Chapter 01: The History and Interviewing Process Ball: Seidel's Guide To Physical Examination, 9th Edition

Seidel's Guide to Physical Examination 9th Edition Ball Test Bank
Chapter 01: The History and Interviewing Process

Ball: Seidel’s Guide to Physical Examination, 9th Edition
MULTIPLE CHOICE
1. Which question would be considered a “leading question?”

a. “What do you think is causing your headaches?”
b. “You don’t get headaches often, do you?”
c. “On a scale of 1 to 10, how would you rate the severity of your headaches?”
d. “At what time of the day are your headaches the most severe?”
ANS: B
Stating to the patient that he or she does not get headaches would limit the information in the
patient’s answer. Asking the patient what he or she thinks is causing the headaches is an
open-ended question. Asking the patient how he or she would rate the severity of the
headaches and asking what time of the day the headaches are the most severe are direct
questions.
DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation
2. When are open-ended questions generally most useful?

a. During sensitive area part of the interview
b. After several closed-ended questions have been asked
c. While designing the genogram
d. During the review of systems
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ANS: A
Asking open-ended questions during the sensitive part of the interview allows you to gather
more information and establishes you as an empathic listener, which is the first step of
effective communication. Asking closed-ended questions may stifle the patient’s desire to
discuss the history of the illness. Interviewing for the purpose of designing a genogram or
conducting a review of systems requires more focused data than can be more easily gathered
with direct questioning.
DIF: Cognitive Level: Understanding (Comprehension)

3. Periods of silence during the interview can serve important purposes, such as:
a. allowing the clinician to catch up on documentation.
b. promoting calm.
c. providing time for reflection.
d. increasing the length of the visit.
ANS: C
Silence is a useful tool during interviews for the purposes of reflection, summoning courage,
and displaying compassion. This is not a time to document in the chart, but rather to focus on
the patient. Periods of silence may cause anxiety rather than promote calm. The length of the
visit is less important than getting critical information.
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4. Mr. Franklin is speaking with you, the healthcare provider, about his respiratory problem. Mr.
Franklin says, “I’ve had this cough for 3 days, and it’s getting worse.” You reply, “Tell me
more about your cough.” Mr. Franklin states, “I wish I could tell you more. That’s why I’m
here. You tell me what’s wrong!” Which caregiver response would be most appropriate for
enhancing communication?
a. “After 3 days, you’re tired of coughing. Have you had a fever?”
b. “I’d like to hear more about your experiences. Where were you born?”
c. “I don’t know what’s wrong. You could have almost any disease.”
d. “I’ll examine you and figure out later what the problem is.”
ANS: A
“After 3 days, you’re tired of coughing. Have you had a fever?” is the only response aimed at
focusing on the chief compliant to gather more data and does not digress from the issue.
DIF: Cognitive Level: Analyzing (Analysis)

5. After you ask a patient about her family history, she says, “Tell me about your family now.”
Which response is generally most appropriate?
a. Ignore the patient’s comment and continue with the interview.
b. Give a brief, undetailed answer.
c. Ask the patient why she needs to know.
d. Tell the patient that you do not discuss your family with patients.
ANS: B N R I G B.C M
U will
Giving a brief, undetailed answer S Nsatisfy
T the Opatient’s curiosity about yourself without
invading your private life. Ignoring the patient’s comment, continuing with the interview, and
telling the patient that you do not discuss your family with patients will potentially anger or
frustrate her and keep her from sharing openly. Asking the patient why she needs to know will
distract from the real reason she is seeking care and instead move the interview conversation
away from the topics that should be discussed.

6. A 36-year-old woman complains that she has had crushing chest pain for the past 2 days. She
seems nervous as she speaks to you. An appropriate response is to:
a. continue to collect information regarding the chief complaint in an unhurried
manner.
b. finish the interview as rapidly as possible.
c. ask the patient to take a deep breath and calm down.
d. ask the patient if she wants to wait until another day to talk to you.
ANS: A
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With an anxious, vulnerable patient, it is best to not hurry; a calm demeanor will communicate
caring to the patient. If you as a healthcare provider are hurried, the patient will be more
anxious. The best way to assist an anxious patient is to not hurry and remain calm, because
this will communicate caring to the patient. Asking the patient if she wants to wait until
another day to talk to you delays the needed health care.

7. Ms. A states, “My life is just too painful. It isn’t worth it.” She appears depressed. Which one
of the following statements is the most appropriate caregiver response?
a. “Try to think about the good things in life.”
b. “What in life is causing you such pain?”
c. “You can’t mean what you’re saying.”
d. “If you think about it, nothing is worth getting this upset about.”
ANS: B
Specific but open-ended questions are best used when the patient has feelings of loss of
self-worth and depression. “Try to think about the good things in life,” “You can’t mean what
you’re saying,” and “If you think about it, nothing is worth getting this upset about” are
statements that will hurry the patient and offer only superficial assurance.

8. You are collecting a history from a 16-year-old girl. Her mother is sitting next to her in the
examination room. When collecting history from older children or adolescents, they should
be: NURSINGTB.COM
a. given the opportunity to be interviewed without the parent at some point during the
interview.
b. mailed a questionnaire in advance to avoid the need for them to talk.
c. ignored while you address all questions to the parent.
d. allowed to direct the flow of the interview.
ANS: A
The adolescent should be given the opportunity to give information directly. This enhances
the probability that the adolescent will follow your advice. Mailing a questionnaire in advance
to avoid the need for her to talk does not assist the adolescent in learning to respond to
answers regarding her health. The parent can help fill in gaps at the end. If she is ignored
while you address all questions to the parent, the patient will feel as though she is just being
discussed and is not part of the process for the health care. The healthcare provider should
always direct the flow of the interview according to the patient’s responses.

9. Information that is needed during the initial interview of a pregnant woman includes all the
following except:
a. the gender that the woman hopes the baby will be.
b. past medical history.
c. healthcare practices.
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d. the woman’s remembering (knowledge) about pregnancy.

ANS: A
The initial interview for the pregnant woman should include information about her past
medical history, assessment of health practices, identification of potential risk factors, and
assessment of remembering (knowledge) as it affects the pregnancy. The gender of the fetus is
not as important as the information about her past medical history, healthcare practices, and
the woman’s remembering (knowledge) about her pregnancy.

10. When interviewing older adults, the examiner should:

a. speak extremely loudly, because most older adults have significant hearing
impairment.
b. provide a written questionnaire in place of an interview.
c. position himself or herself facing the patient.
d. dim the lights to decrease anxiety.
ANS: C
The healthcare provider should position himself or herself so that the older patient can see his
or her face. Shouting distorts speech, dimming the lights impairs vision, and a written
interview may be necessary if all else fails.

11. To what extent should the patient

N Rwith
I aGphysical
B.C disability
M or emotional disorder be involved
U S Nto Tthe health
in providing health history information O professional?
a. The patient should be present during information collection but should not be
addressed directly.
b. All information should be collected from past records and family members while
the patient is in another room.
c. The patient should be involved only when you sense that he or she may feel
ignored.
d. The patient should be fully involved to the limit of his or her ability.
ANS: D
Patients who are disabled may not give an effective history, but they must be respected, and
the history must be obtained from them to the greatest extent possible. Patients should be
addressed directly and participate in the interview to the extent of their ability.

12. When taking a history, the nurse should:

a. ask the patient to give you any information he or she can recall about his or her
health.
b. start the interview with the patient’s family history.
c. use a chronologic and sequential framework.
d. use a holistic and eclectic structure.
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ANS: C
To give structure to the present problem or chief complaint, the provider should proceed in a
chronologic and sequential framework. Asking patients to give any information they can
recall about their health and using a holistic and electric structure do not provide structure to
the history. Gathering the patient’s family history is only the first step.

13. When questioning the patient regarding his or her sexual history, which question should be
asked initially?
a. “Do you have any particular sexual likes or dislikes?”
b. “Do you have any worries or concerns regarding your sex life?”
c. “How often do you have intercourse and with whom?”
d. “Do you have any reason to think you may have been exposed to a sexually
transmitted infection?”
ANS: B
When approaching questioning about a sensitive area, it is recommended that the provider
first ask open-ended questions that explore the patient’s feelings about the issue. “Do you
have any particular sexual likes or dislikes?” is not a question that should be asked in an
interview regarding sexual history. “How often do you have intercourse and with whom?” and
“Do you have any reason to think you may have been exposed to a sexually transmitted
infection?” are not questions that should be asked initially in an interview regarding the
patient’s sexual history.

NURSINGMSC:
OBJ: Nursing process—assessment TB.COM
Physiologic Integrity: Physiologic Adaptation
14. A guideline for history taking is for caregivers to:

a. ask direct questions before open-ended questions so that data move from simple to
complex.
b. ask for a complete history at once so that data are not forgotten between meetings.
c. make notes sparingly so that the patient can be observed during the history taking.
d. write detailed information as stated by patients so that their priorities are reflected.
ANS: C
During the interview, you should maintain eye contact with the patient, observing body
language and proceeding from open-ended to direct questions. Asking direct questions first
may upset the patient. During the interview you should gather as much information as you
need for the current reason the patient is seeking health care. It is important to focus on the
patient. Brief notes can be charted, but you should maintain eye contact with the patient,
observing body language and proceeding from open-ended to direct questions.

