse to consider in preparation for the class? a. Women who perform breast self-examinations should be trained in proper technique to avoid false-negative findings. b. Breast examinations should be performed yearly for all women over the age of 25 years. c. Clinical breast exams are recommended for average-risk women at any age. d. A breast examination that includes assessment of the breast and axillae is indicated only if the woman is at high risk for breast cancer. - -a. This is correct. Researchers agree that women who perform breast self-examinations should be trained in proper technique to avoid false-negative findings. b. This is incorrect. Breast exams should be done annually for women aged 40 and older, and every 1 to 3 years for women aged 20 to 39. c. This is incorrect. Clinical breast exams are not recommended for average-risk women at any age. d. This is incorrect. The majority of breast tumors are found in the tail of Spence, in the axilla. A breast exam for all women (not just high risk) always includes an exam of the axillae. Which statements describe the proper technique for auscultating heart sounds? Select all that apply. a. Auscultate in an orderly fashion, starting at the aortic area and proceeding to pulmonic, tricuspid, and mitral areas. b. Listen for S1 first in all landmark areas, and then proceed to listening for S2 in all landmark areas. c. Use the diaphragm of the stethoscope for normal sounds and the bell of the stethoscope to detect any extra sounds. d. Rotate the starting point of landmarks at each patient assessment to detect any changes. e. Perform cardiac auscultation from the patient's left side, whenever possible. - -a. This is correct. Auscultate in an orderly fashion, starting in the aortic area and moving gradually through each landmark. The mnemonic of A-P-T-M (aortic-pulmonic-tricuspid NUR216 NUR216 mitral) can be used. The nurse should listen carefully at each site to each component of the heart sound. b. This is incorrect. The nurse listens for S1 and then S2 in each landmark before moving to the next site. c. This is correct. The diaphragm is used to auscultate high-pitched sounds that normally occur in the heart, lungs, and abdomen. The bell is used to auscultate low pitched sounds, such as extra heart sounds, murmurs, or bruits. d. This is incorrect. The nurse should be systematic. To keep from missing important parts of the examination, always auscultate in the same order through all the areas. e. This is incorrect. Perform cardiac palpation and auscultation from the patient's right (not the left) side, whenever possible. Which information describes the nurse's general survey? Select all that apply. a. Consists of an overall impression of the patient b. Assists in identifying deviations that need further exploration c. Includes obtaining a full set of vital signs d. Includes the comprehensive physical assessment e. Focuses solely on the physical - -a. This is correct. The general survey is the nurse's overall impression of the patient. It begins at first contact and continues throughout the examination. b. This is correct. If a deviation from normal is discovered during the general survey, the nurse can then explore the finding further during a focused assessment of that body system. c. This is correct. The general survey includes obtaining a full set of vital signs. d. This is incorrect. The general survey does not include a comprehensive physical assessment (CPA), as the CPA includes the health history interview and a complete head-to-toe examination of every body system. e. This is incorrect. The general survey focuses on both emotional and physical aspects, not just solely on the physical. The nurse obtains vital signs for a 56-year-old patient who underwent surgery yesterday. Which findings require further assessment? Select all that apply. a. Blood pressure 110/64 mm Hg b. Pulse rate 118 beats/min c. Respiratory rate 35 breaths/min d. Oral temperature 98.6°F (37°C) e. Blood pressure 118/78 mm Hg - -a. This is incorrect. Blood pressure of 110/64 mm Hg is considered normal and does not require further assessment. b. This is correct. Pulse rate of 118 beats/min is abnormally elevated and requires further assessment. c. This is correct. Respiratory rate of 35 breaths/min is abnormally elevated and requires further assessment. d. This is incorrect. Oral temperature of 98.6°F (37°C) is considered normal and does not require further assessment. e. This is incorrect. Blood pressure of 118/78 mm Hg is within the normal range