1. Mr. Teban is a 73-year old patient diagnosed with pneumonia.

Which data would

be of greatest concern to the nurse when completing the nursing assessment of the
patient?

A. Alert and oriented to date, time, and place

B. Buccal cyanosis and capillary refill greater than 3 seconds
C. Clear breath sounds and nonproductive cough
D. Hemoglobin concentration of 13 g/dl and leukocyte count 5,300/mm3

2. During the nursing assessment, which data represent information

concerning health beliefs?

A. Family role and relationship patterns

B. Educational level and financial status
C. Promotive, preventive, and restorative health practices
D. Use of prescribed and over-the-counter medications

3. Nurse Patrick is acquiring information from a client in the emergency

department. Which is an example of biographic information that may be obtained
during a health history?

A. The chief complaint

B. Past health status
C. History immunizations
D. Location of an advance directive

4. John Joseph was scheduled for a physical assessment. When percussing the
client’s chest, the nurse would expect to find which assessment data as a normal sign
over his lungs?

A. Dullness
B. Resonance
C. Hyperresonance
D. Tympany

5. Matteo is diagnosed with dehydration and underwent series of tests. Which

laboratory result would warrant immediate intervention by the nurse?

A. Serum sodium level of 138 mEq/L

B. Serum potassium level of 3.1 mEq/L
C. Serum glucose level of 120 mg/dl
D. Serum creatinine level of 0.6 mg/100 ml

6. During an otoscopic examination, which action should be avoided to prevent the

client from discomfort and injury?

A. Tipping the client’s head away from the examiner and pulling the ear up and back
B. Inserting the otoscope inferiorly into the distal portion of the external canal
C. Inserting the otoscope superiorly into the proximal two-thirds of the external canal
D. Bracing the examiner’s hand against the client’s head

7. When assessing the lower extremities for arterial function, which intervention
should the nurse perform?

A. Assessing the medial malleoli for pitting edema

B. Performing Allen’s test
C. Assessing the Homans’ sign
D. Palpating the pedal pulses

8. Newly hired nurse Liza is excited to perform her very first physical assessment
with a 19-year-old client. Which assessment examination requires Liza to wear
gloves?
A. Breast
B. Integumentary
C. Ophthalmic
D. Oral

9. Nurse Renor is about to perform Romberg’s test to Pierro. To ensure the latter’s
safety, which intervention should nurse Renor implement?

A. Allowing the client to keep his eyes open

B. Having the client hold on to furniture
C. Letting the client spread his feet apart
D. Standing close to provide support

10. Physical assessment is being performed to Geoff by Nurse Tine. During the
abdominal examination, Tine should perform the four physical examination
techniques in which sequence?

A. Auscultation immediately after inspection and then percussion and palpation

B. Percussion, followed by inspection, auscultation, and palpation
C. Palpation of tender areas first and then inspection, percussion, and auscultation
D. Inspection and then palpation, percussion, and auscultation

11. Which assessment data should the nurse include when obtaining a review of
body systems

A. Brief statement about what brought the client to the health care provider
B. Client complaints of chest pain, dyspnea, or abdominal pain
C. Information about the client’s sexual performance and preference
D. The client’s name, address, age, and phone number

12. Tywin has come to the nursing clinic for a comprehensive health assessment.
Which statement would be the best way to end the history interview?
A. “What brought you to the clinic today?”
B. “Would you describe your overall health as good?”
C. “Do you understand what is happening?”
D. “Is there anything else you would like to tell me?”

13. For which time period would the nurse notify the health care provider that the
client had no bowel sounds?

A. 2 minutes
B. 3 minutes
C. 4 minutes
D. 5 minutes

14. Evaluating the apical pulse is the most reliable noninvasive way to assess cardiac
function. Which is the best area for auscultating the apical pulse?

A. Aortic arch
B. Pulmonic area
C. Tricuspid area
D. Mitral area

15. Beginning in their 20s, women should be told about the benefits and limitations
of breast self-exam (BSE). Which scientific rationale should the nurse remember
when performing a breast examination on a female client?

A. One half of all breast cancer deaths occur in women ages 35 to 45

B. The tail of Spence area must be included in self-examination
C. The position of choice for the breast examination is supine
D. A pad should be placed under the opposite scapula of the breast being palpated

16. Mr. Lim, who has chronic pain, loss of self-esteem, no job, and bodily
disfigurement from severe burns over the trunk and arms, is admitted to a pain
center. Which evaluation criteria would indicate the client’s successful
rehabilitation?