15. Mr. D complains of a headache. During the history, he mentions his use of alcohol and illicit
drugs. This information would most likely belong in the:
a. chief complaint.
b. past medical history.
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c. personal and social history.

d. review of systems.
ANS: C
Habits are included within the personal and social history. The chief complaint is the reason
the patient is seeking health care. The past medical history is made up of the previous medical
conditions that the patient has had. The review of systems is an overview of problems with
other body systems.

16. Direct questioning about domestic violence in the home should be:
a. a routine component of history taking with female patients.
b. avoided for fear of offending the woman’s partner.
c. conducted only in cases in which there is a history of abuse.
d. used only when the patient is obviously being victimized.
ANS: A
The presence of domestic violence should be routinely queried, and the questioning should be
direct for all female patients. Direct questioning about domestic violence in the home should
not be avoided for fear of offending the woman’s partner, should be part of a routine
examination, and should not be used only when the patient is obviously being victimized.
DIF: Cognitive Level: Remembering (Knowledge)

17. A tool used to screen adolescents

NURfor alcoholism is the:
a. CAGE. SINGTB.COM
b. CRAFFT.
c. PACES.
d. HITS.
ANS: B
The CRAFFT tool is used to screen for alcoholism in adolescents. The CAGE test is used to
screen for alcoholism in adults. PACES is used to screen adolescents for important issues in
their life. HITS is the screen for domestic violence.

18. Tom is a 16-year-old diabetic who does not follow his diet. He enjoys his dirt bike and seems
unconcerned about any consequences of his activities. Which factor is typical of adolescence
and pertinent to Tom’s health?
a. Attachment to parents
b. High self-esteem
c. Low peer support needs
d. Propensity for risk taking
ANS: D
Adolescents tend to experiment with risky behaviors that can lead to a high incidence of
morbidity and mortality.
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19. Mr. Mills is a 55-year-old patient who presents to the office for an initial visit for health
promotion. A survey of mobility and activities of daily living (ADL) is part of a(n):
a. ethnic assessment.
b. functional assessment.
c. genetic examination.
d. social history.
ANS: B
A functional assessment is an assessment of a patient’s mobility, upper extremity movement,
household management, ADL, and instrumental activities of daily living (IADL).

20. Constitutional symptoms in the ROS refer to:

a. height, weight, and body mass index.
b. fever, chills, fatigue, and malaise.
c. hearing loss, tinnitus, and diplopia.
d. rashes, skin turgor, and temperature.
ANS: B
General constitutional symptoms refer to pain, fever, chills, malaise, fatigue, night sweats,
sleep patterns, and weight (average, preferred, present, change).
N R I G B.C M
U S (Comprehension)
DIF: Cognitive Level: Understanding N T O
21. JM has been seen in your clinic for 5 years. She presents today with signs and symptoms of
acute sinusitis. The type of history that is warranted is a(n) _________ history.
a. complete
b. inventory
c. problem or focused
d. interim
ANS: C
If the patient is well known, or if you have been seeing the patient for the same problem over
time, a focused history is appropriate. A complete history is only obtained during initial visits
or during a complete history and physical examination (H&P). An inventory is related to but
does not replace the complete history. It touches on the major points without going into detail.
This is useful when the entire history taking will be completed in more than one session. An
interim history is only obtained during a return of the patient after several months of absence.

MULTIPLE RESPONSE
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1. Which are appropriate for the interview setting with a patient? (Select all that apply.)
a. Playing music in the background
b. Ensuring comfort for all involved
c. Maintaining eye contact
d. Using a conversational tone
e. Keeping the door open
f. Removing physical barriers
ANS: B, C, D, F
The interview setting requires comfort for all involved, removal of physical barriers,
unobtrusive access to a clock, maintaining eye contact, and using a conversational tone.
Playing music in the background may be distracting and keeping the door open does not
provide for privacy.

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Chapter 02: Cultural Competency

MULTIPLE CHOICE
1. Which statement is true regarding the relationship of physical characteristics and culture?
a. Physical characteristics should be used to identify members of cultural groups.
b. There is a difference between distinguishing cultural characteristics and
distinguishing physical characteristics.
c. To be a member of a specific culture, an individual must have certain identifiable
physical characteristics.
d. Gender and race are the two essential physical characteristics used to identify
cultural groups.
ANS: B
Physical characteristics are not used to identify cultural groups; there is a difference between
the two, and they are considered separately. Physical characteristics should not be used to
identify members of cultural groups. To be a member of a specific culture, an individual does
not need to have certain identifiable physical characteristics. You should not confuse physical
characteristics with cultural characteristics. Gender and race are physical characteristics, not
cultural characteristics, and are not used to identify cultural groups.

2. An image of any group that rejects its potential for originality or individuality is known as
a(n):
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a. acculturation.
b. norm.
c. stereotype.
d. ethnos.
ANS: C
A fixed image of any group that rejects its potential for originality or individuality is the
definition of stereotype. Acculturation is the process of adopting another culture’s behaviors.
A norm is a standard of allowable behavior within a group. Ethnos implies the same race or
nationality.

3. Mr. L presents to the clinic with severe groin pain and a history of kidney stones. Mr. L’s son
tells you that for religious reasons, his father wishes to keep any stone that is passed into the
urine filter that he has been using. What is your most appropriate response?
a. “With your father’s permission, we will examine the stone and request that it be
returned to him.”
b. “The stone must be sent to the lab for examination and therefore cannot be kept.”
c. “We cannot let him keep his stone because it violates our infection control policy.”
d. “We don’t know yet if your father has another kidney stone, so we must analyze
this one.”
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ANS: A
We should be willing to modify the delivery of health care in a manner that is respectful and
in keeping with the patient’s cultural background. “With your father’s permission, we will
examine the stone and request that it be returned to him” is the most appropriate response.
“The stone must be sent to the lab for examination and therefore cannot be kept” and “We
don’t know yet if your father has another kidney stone, so we must analyze this one” do not
support the patient’s request. “We cannot let him keep his stone because it violates our
infection control policy” does not provide a reason that it would violate an infection control
policy.

4. The motivation of the healthcare professional to “want to” engage in the process of becoming
culturally competent, not “have to,” is called:
a. cultural knowledge.
b. cultural awareness
c. cultural desire
d. cultural skill.
ANS: C
Cultural encounters are the continuous process of interacting with patients from culturally
diverse backgrounds to validate, refine, or modify existing values, beliefs, and practices about
a cultural group and to develop cultural desire, cultural awareness, cultural skill, and cultural
knowledge. Cultural awareness is deliberate self-examination and in-depth exploration of
one’s biases, stereotypes, prejudices, assumptions, and “-isms” that one holds about
individuals and groups who are NUdifferent
RSINGfrom TB.C OMCultural knowledge is the process of
them.
seeking and obtaining a sound educational base about culturally and ethnically diverse groups.
Cultural skill is the ability to collect culturally relevant data regarding the patient’s presenting
problem, as well as accurately performing a culturally based physical assessment in a
culturally sensitive manner. Cultural desire is the motivation of the healthcare professional to
want to engage in the process of becoming culturally competent, not have to.

5. Mr. Marks is a 66-year-old patient who presents for a physical examination to the clinic.
Which question has the most potential for exploring a patient’s cultural beliefs related to a
health problem?
a. “How often do you have medical examinations?”
b. “What is your age, race, and educational level?”
c. “What types of symptoms have you been having?”
d. “Why do you think you are having these symptoms?”
ANS: D
“Why do you think you are having these symptoms?” is an open-ended question that avoids
stereotyping, is sensitive and respectful toward the individual, and allows for cultural data to
be exchanged. The other questions do not explore the patient’s cultural beliefs about health
problems.
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6. The definition of ill or sick is based on a:

a. stereotype.
b. cultural behavior.
c. belief system.
d. cultural attitude.
ANS: C
The definition of ill or sick is based on the individual’s belief system and is determined in
large part by his or her enculturation.

7. A 22-year-old female nurse is interviewing an 86-year-old male patient. The patient avoids
eye contact and answers questions only by saying, “Yeah,” “No,” or “I guess so.” Which of
the following is appropriate for the interviewer to say or ask?
a. “We will be able to communicate better if you look at me.”
b. “It’s hard for me to gather useful information because your answers are so short.”
c. “Are you uncomfortable talking with me?”
d. “Does your religion make it hard for you to answer my questions?”
ANS: C
It is all right to ask if the patient is uncomfortable with any aspect of your person and to talk
about it; the other choices are less respectful.
N R I G B.C M
DIF: Cognitive Level: ApplyingU(Application)
S N T O
8. As you explain your patient’s condition to her husband, you notice that he is leaning toward
you and pointedly blinking his eyes. Knowing that he is from England, your most appropriate
response to this behavior is to:
a. tell him that you understand his need to be alone.
b. ask whether he has any questions.
c. ask whether he would prefer to speak to the clinician.
d. tell him that it is all right to be angry.
ANS: B
The English worry about being overheard and tend to speak in modulated voices so, when
they lean in toward you, they are probably poised to ask a question.

