Final Exam Review
Questions And Answers
\. A deep tendon reflex with a normal response is scored as:
A. 0
B. 3+
C. 1+
D. 2+ - Answer- ANS:
D. 2+
2+ is considered an active or expected response for deep tendon reflex; this is a normal
response. 0 indicates no response for deep tendon reflex; this is an abnormal response. 1+
indicates a sluggish or diminished response for deep tendon reflex; this is an abnormal
response. 3+ is a brisker-than-expected or slightly hyperactive response; this is an abnormal
response.
\. A nurse is inspecting the patient's ears with an otoscope. Which of the following findings
would be considered abnormal?
A. Visible cone of light
B. Small amount of cerumen
,C. Pearly gray tympanic membrane
D. Perforation of the tympanic membrane - Answer- ANS:
D. Perforation of the tympanic membrane
The tympanic membrane should not have any perforations. A visible cone of light is a normal
finding in an otoscopic examination. The tympanic membrane should appear pearly gray. A
small amount of cerumen is a normal finding in an otoscopic examination.
\. A nursing assistive personnel (NAP) is preparing to weigh a resident in a skilled nursing
facility. The patient is usually weighed in street clothing and socks, with his shoes off. The
patient is currently wearing street clothing with shoes and socks. What will the NAP do to
ensure that the patient's weight is correctly measured?
A. Take off the patient's street clothing.
B. Take off the patient's street clothing and put on a hospital gown and nonskid socks.
C. Take off the patient's shoes, but leave his socks on.
D. Take off the patient's shoes and socks, and put on slippers. - Answer- ANS:
C. Take off the patient's shoes, but leave his socks on.
Since the patient is usually weighed in street clothing and socks, the NAP should remove the
patient's shoes and leave his socks on.The patient's street clothing need not be removed. The
patient need not wear slippers. The patient need not wear a hospital gown and nonskid socks;
however, his shoes must be removed and his own socks left on.
,\. A whispered voice test includes which of the following?
A. Having the patient wiggle a finger in the opposite ear.
B. Whispering while standing 1 to 2 feet from the patient's ear.
C. Playing soothing music in the examination room.
D. Both A and B. - Answer- ANS:
D. Both A and B
Having the patient wiggle a finger in opposite ear ensures that patient is hearing the whisper in
the ear being tested. A whispered voice test is performed while standing 1 to 2 feet from the
patient's ear. Music can be a distraction or interference with a whispered voice test.
\. An ABNORMAL angle between the nail base and the nail is called clubbing and may indicate
which of the following conditions?
A. Poor hygiene
B. Skin cancer
C. Dehydration
D. Cardiopulmonary disorder - Answer- ANS:
D. Cardiopulmonary disorder
, Clubbing may indicate a cardiopulmonary disorder. Clubbing does not indicate poor hygiene,
dehydration or skin cancer.
\. As the nurse is conducting an admission interview, the patient states, I've lost 30 pounds over
the last 4 months. Which question might the nurse ask to determine if the weight loss was
intentional or unintentional?
A. Is your health care provider aware of this weight loss?
B. Is it easy for you to lose weight?
C. Has your weight fluctuated like this before?
D. Have you been following a specific diet? - Answer- ANS:
D. Have you been following a specific diet?
Asking if the patient has been following a specific diet will help determine if the patient's weight
loss was intentional or unintentional because it asks the patient to offer a possible explanation
for the weight loss. Whether the patient has reported the weight loss to a health care provider
is irrelevant. Asking if the patient's weight has fluctuated before or if it's easy for the patient to
lose weight will not help determine if the patient's weight loss was intentional or unintentional.
It merely asks about the patient's history of weight loss.
\. Assessment of the ears includes which of the following?
Multiple choice question
A. Inspection