A. The client remains free of the aftermath phase of the pain experience.
B. The client experiences decreased frequency of acute pain episodes.
C. The client continues normal growth and development with intact support systems.
D. The client develops increased tolerance for severe pain in the future.

17. Christine Ann is about to take her NCLEX examination next week and is
currently reviewing the concept of pain. Which scientific rationale would indicate
that she understands the topic?

A. Pain is an objective sign of a more serious problem

B. Pain sensation is affected by a client’s anticipation of pain
C. Intractable pain may be relieved by treatment
D. Psychological factors rarely contribute to a client’s pain perception

18. Miggy, a 6-year-old boy, received a small paper cut on his finger, his mother let
him wash it and apply small amount of antibacterial ointment and bandage. Then
she let him watch TV and eat an apple. This is an example of which type of pain
intervention?

A. Pharmacologic therapy
B. Environmental alteration
C. Control and distraction
D. Cutaneous stimulation

19. Which statement represents the best rationale for using noninvasive and non-
pharmacologic pain-control measures in conjunction with other measures?

A. These measures are more effective than analgesics.

B. These measures decrease input to large fibers.
C. These measures potentiate the effects of analgesics.
D. These measures block transmission of type C fiber impulses.

20. When evaluating a client’s adaptation to pain, which behavior indicates

appropriate adaptation?

A. The client distracts himself during pain episodes.

B. The client denies the existence of any pain.
C. The client reports no need for family support.
D. The client reports pain reduction with decreased activity.

21. In planning pain reduction interventions, which pain theory provides

information most useful to nurses?

A. Specificity theory
B. Pattern theory
C. Gate-control theory
D. Central-control theory

22. Ryan underwent an open reduction and internal fixation of the left hip. One day
after the operation, the client is complaining of pain. Which data would cause the
nurse to refrain from administering the pain medicationand to notify the health care
provider instead?

A. Left hip dressing dry and intact

B. Blood pressure of 114/78 mm Hg; pulse rate of 82 beats per minute
C. Left leg in functional anatomic position
D. Left foot cold to touch; no palpable pedal pulse

23. Which term would the nurse use to document pain at one site that is perceived in
other site?
A. Referred pain
B. Phantom pain
C. Intractable pain
D. Aftermath of pain

24. Chuck, who is in the hospital, complains of abdominal pain that ranks 9 on a
scale of 1 (no pain) to 10 (worst pain). Which interventions should the nurse
implement? (Select all that apply.)

A. Assessing the client’s bowel sounds

B. Taking the client’s blood pressure and apical pulse
C. Obtaining a pulse oximeter reading
D. Notifying the health care provider
E. Determining the last time the client received pain medication
F. Encouraging the client to turn, cough, and deep breathe

25. Albert who suffered severe burns 6 months ago is expressing concern about the
possible loss of job-performance abilities and physical disfigurement. Which
intervention is the most appropriate for him?

A. Referring the client for counseling and occupational therapy

B. Staying with the client as much as possible and building trust
C. Providing cutaneous stimulation and pharmacologic therapy
D. Providing distraction and guided imagery techniques

26. Mrs. Bagapayo who had abdominal surgery 3 days earlier complains of sharp,
throbbing abdominal pain that ranks 8 on a scale of 1 (no pain) to 10 (worst pain).
Which intervention should the nurse implement first?

A. Assessing the client to rule out possible complications secondary to surgery

B. Checking the client’s chart to determine when pain medication was last administered
C. Explaining to the client that the pain should not be this severe 3 days postoperatively
D. Obtaining an order for a stronger pain medication because the client’s pain has
increased

27. Which term refers to the pain that has a slower onset, is diffuse, radiates, and is
marked by somatic pain from organs in any body activity?

A. Acute pain
B. Chronic pain
C. Superficial pain
D. Deep pain

28. A 50-year-old widower has arthritis and remains in bed too long because it hurts
to get started. Which intervention should the nurse plan?

A. Telling the client to strictly limit the amount of movement of his inflamed joints
B. Teaching the client’s family how to transfer the client into a wheelchair
C. Teaching the client the proper method for massaging inflamed, sore joints
D. Encouraging gentle range-of-motion exercises after administering aspirin and before
rising

29. Which intervention should the nurse include as a nonpharmacologic pain-relief

intervention for chronic pain?