9. An aspect of traditional Western medicine that may be troublesome to many Hispanics,

Native Americans, Asians, and Middle Eastern groups is Western medicine’s attempts to:
a. use a holistic approach that views a particular medical problem as part of a bigger
picture.
b. determine a specific cause for every problem in a precise way.
c. establish harmony between a person and the entire cosmos.
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d. restore balance in an individual’s life.

ANS: B
A more scientific approach to healthcare problem solving, in which a cause can be determined
for every problem in a precise way, is a Western approach. Hispanics, Native Americans,
Asians, and Arabs embrace a more holistic approach. Using a holistic approach, establishing
harmony between a person and the entire cosmos, and restoring balance in an individual’s life
would not be troublesome to many Hispanics, Native Americans, Asians, and Arabs.

10. The attitudes of the healthcare professional:

a. are largely irrelevant to the success of relationships with the patient.
b. do not influence patient behavior.
c. are difficult for the patient to sense.
d. are culturally derived.
ANS: D
The attitudes of the healthcare provider are foundationally derived from his or her own
culture; understanding this is relevant to the success of patient relationships. Attitudes of the
healthcare professional are easily detected by others, and they influence patient behavior; they
are not irrelevant to the success of relationships with the patient; they do influence patient
behavior; and they are not difficult for the patient to sense.

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U S N whoT has O
11. Mr. Sanchez is a 45-year-old gentleman presented to the office for a physical
examination to establish a new primary care healthcare provider. Which of the following
describes a physical, not a cultural, differentiator?
a. Race
b. Rite
c. Ritual
d. Norm
ANS: A
Race is a physical, not a cultural, differentiator. Rite is a prescribed, formal, customary
observance. Ritual is a stereotypic behavior regulating religious, social, and professional
behaviors. A norm is a prescribed standard of allowable behavior within a group.

12. Mr. Abdul is a 40-year-old Middle Eastern man who presents to the office for a first visit with
the complaint of new abdominal pain. You are concerned about violating a cultural
prohibition when you prepare to do his rectal examination. The best tactic would be to:
a. forego the examination for fear of violating cultural norms.
b. ask a colleague from the same geographic area if this examination is acceptable.
c. inform the patient of the reason for the examination and ask if it is acceptable to
him.
d. refer the patient to a provider more knowledgeable about cultural differences.
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ANS: C
Asking, if you are not sure, is far better than making a damaging mistake. Not completing the
examination could cause the patient further harm. Asking a colleague from the same
geographic area if this examination is acceptable may not be appropriate. Referring the patient
to a provider more knowledgeable about cultural differences at this point is unnecessary.

13. Mr. Jones is a 45-year-old patient who presents to the office. A person’s definition of illness is
likely to be most influenced by:
a. race.
b. socioeconomic class.
c. enculturation.
d. age group.
ANS: C
The definition of illness is determined in large part by the individual’s enculturation (the
process whereby an individual assumes the traits and behaviors of a given culture).

14. As the healthcare provider, you are informing a patient that he or she has a terminal illness.
This discussion is most likely to be discouraged in which cultural group?
a. Navajo Native Americans
b. Dominant Americans NURSINGTB.COM
c. First-generation African descendants
d. First-generation European descendants
ANS: A
The Navajo culture believes that thought and language have the power to shape reality; the
desire to avoid discussing negative information is particularly strong in this culture.

15. Because of common cultural food preferences, avoidance of monosodium glutamate (MSG) is
likely to be most problematic for the hypertensive patient of which group?
a. Native Americans
b. Hispanics
c. Chinese
d. Italians
ANS: C
The Chinese are most likely to use MSG and soy sauce in their diet.

16. An example of a cold condition is:
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a. a fever.
b. a rash.
c. tuberculosis.
d. an ulcer.
ANS: C
A cold condition in cultures with a holistic approach is tuberculosis.

MULTIPLE RESPONSE
1. Which variables can intrude on successful communication? (Select all that apply.)
a. Social class
b. Gender
c. Stereotype
d. Phenotype
e. Age
ANS: A, B, E
Social class, age, and gender are variables that characterize everyone; they can intrude on
successful communication if there is no effort for mutual knowledge and understanding.

2. Campinha-Bacote’s Process N RSINGCompetence

ofUCultural TB.COM Model includes which cultural
constructs? (Select all that apply.)
a. Desire
b. Awareness
c. Thought processes
d. Skill
e. Language
ANS: A, B, D
Campinha-Bacote’s Process of Cultural Competence Model includes the cultural constructs
encounters, desires, awareness, knowledge, and skill.

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Chapter 03: Examination Techniques and Equipment

MULTIPLE CHOICE
1. According to the guidelines for Standard Precautions, the caregiver’s hands should be washed:
a. only after touching body fluids with ungloved hands and between patient contacts.
b. only after touching blood products with ungloved hands and after caring for
infectious patients.
c. only after working with patients who are thought to be infectious.
d. after touching any body fluids or contaminated items, regardless of whether gloves
are worn.
ANS: D
Handwashing is to be done after removal of gloves, between patient contacts, and after
touching body fluids, regardless of whether gloves are used. The nurse should never touch
body fluids or blood products with ungloved hands. The nurse should use hand hygiene
regardless of a patient’s possible infection.

2. Which patient is at the highest risk for developing latex allergy?

a. The new patient who has no chronic illness and has never been hospitalized
b. The patient who has had multiple procedures or surgeries
c. The patient who is a vegetarian
NUtoRcontrast
d. The patient who is allergic SINGTdye B.COM
ANS: B
The patient who has had multiple procedures or surgeries has a higher rate of exposure to
rubber gloves and to equipment and supplies that contain latex and therefore is at a higher risk
for developing an allergic response.

3. Which technique is used during both the history taking and the physical examination process?
a. Auscultation
b. Inspection
c. Palpation
d. Percussion
ANS: B
Inspection is the technique that is used while gathering and validating data during both the
history taking and the actual hands-on physical examination. Auscultation, palpation, and
percussion are not used during the history taking and physical examination processes. It is not
possible to listen to the patient talking and use the stethoscope at the same time. The focus is
on the patient’s response to your touch and what you are feeling; it is not possible to perform
palpation and listen to the patient talking at the same time.
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4. The use of secondary, tangential lighting is most helpful in the detection of:
a. variations in skin color.
b. enlarged tonsils.
c. foreign objects in the nose or ear.
d. variations in contour of the body surface.
ANS: D
Tangential lighting is used to cast shadows to observe contours and variations in body
surfaces best.

5. You are caring for a nonambulatory 80-year-old male patient and he tells you, a female nurse,
that he feels like he is having drainage from his rectum. Which initial nursing action is
appropriate?
a. Drape the patient and observe the rectal area.
b. Tell the patient that his doctor will be notified of his problem.
c. Tell the patient that you will ask the male nurse on the next shift to check on the
problem.
d. Give the patient an ice pack to apply to the area.
ANS: A
Necessary exposure for direct observation, while adjusting for modesty, is warranted. The
complaint warrants validationNbefore
RSIreferral or delegation.
GTB.C M Before you call the clinician, you
U N O
need to assess the patient. The assessment should not wait for another shift. Before treatment,
it is important to assess the complaint.

6. You are planning to palpate the abdomen of your patient. Which part of the examiner’s hand
is best for palpating vibration?
a. Dorsal surface
b. Finger pads
c. Fingertips
d. Ulnar surface
ANS: D
The ulnar surface of the hand and bases of the fingers can best feel vibratory sensations such
as thrills and fremitus. The dorsal surface of the hand is best for assessing temperature. The
finger pads and fingertips are best for palpating pulses.

7. The dorsal surface of the hand is most often used for the assessment of:
a. crepitus.
b. temperature.
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c. texture.
d. vibration.
ANS: B
The dorsal surface, or back of the hand, is best for assessing warmth, or temperature. The
palmar surface, rather than the dorsal surface, is best for assessing crepitus. The palmar
surface, rather than the dorsal surface, is best for assessing texture. The ulnar surfaces of the
hand and fingers, rather than the dorsal surface, are best for assessing vibration.

8. Mrs. Berger is a 39-year-old woman who presents with a complaint of epigastric abdominal
pain. You have completed the inspection of the abdomen. What is your next step in the
assessment process?
a. Light palpation
b. Deep palpation
c. Percussion
d. Auscultation
ANS: D
Auscultation precedes palpation or percussion of the abdomen because these techniques can
stimulate peristalsis, which may alter correct assessment of the abdominal sounds. Light
palpation, deep palpation, and percussion should not be completed until auscultation is
completed.

OBJ: Nursing process—assessment
N R I GMSC: B.CPhysiologic
M Integrity: Physiologic Adaptation
U S N T O
9. The degree of percussion tone is determined by the density of the medium through which the
sound waves travel. Which statement is true regarding the relationship between density of the
medium and percussion tone?
a. The more dense the medium, the louder the percussion tone.
b. The less dense the medium, the louder the percussion tone.
c. The more hollow the area percussed, the quieter the percussion tone.
d. Percussion over muscle areas produces the loudest percussion tones.
ANS: B
Percussion sounds vary according to the tissue being percussed. Less dense tissue (such as
that over normal lungs) produces a loud tone, whereas more dense tissue (such as a muscle)
produces a softer tone. The more dense the medium, the softer is the percussion tone. The
more hollow the area, the louder is the percussion tone. Percussion tones over muscle are soft
and flat.

10. Expected normal percussion tones include:

a. dullness over the lungs.
b. hyperresonance over the lungs.
c. tympany over an empty stomach.
d. flatness over an empty stomach.
NURSINGTB.COM
ANS: C
A normal lung produces resonance percussion tones, whereas an empty stomach is expected
to produce tympany. Dullness indicates atelectasis of the lung. Hyperresonance over the lungs
indicates emphysema. Flatness occurs over muscle.

11. During percussion, a dull tone is expected to be heard over:

a. healthy lung tissue.
b. emphysemic lungs.
c. the liver.
d. most of the abdomen.
ANS: C
Dull tones are expected over denser areas such as the liver. Healthy lung tissue is resonant.
Emphysemic lungs are hyperresonant. Tympany is heard over most of the abdomen.

12. When using mediate or indirect percussion, which technique is appropriate?

a. Place the palmar surface of the nondominant hand on the body surface, with the
fingers held together.
b. Place the palmar surface of the nondominant hand on the body surface, with the
fingers slightly spread apart.
c. Place the ulnar surface ofNtheRnondominant hand on the body surface, with the
fingers together. U SINGTB.COM
d. Place the ulnar surface of the nondominant hand on the body surface, with the
fingers slightly spread apart.
ANS: B
The palmar surface of the nondominant (stationary) hand should rest against the body surface,
with the fingers spread slightly. A helpful tip to improve elicitation of correct tones is to
hyperextend the middle finger of the stationary hand and place the distal interphalangeal joint
firmly against the body surface. This lifting of the fingertip avoids dampening of the vibratory
sounds.

13. During percussion, the downward snap of the striking fingers should originate from the:
a. shoulder.
b. forearm.
c. wrist.
d. interphalangeal joint.
ANS: C
The downward snap of the striking fingers should originate from the wrist.
NURSINGTB.COM
14. Which technique is commonly used to elicit tenderness arising from the liver, gallbladder, or
kidneys?
a. Finger percussion
b. Palmar percussion
c. Fist percussion
d. Forearm percussion
ANS: C
Fist percussion is a direct percussion technique used to elicit tenderness over organs such as
the liver, gallbladder, or kidneys.

15. During auscultation, you can limit your perceptual field best by:
a. asking patients to describe their symptoms.
b. closing your eyes.
c. performing auscultation before percussion.
d. using an aneroid manometer.
ANS: B
By closing your eyes, your sense of hearing becomes more acute, and it increases your ability
to isolate sounds. Asking patients to describe their symptoms does not assist in the technique
of auscultation. The only time that auscultation occurs before percussion is in examination of
the abdomen. Using an aneroid manometer does not assist in the technique of auscultation.
During auscultation, the onlyNequipment
R I Gneeded B.Cis the
M stethoscope.
U S N T O
16. You are auscultating a patient’s chest. The sounds are not clear, and you are having difficulty
distinguishing between respirations and heartbeats. Which technique can you use to facilitate
your assessment?
a. Anticipate the next sounds.
b. Isolate each cycle segment.
c. Listen to all sounds together.
d. Move the stethoscope clockwise.
ANS: B
If you are hearing everything at once, it is more difficult to distinguish different sounds. Try
isolating each segment and listen to that segment intently; then move on to another segment.
For example, listen only to breath sounds, then only to inspiratory breath sounds, and then
only to expiratory breath sounds. Anticipating the next sounds will not facilitate the
assessment. Listening to all sounds together will not facilitate the assessment. One of the most
difficult achievements in auscultation is learning to isolate sounds. Moving the stethoscope
clockwise will not facilitate the assessment.

NURSINGTB.COM
17. Auscultation should be carried out last, except when examining the:
a. neck area.
b. heart.
c. lungs.
d. abdomen.
ANS: D
Auscultation is the last examination technique used for all areas except the abdomen. In this
case, it is performed after inspection.

18. Tympanic thermometers measure body temperature when a probe is placed:

a. anterior to the ear.
b. posterior to the ear.
c. under the ear.
d. in the auditory canal.
ANS: D
Tympanic thermometer probes are placed at the external opening of the auditory canal.

19. A scale used to assess patients’ weight should be calibrated:

a. only by the manufacturer.
b. by a qualified technician Nat regularly scheduled intervals.
c. each time it is used. URSINGTB.COM
d. when necessary, with the patient standing on the scale.
ANS: C
Obtaining weight begins with a manual calibration of the scale before the patient stands on the
scale. Electronic scales are automatically calibrated before each reading. The manufacturer
does not calibrate the scale after it is sold. A qualified technician does not calibrate the scale at
regularly scheduled intervals. Scales cannot be calibrated with the patient standing on the
scale.

20. The height-measuring attachment of the standing platform scale should be pulled up:
a. before the patient steps on the scale.
b. before the scale is balanced.
c. after the patient steps on the scale.
d. only after weight has been assessed.
ANS: A
To ensure patient safety, the arm of the height-measuring attachment should be pulled up
before the patient steps on the scale, after the scale is balanced, and before weight is assessed.
NURSINGTB.COM
21. The infant should be placed in which position to have his or her height or length measured?
a. Vertically, with the examiner’s hands under the infant’s axillae
b. Supine on a measuring board
c. Prone on a measuring board
d. In the lateral position, with the toes against a measuring board
ANS: B
The infant should be placed supine on a measuring board to measure height or length.

22. You are using an ophthalmoscope to examine a patient’s inner eye. You rotate the lens
selector clockwise and then counterclockwise to compensate for:
a. amblyopia.
b. astigmatism.
c. myopia.
d. strabismus.
ANS: C
Rotating the lens selector compensates for myopia (nearsightedness) or hyperopia
(farsightedness) in the examiner and patient.

N R I G B.C M
23. The pneumatic attachment for U
the S N Tis usedO to evaluate:
otoscope
a. ear canal patency.
b. eardrum landmarks.
c. hearing acuity.
d. tympanic membrane movement.
ANS: D
The pneumatic attachment on the otoscope produces a puff of air directed to the tympanic
membrane, resulting in its movement. The pneumatic attachment for the otoscope is not used
to evaluate ear canal patency, eardrum landmarks, or hearing acuity. Ear canal patency is
assessed by visually inspecting the ear. Hearing acuity is assessed by the whisper test.

24. Mr. Walters, a 32-year-old patient, tells you that his ears are “stopped up.” An objective
assessment of this complaint is achieved by using the:
a. tuning fork.
b. reflex hammer.
c. otoscope with pneumatic attachment.
d. tympanometer.
ANS: D
NURSINGTB.COM
This patient is describing eustachian tube dysfunction. The tympanometer measures

compliance of the middle ear as air pressures are varied. It is an objective means of assessing
the function of the ossicular chain, eustachian tube, and tympanic membrane. The tuning fork
assesses vibration. The reflex hammer assesses tendon reflexes. The otoscope with pneumatic
attachment assesses tympanic membrane movement.

25. Tuning forks with a frequency of 500 to 1000 Hz are most commonly used to measure:
a. buzzing or tingling sensations.
b. buzzing from bone conduction.
c. hearing range of normal speech.
d. noise above the threshold level.
ANS: C
Normal speech has a range of 300 to 3000 Hz; therefore the 500- to 1000-Hz fork is used
most often because it can estimate hearing loss in the range of normal speech.

26. To perform a deep tendon reflex measurement, you should:

a. briskly tap the tendon with the rubber end of the hammer.
b. place the hammer firmly on the tendon for 3 to 5 seconds.
c. tap the silver end of the hammer on the tendon.
d. use the needle implement to determine sensory perception.
NURSINGTB.COM
ANS: A
Deep tendon reflexes are measured by quickly and firmly tapping either end of the rubber
hammer on the stretched tendon and then observing muscle movement.

27. A variant of the percussion hammer is the neurologic hammer, which is equipped with which
of the following?
a. Brush and needle
b. Tuning fork and cotton swab
c. Penlight and goniometer
d. Ruler and bell
ANS: A
The neurologic hammer unscrews at the handle to reveal a soft brush, and the knob on the
head unscrews to reveal an attached sharp needle.

28. Transillumination functions on the principle that:

a. air, fluid, and tissue transmit light differentially.
b. black light causes certain substances to fluoresce.
NURSINGTB.COM
c. converging and diverging light brings structures into focus.

d. tangential light casts shadows that illuminate contours.
ANS: A
Transillumination functions to differentiate between various media in a cavity. It can
distinguish among air, fluid, and tissue.

MULTIPLE RESPONSE
1. Which of the following are the causes of hyperreflexia? (Select all that apply.)
a. Cold stirrups
b. Standard scale
c. Insertion of a speculum
d. Fever
e. Pressure during bimanual examination
ANS: A, C, E
Hyperreflexia is often caused by a cold, hard, examination table, cold stirrups, insertion or
manipulation of a speculum, or pressure during bimanual or rectal examinations.