A. Referring the client for hypnosis

B. Administering pain medication as prescribed
C. Removing all glaring lights and excessive noise
D. Using transcutaneous electric nerve stimulation

30. A 12-year-old student fall off the stairs, grabs his wrist, and cries, “Oh, my
wrist! Help! The pain is so sharp, I think I broke it.” Based on this data, the pain the
student is experiencing is caused by impulses traveling from receptors to the spinal
cord along which type of nerve fibers?
A. Type A-delta fibers
B. Autonomic nerve fibers
C. Type C fibers
D. Somatic efferent fibers

Answers and Rationale

Here are the answers for this exam. Gauge your performance by counter checking your
answers to those below. If you have any disputes or clarifications, please direct them to
the comments section.

1. Answer: B. Buccal cyanosis and capillary refill greater than 3 seconds

Buccal cyanosis and capillary refill greater than 3 seconds are indicative of decreased
oxygen to the tissues, which requires immediate intervention. Alert and oriented, clear
breath sounds, nonproductive cough, hemoglobin concentration of 13 g/dl, and leukocyte
count of 5,300/mm3 are normal data.

2. Answer: C. Promotive, preventive, and restorative health practices

The health-beliefs assessment includes expectations of health care; promotive,

preventive, and restorative practices, such as breast self-examination, testicular
examination, and seat-belt use; and how the client perceives illness. Use of medications
provides information about the client’s personal habits. Educational level, financial
status, and family role and relationship patterns represent information associated with
role and relationship patterns.

3. Answer: D. Location of an advance directive

Biographic information may include name, address, gender, race, occupation, and
location of a living will or a durable power of attorney for health care. The chief
complaint, past health status, and history of immunizations are part of assessing the
client’s health and illness patterns.

4. Answer: B. Resonance

Normally, when percussing a client’s chest, percussion over the lungs reveals resonance,
a hollow or loud, low-pitched sound of long duration. Tympany is typically heard on
percussion over such areas as a gastric air bubble or the intestine. Dullness is typically
heard on percussion of solid organs, such as the liver or areas of consolidation.
Hyperresonance would be evidenced by percussion over areas of overinflation such as an
emphysematous lungs.

5. Answer: B. Serum potassium level of 3.1 mEq/L

A normal potassium level is 3.5 to 5.5 mEq/L. A normal sodium level is 135 to 145
mEq/L, a normal nonfasting glucose level is 85 to 140 mg/dl, and a normal creatinine
level is 0.2 to 0.8 mg/100 ml.

6. Answer: C. Inserting the otoscope superiorly into the proximal two-thirds of the
external canal

In the superior position, the speculum of the otoscope is nearest the tympanic membrane,
and the most sensitive portion of the external canal is the proximal two-thirds. It is
important to avoid these structures during the examination. Tipping the client’s head
away from the examiner, pulling the ear up and back, inserting the otoscope inferiorly,
and bracing the examiner’s hand against the client’s head are all appropriate techniques
used during an otoscopic examination.

7. Answer: D. Palpating the pedal pulses

Palpating the client’s pedal pulses assists in determining if arterial blood supply to the
lower extremities is sufficient. Assessing the medial malleoli for pitting edema is
appropriate for assessing venous function of the lower extremity. Allen’s test is used to
evaluate arterial blood flow before inserting an arterial line in an upper extremity or
obtaining arterial blood gases. Homans’ sign is used to evaluate the possibility of deep
vein thrombosis.

8. Answer: D. Oral

Gloves should be worn any time there is a risk of exposure to the client’s blood or body
fluids. Oral, rectal, and genital examinations require gloves because they involve contact
with body fluids. Ophthalmic, breast, or integumentary examinations normally do not
involve contact with the client’s body fluids and do not require the nurse to wear gloves
for protection. However, if there are areas of skin breakdown or drainage, gloves should
be used.

9. Answer: D. Standing close to provide support

During Romberg’s test, the client is asked to stand with feet together and eyes shut and
still maintain balance with the minimum of sway. If the client loses his balance, the nurse
standing close to provide support, such as having an arm close around his shoulder, can
prevent a fall. Allowing the client to keep his eyes open, spread his feet apart, or hang on
to a piece of furniture interferes with the proper execution of the test and yields invalid
results.