NURSINGTB.COM
NURSINGTB.COM
Chapter 04: Clinical Reasoning

MULTIPLE CHOICE
1. After the subjective and objective data have been prioritized, the next step is to:
a. order laboratory tests.
b. formulate a problem list.
c. initiate appropriate referrals.
d. initiate therapy.
ANS: B
After the data have been prioritized and a presumed diagnosis is made, the next step is to
consider the appropriate laboratory tests, imaging studies, or specialty consultations.
DIF: Cognitive Level: Understanding (Comprehension) OBJ: Nursing process—evaluating

MSC: Safe and Effective Care: Management of Care
2. New findings of unknown causes are:

a. problems to be noted on the problem list.
b. deferred for subsequent visits.
c. diagnosed before physical examination.
d. reserved for specialists.
ANS: A
New findings of unknown causes are added to the problem list, but do not let them become a
red herring that distracts yourNattention
URSINfrom GTB.C OM issues.
the central
DIF: Cognitive Level: Understanding (Comprehension) OBJ: Nursing process—diagnosis

3. Which is an accepted method of making a diagnosis?

a. Relying on intuition
b. Making maximal use of laboratory tests
c. Using first assumptions
d. Using algorithms
ANS: D
Methods to make a diagnosis include recognizing patterns, sampling the universe, and using
algorithms. Do not rely on intuition, extensive use of laboratory findings, or always going
with your first assumptions.
DIF: Cognitive Level: Remembering (Knowledge) OBJ: Nursing process—diagnosis

4. The adage that “common problems occur commonly” advises the practitioner to:
a. always diagnose the patient’s problem in terms of what their practice usually sees.
b. refer any uncommon complaints to specialists as soon as possible.
c. not consider more than one diagnosis unless necessary.
d. examine uncommon problems critically before assuming that the issue is an
unusual presentation of a common problem.
NURSINGTB.COM
ANS: C
This adage is to guide the practitioner to pay attention to unexpected or unusual findings but
not to consider more than one diagnosis unless necessary and to favor the simplest hypothesis
when competing hypotheses exist.
DIF: Cognitive Level: Analyzing (Analysis) OBJ: Nursing process—diagnosis

5. The most important guide to sequencing actions should be:

a. probability and utility.
b. assumption and intuition.
c. costs and risks of procedures.
d. reimbursement potential and patient acceptance.
ANS: A
Although all choices are relevant, the prioritized guide is to select actions based on an
estimate of the probability of successfully achieving the patient’s goals and on the utility of
implementation.

6. Utilitarianism can be described as:

a. balancing interests.
b. preventing harm.
c. choosing wisely.
d. doing good.
NURSINGTB.COM
ANS: C
Utilitarianism occurs when one considers appropriate use of resources with concern for the
greater good of the larger community. It also means to “choose wisely.”

7. Positive outcomes depend on the:

a. number of laboratory tests ordered.
b. quality of decisions made.
c. use of pharmacologic modalities.
d. time saved by the use of ancillary personnel.
ANS: B
Positive patient outcomes are dependent on your ability to arrive at accurate hypotheses that
then direct quality patient care decisions.

8. Self-analysis assists providers in giving proper context to:

a. history and physical findings.
b. therapeutic options.
NURSINGTB.COM
c. attitudes, values, and feelings.

d. differential diagnoses.
ANS: C
Knowing the intensity of your personal attitudes, values, and emotional feelings about patient
care situations helps prevent you from being overtaken by your own impaired or distorted
viewpoints.

9. Medical decision making requires a balance between:

a. trust and suspicion.
b. ethical and unethical behavior.
c. remembering and superstition.
d. mechanism and probabilism.
ANS: D
In making medical decisions, you cannot be too scientific or pursue every possible scenario.

10. A valid history and physical examination can serve to:

a. create higher healthcare costs.
b. limit the indiscriminate use of diagnostics.
c. threaten patient satisfaction.
d. increase the risk of liability.
N R I G B.C M
U S N T O
ANS: B
A comprehensive history with a competent clinical examination can lead you to generate a
more accurate problem list, and therefore increase the proper usage of diagnostic testing while
limiting its indiscriminate use.

11. A specific test is one that has the ability to:

a. correctly identify those who have the disease.
b. correctly identify those who do not have the disease.
c. be exclusively used to make a diagnosis.
d. exclude competing explanations for another test finding.
ANS: B
The specificity of a test is determined by its ability to identify those who do not have the
disease for which the test has been designed. Negative results are more likely to be valid.

12. Mr. Johnson actually has streptococcal pharyngitis; however, the throat culture is initially read
as negative. This situation describes a test with a:
NURSINGTB.COM
a. low sensitivity.
b. high sensitivity.
c. high specificity.
d. low specificity.
ANS: A
This situation describes a test designed to test those who are positive for the disease. At this
time, the test was not able to detect a true-positive; therefore, the test had a low sensitivity.

13. Which of the following is not a component of a management plan?

a. Presumptive diagnosis
b. Patient education
c. Diet modification
d. Physical therapy
ANS: A
The management plan details what you are going to do about a patient problem such as
education, diet modifications, and physical therapy referrals.

OBJ: Nursing process—implementing MSC: Safe and Effective Care: Management of Care
14. When determining actions for the management plan, the practitioner should first address:
a. problems in the order of their chronologic development.
b. the patient’s concern about
NUaRparticular problem.
SIcircumstances.
c. the patient’s social and economic NGTB.COM
d. the most urgent problem.
ANS: D
In developing patient care plans, priority should be given to the most life-threatening and
urgent physical needs of the patient. Then focus on addressing the patient’s social and
economic circumstances.

MULTIPLE RESPONSE
1. When utilizing a joint approach with the patient, which factors are likely to be considered?
(Select all that apply.)
a. Consultations
b. Laboratory studies
c. Assistive technology
d. Patient education
e. Practitioner background
ANS: A, B, C
NURSINGTB.COM
A joint approach between the patient and practitioner should include laboratory and imaging
studies, subspecialty consultation, medications, equipment, special care, diet and activity
modification, follow-up visit, and patient education.
DIF: Cognitive Level: Remembering (Knowledge) OBJ: Nursing process—evaluating

NURSINGTB.COM
NURSINGTB.COM
Chapter 05: Documentation

MULTIPLE CHOICE
1. Which part of the information contained in the patient’s record may be used in court?
a. Subjective information only
b. Objective information only
c. Diagnostic information only
d. All information
ANS: D
Anything that is entered into a patient’s record, in paper or electronic form, is a legal
document and can be used in court.

OBJ: Integrated process—communication and documentation
MSC: Physiologic Integrity: Basic Care and Comfort
2. Ms. S reports that she is concerned about her loss of appetite. During the history, you learn
that her last child recently moved out of her house to go to college. Rather than infer the cause
of Ms. S’s loss of appetite, it would be better to:
a. defer or omit her comments.
b. have her husband call you.
c. quote her concerns verbatim.
d. refer her for psychiatric treatment.
NURSINGTB.COM
ANS: C
It is best to document what you observe and what is said by the patient rather than
documenting your interpretation. Listening and quoting exactly what the patient says is the
better rule to follow.

3. Which is an effective adjunct to document the location of findings during the recording of the
physical examination?
a. Relationship to anatomic landmarks
b. Computer graphics
c. Comparison with other patients of same gender and size
d. Comparison to previous examinations using light pen markings
ANS: A
Abnormal or normal findings are best described in relationship to universal topographic and
anatomic landmarks.

NURSINGTB.COM
4. The position on a clock, topographic notations, and anatomic landmarks:

a. are methods for recording locations of findings.
b. are used for noting disease progression.
c. are ways for recording laboratory study results.
d. should not be used in the legal record.
ANS: A
Descriptions of the locations of findings are universally referenced by using positions on a
clock, topographic notations, or anatomic landmarks.

5. Regardless of the origin, discharge is described by noting:

a. a grading scale of 0 to 4.
b. color and consistency.
c. demographic data and risk factors.
d. associated symptoms in alphabetic order.
ANS: B
Regardless of where the discharge originates, color and consistency determine whether it is an
expected finding.

N R I G B.COM
U useful
6. Drawing of stick figures is most S Nto:T
a. compare findings in extremities.
b. demonstrate radiation of pain.
c. indicate consistency of lymph nodes.
d. indicate mobility of masses.
ANS: A
Simple drawings, such as stick figures, are more practical illustrations for findings in
extremities. Radiation of pain, consistency of lymph nodes, and mobility of masses would not
be adequately described by such simple drawings.

7. Which is an example of a problem that requires recording on the patient’s problem list?
a. Common age variations
b. Expected findings
c. Problems needing further evaluation
d. Minor variations
ANS: C
NURSINGTB.COM
Any problem is worth noting on the patient problem list, even if the cause or significance is
unknown. Common age variations, expected findings, and minor variations within normal
limits should not be classified as a problem.

8. A problem may be defined as anything that will require:

a. evaluation.
b. medication.
c. surgery.
d. treatment.
ANS: A
The need for further evaluation or attention indicates a problem. If a problem is found, it does
not necessarily warrant medication, surgery, or treatment.

9. Differential diagnoses belong in the:

a. history.
b. physical examination.
c. assessment.
d. plan.
ANS: C
NURSINGTB.COM
Differential diagnoses for problems that have not been diagnosed are placed in the assessment
category for each problem. The differentials are prioritized, and contributing factors are
identified.

10. Which of the following is not a component of the plan portion of the problem-oriented
medical record?
a. Diagnostics ordered
b. Therapeutics
c. Patient education
d. Differential diagnosis
ANS: D
The differential diagnosis is part of the assessment phase.

NURSINGTB.COM
11. Your patient returns for a blood pressure check 2 weeks after a visit during which you
performed a complete history and physical examination. This visit would be documented by
creating a(n):
a. progress note.
b. accident report.
c. problem-oriented medical record.
d. triage note.
ANS: A
A second visit with the clinician is always recorded on a progress note, noting any updates to
the condition.

12. A detailed description of the symptoms related to the chief complaint is presented in the:
a. history of present illness.
b. differential diagnosis.
c. assessment.
d. general patient information section.
ANS: A
The signs and symptoms and historical data of the patient’s experience that led up to the chief
complaint are placed in the history of present illness.

OBJ: Integrated process—communication
NURSINGand documentation
MSC: Physiologic Integrity: Basic TB.COM
Care and Comfort
13. The effect of the chief complaint on the patient’s lifestyle is recorded in which section of the
medical record?
a. Chief complaint
b. History of present illness
c. Past medical history
d. Social history
ANS: B
The effect of the patient’s complaint on current everyday lifestyle or work performance is
recorded in the history of present illness.

14. The patient’s perceived disabilities and functional limitations are recorded in the:
a. problem list.
b. general patient information.
c. social history.
d. history of present illness.
ANS: D
NURSINGTB.COM
The history of present illness contains information about the patient’s lifestyle, as well as
disabilities or functional limitations that alter activities of daily living.

15. The review of systems is a component of the:

a. physical examination.
b. health history.
c. assessment.
d. past medical-surgical history.
ANS: B
The review of systems relates health history according to physical systems and is presented
just before the actual physical examination.

16. Allergies to drugs and foods are generally listed in which section of the medical record?
a. History of present illness
b. Past medical history
c. Social history
d. Problem list
ANS: B
N R I G B.C M
U contains
The past medical history section S N T O such as allergies to drugs and foods and
information
environmental allergies.

17. Information recorded about an infant differs from that recorded about an adult, mainly
because of the infant’s:
a. attention span.
b. developmental status.
c. nutritional differences.
d. source of information.
ANS: B
The organizational structure of an infant’s record is different because the infant’s current and
future health is referenced in terms of developmental status.

18. Which finding is unique to the documentation of a physical examination of an infant?

a. Fontanel size
NURSINGTB.COM
b. Liver span
c. Prostate size
d. Thyroid position
ANS: A
The size and characteristic of the fontanel are unique and important in the assessment of an
infant.

19. Data relevant to the social history of older adults includes information on:
a. family support systems.
b. previous healthcare visits.
c. over-the-counter medication intake.
d. date of last cancer screening.
ANS: A
The social history of older adults includes community and family support systems.

20. A SOAP note is used in which type of recording system?

a. Preventive care
b. Problem oriented
c. Systems review
NURSINGTB.COM
d. Traditional treatment
ANS: B
A SOAP note—subjective problem data, objective problem data, assessment, and plan—is a
type of recording system that has a problem-oriented style.

21. The examiner’s evaluation of a patient’s mental status belongs in the:

a. history of present illness.
b. review of systems.
c. physical examination.
d. patient education.
ANS: C
Mental status assessment, including cognitive and emotional stability and speech and
language, is part of the physical examination.

NURSINGTB.COM
22. Which format would be used for visits that address problems not yet identified in the
problem-oriented medical record (POMR)?
a. Brief SOAP note
b. Comprehensive health history
c. Progress note
d. Referral note
ANS: A
Follow-up visits for problems identified in the POMR are recorded in the progress notes.
Those visits not identified as problems are recorded using the SOAP format. Careful review of
all SOAP notes on a regular basis will detect the emergence of a condition that explains the
patient’s complaints; at that point, SOAP documentation is stopped.

23. George Michaels, a 22-year-old patient, tells the nurse that he is here today to “check his
allergies.” He has been having “green nasal discharge” for the last 72 hours. How would the
nurse document his reason for seeking care?
a. GM is a 22-year-old male here for “allergies.”
b. GM came into the clinic complaining of green discharge for the past 72 hours.
c. GM, a 22-year-old male, states that he has allergies and wants them checked.
d. GM is a 22-year-old male here for having “green nasal discharge” for the past 72
hours.
ANS: D
NURSINshould
Documentation of the chief complaint GTB.C OM be done by using the patient’s own
always
words in quotation marks.

NURSINGTB.COM
Chapter 06: Vital Signs and Pain Assessment

MULTIPLE CHOICE
1. The pyrexia response is triggered by the production and release of:

a. prostaglandins.
b. endogenous pyrogens.
c. hypothalamic enzymes.
d. thyroid hormones.
ANS: A
When microorganisms invade the body, pyrogens are released and travel to the hypothalamus.
The pyrexia response is then triggered by the production and release of prostaglandins.

2. During expiration, the internal intercostals:

a. increase the force of muscular contraction.
b. decrease the lateral diameter during expiration.
c. decrease the intrathoracic space.
d. increase elastic recoil during expiration.
ANS: B
The diaphragm is the dominant muscle during respiration. It contracts and pushes downward
during inspiration to increaseNthe
URintrathoracic
SINGTB.C OM The external intercostal muscles increase
space.
the AP diameter during inspiration and the internal intercostals decrease the lateral diameter
during expiration.

3. The fifth vital sign is:

a. pain.
b. orientation.
c. waist-to-hip ratio.
d. body mass index (BMI).
ANS: A
Pain, the universal distress signal, is now recognized as the fifth vital sign.

4. The Joint Commission (TJC) requires that:

a. pain be assessed on all discharges.
b. repeated assessment of pain be limited to those patients who complain of pain.
c. repeated intensity documentation be made of the course of pain relief for all
patients.
d. pain be assessed on surgical patients.
NURSINGTB.COM
ANS: C
TJC requires pain assessment on all admissions, repeated assessments for pain regardless of
the initial complaint or surgical experience, and repeated intensity documentation of the
course of pain relief for all patients.

5. The perception of pain:

a. is the same across cultures.
b. can be easily assessed in neonates.
c. is predictable with the same circumstances.
d. is affected by emotions and quality of sleep.
ANS: D
The perception of pain is variable and is affected by emotions, cultural background, sleep
deprivation, previous pain experience, and age. Perception of pain is different among different
cultures. Neonates do feel pain, but perception of pain cannot be assessed in neonates. Each
circumstance will provide different pain perception.

6. The most frequent cause of serious hypertension in children is:

a. heart disease.
b. liver failure.
c. renal disease.
d. rheumatic fever.
NURSINGTB.COM
ANS: C
If the systolic blood pressure is elevated and the diastolic blood pressure is not, anxiety may
be responsible. Blood pressure in children varies by gender and height at any age.
Hypertension in children is becoming more common because of the increased prevalence of
overweight children. Usually, hypertension is caused by kidney disease, renal arterial disease,
coarctation of the aorta, and pheochromocytoma, not heart disease, liver failure, or rheumatic
fever.

OBJ: Nursing process—assessment MSC: Physiologic Integrity: Reduction of Risk Potential
7. Underestimation of blood pressure will occur if the cuff’s width covers:

a. less than half of the upper arm.
b. less than 5 inches of the lower arm.
c. more than two-thirds of the upper arm.
d. more than 4 inches of the lower arm.
ANS: C
Cuffs that are too wide will underestimate blood pressure, which would occur with a cuff that
covers more than two-thirds of the upper arm.
NURSINGTB.COM
8. Which pulse characteristic in the neonate may indicate infection?

a. Bounding pulse rate
b. Regular pulse rate
c. Sustained high pulse rate
d. Intermittent slow pulse rate
ANS: C
Sustained tachycardia in a neonate may be the first indication of infection.

9. Infants delivered by Cesarean section demonstrate which respiratory characteristic in

comparison to infants delivered vaginally?
a. Slower respiratory rate
b. Faster respiratory rate
c. Shallower respirations
d. Deeper respirations
ANS: B
Infants delivered by Cesarean section may have a more rapid respiratory rate than babies
delivered vaginally.

NURSINGTB.COM
MULTIPLE RESPONSE
1. Which occurs with malignant hypertension? (Select all that apply.)

a. Blurred vision
b. Sleep disturbance
c. Tachycardia
d. Dyspnea
e. Encephalopathy
ANS: A, D, E
Signs of malignant hypertension include headache, blurred vision, dyspnea, and
encephalopathy.

2. In a syndrome in which regional pain extends beyond this specific peripheral nerve injury,
you would notice which of the following? (Select all that apply.)
a. Allodynia
b. Sleep disturbance
c. Blood flow changes
d. Numbness
e. Edema
NURSINGTB.COM
ANS: A, C, D, E
Complex regional pain syndrome includes the following symptoms: burning shooting pain
with aching character, exaggerated sensitivity to cold, allodynia, numbness, edema, blood
flow changes, and temperature changes.

NURSINGTB.COM
NURSINGTB.COM
Chapter 07: Mental Status

MULTIPLE CHOICE
1. When is the mental status portion of the neurologic system examination performed?
a. During the history-taking process
b. During assessment of cranial nerves and deep tendon reflexes
c. During the time when questions related to memory are asked
d. Continually, throughout the entire interaction with a patient
ANS: D
A mental status evaluation should be continually performed throughout the patient encounter.
Assessing and validating clues to determine the individual’s ability to interact within the
environment is a priority of the mental status evaluation.