10. Answer: A. Auscultation immediately after inspection and then percussion and
palpation

With an abdominal assessment, auscultation always is performed before percussion and

palpation because any abdominal manipulation, such as from palpation or percussion, can
alter bowel sounds. Percussion should never precede inspection or auscultation, and any
tender or painful areas should be palpated last.

11. Answer: B. Client complaints of chest pain, dyspnea, or abdominal pain

Client complaints about chest pain, dyspnea, or abdominal pain are considered part of the
review of body systems. This potion of the assessment elicits subjective information on
the client’s perceptions of major body system functions, including cardiac, respiratory,
and abdominal. The client’s name, address, age, and phone number are biographical data.
A brief statement about what brought the client to the health care provider is the chief
complaint. Information about the client’s sexual performance and preference addresses
past health status.

12. Answer: D. “Is there anything else you would like to tell me?”

By asking the client if there is anything else, the nurse allows the client to end the
interview by discussing feelings and concerns. Asking about what brought the client to
the clinic is an ambiguous question to which the client may answer “my car” or any
similarly disingenuous reply. Asking if the client describes his overall health as good is a
leading question that puts words in his mouth. Asking if the client understands what is
happening is a yes-or-no question that can elicit little information.

13. Answer: D. 5 minutes

To completely determine that bowel sounds are absent, the nurse must auscultate each of
the four quadrants for at least 5 minutes; 2, 3, or 4 minutes is too short a period to arrive
at this conclusion.

14. Answer: D. Mitral area

The mitral area (also known as the left ventricular area or the apical area), the fifth
intercostal space (ICS) at the left midclavicular line, is the best area for auscultating the
apical pulse. The aortic arch is the second ICS to the right of sternum. The pulmonic area
is the second intercostal space to the left of the sternum. The tricuspid area is the fifth
ICS to the left of the sternum.

15. Answer: B. The tail of Spence area must be included in self-examination

The tail of Spence, an extension of the upper outer quadrant of breast tissue, can develop
breast tumors. This area must also be included in breast self-examination. One half of all
women who die of breast cancer are older than age 65. The correct position for breast
self-examination is not limited to the supine position; the sitting position with hands at
sides, above head, and on the hips is also recommended. A pad is placed under the
ipsilateral (e.g., same side) scapula of the breast being palpated.

16. Answer: C. The client continues normal growth and development with intact
support systems.

Even though the client may experience an aftermath phase, progress is still possible, as is
effective rehabilitation. Aftermath reactions may occur but need not interfere with
rehabilitation. Acute pain is not expected at this stage of recovery. Conditioning probably
would produce less pain tolerance.

17. Answer: B. Pain sensation is affected by a client’s anticipation of pain

Phases of pain experience include the anticipation of pain. Fear and anxiety affect a
person’s response to sensation and typically intensify the pain. Intractable pain is
moderate to severe pain that cannot be relieved by any known treatment. Pain is a
subjective sensation that cannot be quantified by anyone except the person experiencing
it. Psychological factors contribute to a client’s pain perception. In many cases, pain
results from emotions, such as hostility, guilt, or depression.

18. Answer: C. Control and distraction

The mothers actions are example of control and distraction. Involving the child in care
and providing distraction took his mind off the pain. Pharmacologic agents for pain
analgesics — were not used. The home environment was not changed, and cutaneous
stimulation, such as massage, vibration, or pressure, was not used.

19. Answer: C. These measures potentiate the effects of analgesics.

Noninvasive measures may result in release of endogenous molecular neuropeptides with
analgesics properties. They potentiate the effect of analgesics. No evidence indicates that
noninvasive and nonpharmacologic measures are more effective than analgesics in
relieving pain. Decreased input over large fibers allows more pain impulses to reach the
central nervous system. There is no connection between type C fiber impulses and
noninvasive and nonpharmacologic pain-control measures.

20. Answer: A. The client distracts himself during pain episodes.

Distraction is an appropriate method of reducing pain. Denying the existence of any pain
is inappropriate and not indicative of coping. Exclusion of family members and other
sources of support represents a maladaptive response. Range-of-motion exercises and at
least mild activity, not decreased activity, can help reduce pain and are important to
prevent complications of immobility.