2. A 69-year-old truck driver presents with a sudden loss of the ability to understand spoken
language. This indicates a lesion in the:
a. temporal lobe.
b. Broca area.
c. frontal cortex.
d. cerebellum.
ANS: A NURSINGTB.COM
The temporal lobe, specifically in the Wernicke speech area, is responsible for the
comprehension of spoken and written language.

3. The ability for abstract thinking normally develops during:

a. infancy.
b. early childhood.
c. adolescence.
d. adulthood.
ANS: C
Abstract thinking is an intellectual maturation that develops during adolescence.

4. The Mini-Mental State Examination (MMSE) may be used to:

a. estimate cognitive changes quantitatively.
b. estimate personality disorders qualitatively.
c. diagnose neurologic disorders.
d. determine the cause of memory loss.
NURSINGTB.COM
ANS: A
The MMSE is a standard tool that functions to estimate cognitive function quantitatively or to
document cognitive changes serially.

5. Assessing orientation to person, place, and time helps determine:

a. ability to understand analogies.
b. abstract reasoning.
c. attention span.
d. state of consciousness.
ANS: D
Orientation to person, place, and time are measures of states of consciousness and awareness.

6. When you ask the patient to tell you the meaning of a proverb or metaphor, you are assessing
which of the following?
a. Level of consciousness
b. Abstract reasoning
c. Emotional stability
d. Memory
ANS: B
Asking the patient to tell youNtheRmeaning of a proverb, metaphor, or fable assesses the
U SIAsking
patient’s ability to reason abstractly. NGTB.C OM to tell you the meaning of a proverb or
the patient
metaphor does not assess level of consciousness, emotional stability, or memory. The
Mini-Mental State Examination tests memory.

7. Impairment of arithmetic skills is often the result of:

a. impaired execution of motor skills.
b. impaired judgment.
c. perceptual distortions.
d. depression.
ANS: D
The patient with depression can display difficulty with simple arithmetic calculations.

8. Peripheral neuropathy is most likely to be manifested by:

a. impaired memory.
b. impaired abstract reasoning.
c. impaired writing ability.
d. hallucinations.
NURSINGTB.COM
ANS: C
Uncoordinated writing or drawing may indicate peripheral neuropathy, dementia, parietal lobe
damage, or a cerebellar lesion.

9. Recent memory may be tested by:

a. asking the patient to name the past four presidents.
b. asking the patient to listen to and repeat a series of numbers.
c. showing the patient four items and asking him or her to list the items about 10
minutes later.
d. asking the patient about verifiable information, such as his or her mother’s maiden
name.
ANS: C
Showing the patient four or five objects, saying you will ask about them in a few minutes, and
then 10 minutes later asking the patient to list the objects is a technique to measure recent
memory.

10. Loss of immediate and recent memory with retention of remote memory suggests:
a. attention-deficit/hyperactivity disorder (ADHD).
b. impaired judgment.
c. stupor.
d. dementia.
NURSINGTB.COM
ANS: D
Dementia is the loss of both immediate and recent memory while retaining remote memories.
ADHD is associated with recent and remote memory impairment. Impaired judgment is a
thought process dysfunction. Stupor is impaired consciousness.

11. You ask the patient to follow a series of short commands to assess:
a. judgment.
b. attention span.
c. arithmetic calculations.
d. abstract reasoning.
ANS: B
Asking the patient to follow a series of short commands will test attention span.

12. Which observation would be most significant when assessing the condition of a patient who
has judgment impairment?
NURSINGTB.COM
a. Repeated failure to fulfill family obligations

b. Forgetting family members’ birth dates
c. Going to church three times a week
d. Planning for retirement in 20 years
ANS: A
Inadequately dealing with family and social affairs indicates impaired judgment, whereas the
other choices do not.

13. Appropriateness of logic, sequence, cohesion, and relevance to topics are markers for the
assessment of:
a. mood and feelings.
b. attention span.
c. thought process and content.
d. abstract reasoning.
ANS: C
Thought process and content are examined while observing the patient’s patterns of thinking,
especially appropriateness of sequence, logic, coherence, and relevance to the topics
discussed.

14. Which type of hallucination is

NUmost
RSI commonly associated with alcohol withdrawal?
a. Olfactory NGTB.COM
b. Visual
c. Auditory
d. Tactile
ANS: D
Tactile hallucinations are most commonly associated with alcohol withdrawal.

15. Flight of ideas or loosening of associations is associated with:

a. aphasia.
b. dysphonia.
c. multiple sclerosis.
d. psychiatric disorders.
ANS: D
Flight of ideas, loosening of associations, word salads, neologisms, clang associations,
echolalia, and utterances of unusual sounds are all associated with psychiatric disorders.

NURSINGTB.COM
16. The Glasgow Coma Scale is used to:

a. determine the cause of decreased consciousness.
b. diagnose disorders that alter level of consciousness.
c. quantify consciousness.
d. predict response to stimulant medications.
ANS: C
The Glasgow Coma Scale is used when a patient has an altered level of consciousness and is
used to quantify consciousness.

17. Which condition is considered progressive rather than reversible?

a. Delirium
b. Dementia
c. Depression
d. Anxiety
ANS: B
Dementia is considered progressive and irreversible. Delirium has the potential for reversal.
Depression and anxiety are reversible.

18. A clinical syndrome of failing memory and impairment of other intellectual functions, usually
related to obvious structural diseases
NURSIofNGthe B.C
brain, describes:
a. delirium. T OM
b. dementia.
c. depression.
d. anxiety.
ANS: B
Dementia results from a chronic progressive deterioration of the brain that results in failing
memory and impairment of other intellectual functioning.

19. Mrs. Griffiths, a 28-year-old patient, presents to your office to discuss her
attention-deficit/hyperactivity disorder (ADHD). Which statement is true in regard to ADHD?
a. It occurs before 7 years of age.
b. It is usually related to mental retardation.
c. It is usually related to dementia.
d. It is manifested by prolonged periods of catatonic behavior.
ANS: A
ADHD occurs before 7 years of age. ADHD is not related to mental retardation, dementia, or
prolonged periods of catatonic behavior.
NURSINGTB.COM
20. An aversion to touch or being held, along with delayed or absent language development, is
characteristic of:
a. attention-deficit/hyperactivity disorder.
b. autism.
c. dementia.
d. mental retardation.
ANS: B
Autistic disorder involves a combination of behavioral traits (lack of awareness of others,
aversion to touch or being held, odd or repetitive behaviors, or preoccupation with parts of
objects) and communication deficits (usually echolalia [parrot speech]).

21. You are interviewing a 20-year-old patient with a new-onset psychotic disorder. The patient is
apathetic and has disturbed thoughts and language patterns. The nurse recognizes this
behavior pattern as consistent with a diagnosis of:
a. depression.
b. autistic disorder.
c. mania.
d. schizophrenia.
ANS: D
Schizophrenia manifests as a psychotic disorder of early adult onset, with disturbances in
language and speech, emotions
NUand
RSsocial
INGTwithdrawal,
B.COM and apathy. Depression and mania do
not have the language or speech component. Autistic disorders are not psychotic disorders,
and they usually begin before 3 years of age.

22. While interviewing a patient, you ask him to explain the “Lion and the Mouse” to assess:
a. reading comprehension.
b. attention span.
c. mood and feeling.
d. reasoning skills.
ANS: D
Having the patient explain fables or metaphors determines abstract reasoning skills.

23. The Mini-Mental State Examination (MMSE) should be administered for the patient who:
a. gets lost in her neighborhood.
b. sleeps an excessive amount of time.
c. has repetitive ritualistic behaviors.
d. uses illegal hallucinogenic drugs.
NURSINGTB.COM
ANS: A
The MMSE is a tool used to quantitatively estimate cognitive function or to serially document
cognitive changes. Getting lost in a familiar territory is a sign of possible cognitive
impairment.

MULTIPLE RESPONSE
1. Which clinical assessments test attention span?

a. Spell WORLD backward.
b. Draw a clock.
c. Say the days of the week.
d. Do arithmetic calculations.
e. Explain “a stitch in time saves nine.”
ANS: A, C, D
Clinical assessments to test attention span include spell WORLD backward, say the days of
the week, and do arithmetic calculations. Drawing a clock tests writing ability, and explaining
a “stitch in time saves nine” tests abstract reasoning.

2. Which are signs and symptoms of dementia?

a. Aphasia
b. Apathy
NURSINGTB.COM
c. Odd behaviors
d. Disintegration of personality
e. Lack of awareness of others
ANS: A, B, D
Aphasia, apathy, and disintegration of personality are all characteristics of dementia. Odd
behaviors and lack of awareness of others are characteristics of autism.

COMPLETION
1. Under most conditions, adult patients should be able to repeat forward a series of
_____________ numbers.
ANS:
five to eight
5-8
Most adults should be able to immediately recall a series of five to eight numbers forward and
a series of four to six numbers backward.
NURSINGTB.COM

2. The examiner should be concerned about neurologic competence if a social smile cannot be
elicited by the time a child is _________ old.
ANS:
2 to 3 months
A social smile is expected in the 2- to 3-month-old infant. If it is difficult or impossible to

elicit a social smile by 3 months, the infant may not be neurologically intact.