21. Answer: D. Central-control theory

No one theory explains all the factors underlying the pain experience, but the central-
control theory discusses brain opiates with analgesic properties and how their release can
be affected by actions initiated by the client and caregivers. The gate-control, specificity,
and patter theories do not address pain control to the depth included in the central-control
theory.

22. Answer: D. Left foot cold to touch; no palpable pedal pulse

A left foot cold to touch without palpable pedal pulse represents an abnormal finding on
neurovascular assessment of the left leg. The client is most likely experiencing some
complication from surgery, which requires immediate medical intervention. The nurse
should notify the health care provider of these findings. A dry and intact hip dressing,
blood pressure of 114/78 mm Hg, pulse rate of 82 beats per minute, and a left foot in
functional anatomic position are all normal assessment findings that do not require
medical intervention.
23. Answer: A. Referred pain

Referred pain is pain occurring at one site that is perceived in another site. Referred pain
follows dermatome and nerve root patterns. Phantom pain refers to pain in a part of the
body that is no longer there, such as in amputation. Intractable pain refers to moderate to
severe pain that cannot be relieved by any known treatment. Aftermath of pain, a phase
of the pain experience and the most neglected phase, addresses the client’s response to
the pain experience.

24. Answer: A, B, and E

The nurse must rule out complications prior to administering pain medication, so her
interventions would include assessing to make sure the client has bowel sounds and
determining if the client is hemorrhaging by checking the client’s blood pressure and
pulse. The nurse must also make sure the pain medication is due according to the health
care provider’s orders. Obtaining a pulse oximeter reading and turning, coughing, and
deep breathing will not help the client’s pain. There is no need to notify the health care
provider in this situation.

25. Answer: A. Referring the client for counseling and occupational therapy

Because it has been 6 months, the client needs professional help to get on with life and
handle the limitations imposed by the current problems. Staying with the client, building
trust, and providing method of pain relief, such as cutaneous stimulation, medications,
distraction, and guided imagery interventions, would have been more appropriate in
earlier stages of postburn injury, when physical pain was most severe and fewer
psychologic factors needed to be addressed.

26. Answer: A. Assessing the client to rule out possible complications secondary to
surgery
The nurse immediate action should be assess the client in an attempt to exclude possible
complications that may be causing the client’s complaints. The health care provider
ordered the pain medication for routine postoperative pain that is expected after
abdominal surgery, not for such complications as hemorrhage, infection, or dehiscence.
The nurse should never administer pain medication without assessing the client first.
Obtaining an order for a strong medication may be appropriate after the nurse assesses
the client and checks the chart to see whether the current analgesic is infective. Checking
the client’s chart is appropriate after the nurse determines that the client is not
experiencing complications from surgery. Pain is subjective, and each person has his own
level of pain tolerance. The nurse must always believe the client’s complaint of pain.

27. Answer: D. Deep pain

Deep pain has a slow onset, is diffuse, and radiates, and is marked by somatic pain from
organs in any body activity. Acute pain is rapid in onset, usually temporary (less than 6
months), and subsides spontaneously. Chronic pain is marked by gradual onset and
lengthy duration (more than 6 months). Superficial pain has abrupt onset with sharp,
stinging quality.

28. Answer: D. Encouraging gentle range-of-motion exercises after administering

aspirin and before rising

Aspirin raises the pain threshold and, although range-of-motion exercises hurt,
mild exercise can relieve pain on rising. Strict limitation of motion only increases the
client’s pain. Having others transfer the client into a wheelchair does not increase his
feelings of dependency. Massage increases inflammation and should be avoided with this
client.

29. Answer: D. Using transcutaneous electric nerve stimulation

Nonpharmacologic pain relief interventions include cutaneous stimulation, back rubs,

biofeedback, acupuncture, transcutaneous electric nerve stimulation, and more. Hypnosis
is considered an alternative therapy. Medications are pharmacologic measures. Although
removing glaring lights and excessive noise help to reduce or remove noxious stimuli, it
is not specific to pain relief.

30. Answer: A. Type A-delta fibers

Type A-delta fibers conduct impulses at a very rapid rate and are responsible for
transmitting acute sharp pain signals from the peripheral nerves to the spinal cord. Only
type A-delta fibers transmit sharp, piercing pain. Somatic efferent fibers affect the
voluntary movement of skeletal muscles and joints. Type C fibers transmit sensory input
at a much slower rate and produce a slow, chronic type of pain. The autonomic system
regulates involuntary vital functions and organ control such as breathing.