NURSINGTB.COM
NURSINGTB.COM
Chapter 08: Growth, Measurement, and Nutrition

MULTIPLE CHOICE
1. The gonads begin to secrete estrogen and testosterone during:

a. infancy.
b. puberty.
c. pregnancy.
d. early adulthood.
ANS: B
At puberty, the gonads secrete testosterone and estrogen. As a result, secondary sex
characteristics (e.g., genitalia growth) begin to appear. Maturation occurs at a mean age of
11.5 years in females and 13.5 years in males.

2. Developmental changes of puberty are caused mainly by the interaction of the pituitary gland,
gonads, and:
a. hypothalamus.
b. islet cells.
c. thalamus.
d. thymus.
Under the influence of the hypothalamus, pituitary gland, and gonads, developmental changes
of puberty are established.

3. After 50 years of age, stature:

a. becomes fixed.
b. begins a barely perceptible secondary increase.
c. increases at a rate of 0.5 cm/year.
d. declines.
ANS: D
As the individual reaches 50 years of age, the intervertebral disk begins to thin and become
more compressed, which leads to a decline in stature.

4. By 10 to 12 years of age, lymphatic tissues are about:

a. 25% of adult size.
b. 50% of adult size.
c. the same as adult size.
d. twice the size of those in the adult.
NURSINGTB.COM
ANS: D
Lymphatic tissues are small compared with total body size, but they are almost fully
developed at birth. They grow fast and are about twice the adult size by age 10 to 12 years.

5. During adolescence, the head size normally increases as a result of:

a. sinus development.
b. brain mass increase.
c. evolution of lymphatic tissue.
d. hypertrophy of myelin.
ANS: A
As the facial sinuses grow, the head size enlarges its surface area to accommodate their
growth.

6. Gender-specific skeletal differences first occur during:

a. the second stage of fetal development.
b. late infancy.
c. early childhood.
d. adolescence.
ANS: D
During adolescence, femalesNdevelop
URSIaNwider
GTB.C OMand males develop broad shoulders;
pelvis
males transition from a slight increase in body fat to more lean muscle mass in later puberty,
whereas females maintain an increase in adipose tissue throughout adolescence.

7. Mrs. Layton is a 33-year-old patient who is obese. Most adult obesity begins:
a. in adolescence.
b. in childhood.
c. after the skeletal growth is completed.
d. once sexual maturation is complete.
ANS: A
Most adult obesity begins in adolescence.

8. The legs are the fastest growing body part during:

a. early infancy.
b. late infancy.
c. childhood.
d. early adulthood.
NURSINGTB.COM
ANS: C
Legs grow the fastest during childhood, whereas the trunk grows fastest in infancy, and the
skeletal muscles and organs grow fastest in early adulthood.

9. Skeletal mass and organ systems double in size during:

a. infancy.
b. early childhood.
c. adolescence.
d. early adulthood.
ANS: C
During puberty, sex steroids stimulate secretion of growth hormone, causing the organs and
skeletal mass to double in size.

10. Optimal infant birth weight is difficult for pregnant adolescents to obtain because:
a. they have not completed their own growth spurt.
b. there are insufficient uterine supporting structures.
c. the amniotic fluid is variable in pregnant adolescents.
d. blood volume has not reached adult proportions.
ANS: A
Pregnant adolescents youngerNthan 16 years,B.C
or lessMthan 2 years from menarche, may still be
in their growth spurt. They mayUR SING
require T weight
higher O gains during pregnancy to achieve an
optimal infant birth weight. There are sufficient uterine supporting structures in the pregnant
adolescent. The amnionic fluid is not variable in pregnant adolescents. Blood volume has
reached adult proportions in the pregnant adolescent.

11. How much of the weight gained during a normal pregnancy is accounted for by the fetus?
a. Less than 5 pounds
b. 6 to 8 pounds
c. 9 to 12 pounds
d. 13 to 30 pounds
ANS: B
The growing fetus accounts for only 6 to 8 pounds of the total weight gained. The remainder
results from an increase in maternal tissues (e.g., placenta, amniotic fluid, uterus, blood and
fluid volume, breasts, and fat reserves).

12. The rate of weight gain during pregnancy is expected to be:

a. greatest in the first trimester.
NURSINGTB.COM
b. greatest in the second trimester.

c. greatest in the third trimester.
d. about the same in each trimester.
ANS: B
The rate of weight gain is slow during the first trimester, rapid during the second trimester,
and less rapid during the third trimester. Maternal tissue growth accounts for most of the
weight gained in the first and second trimesters, whereas fetal growth accounts for weight
gained during the third trimester.

13. During a preventive healthcare visit, Ms. G, an older patient, states that she is getting shorter.
She says that her son mentioned that her change in stature became noticeable to him during
his last visit with her. Her posture appears straight and aligned. When addressing Ms. G.’s
present concerns, it is most important to inquire about:
a. the number of pregnancies.
b. her parents’ heights.
c. a history of scoliosis.
d. her usual height and weight.
ANS: D
Stature declines after 50 years of age because of progressive thinning of the intervertebral
disks, so it is important to determine the patient’s height and weight at this age as a baseline
for future trending.
NU(Application)
DIF: Cognitive Level: Applying RSINGTB.COM
14. Over the past 2 decades, there has been a trend toward:
a. increased osteoporosis.
b. preservation of height.
c. obesity in older adults.
d. preservation of muscle mass.
ANS: C
An increase in overweight and obese older adults has been documented over the past 15 to 20
years. A decrease in weight for height and body mass index has been found with increasing
age in patients between 70 and 89 years of age.

15. Milestone achievements are data most likely to appear in the history of:
a. adolescents.
b. infants.
c. school-age children.
d. young adults.
ANS: B
NURSINGTB.COM
As part of developmental assessment in infants, milestone achievements at certain ages, such

as crawling, laughing, picking up their head, and turning over, are recorded.

16. To estimate an individual’s frame size, the examiner should measure:

a. skull circumference.
b. the length from the olecranon process to the acromion process.
c. elbow breadth.
d. hip circumference.
ANS: C
With the patient’s right arm extended and the elbow flexed to 90 degrees, measure the elbow
breadth using a measuring device or skinfold calipers, held on the same plane as the upper
arm, on the two most prominent bones of the elbow.

17. Healthy term babies generally double their birth weight by what age?
a. 3 months
b. 5 months
c. 9 months
d. 12 months
ANS: B
In general, healthy infants double
NURtheir
INbirth
GTB.CweightMby 4 to 5 months of age and triple their
birth weight by 12 months of age. S
Formula-fed O are heavier after the first 6 months of
infants
life than breast-fed infants; they grow faster in the first 6 months of life and experience slower
growth in the second 6 months of the first year.

18. Infants born to the same parents are normally within which range of weight of each other?
a. 6 ounces
b. 12 ounces
c. 1 pound
d. 2 pounds
ANS: A
Siblings born at term to the same parents usually weigh within 6 ounces of each other.

19. To measure head circumference, the tape is wrapped snugly around the child’s head at the
occipital protuberance and the:
a. supraorbital prominence.
b. brow line.
c. nasal bridge.
NURSINGTB.COM
d. chin.
ANS: A
The measuring tape should be snugly wrapped around the child’s head at the occipital
protuberance and supraorbital prominence, thereby documenting the largest circumference.
Care should be taken to ensure that the tape does not cut the skin. Make the reading to the
nearest 0.5 cm or inch, and remember to remeasure the head circumference at least once to
check the accuracy of your measurement.

20. Between 5 and 24 months of life, the infant’s chest circumference is normally:
a. about equal to the head circumference.
b. greater than head circumference by 2 inches.
c. smaller than head circumference by about 4 inches.
d. at least 2 inches smaller than head circumference.
ANS: A
Between the ages of 5 months and 2 years, the infant’s chest circumference should closely
approximate the head circumference; the ratio should be monitored so that possible
microcephaly can be identified.

21. In clinical practice, the Ballard Assessment Tool is used to assess a newborn’s:
a. length. NURSINGTB.COM
b. weight.
c. lung maturity.
d. gestational age.
ANS: D
The Ballard Assessment Tool assesses six physical and six neuromuscular characteristics and
is administered within 36 hours of birth to confirm the newborn’s gestational age.

22. Which situation poses the most concern?

a. The child whose weight and height ratios have remained at the 50th percentile
b. The child whose weight and height ratios have stayed between the 90th and 95th
percentiles
c. The child whose weight and height ratios have never been above the 50th
percentile
d. The child whose weight and height ratios have dropped 15 percentiles since the
last visit
ANS: D
NURSINGTB.COM
Over time, interval measurements should demonstrate that the child has established a growth
pattern, indicated by consistently following a percentile curve on the growth chart. Greatest
concern is for the child who is trending down in a more dramatic fashion. Children who
suddenly fall below or rise above their established percentile growth curve should be
examined more closely to determine the cause.

23. The upper-to-lower segment ratio should be calculated:

a. bimonthly for the first year of life.
b. annually for the first 5 years.
c. only when a child is suspected of having a growth problem or unusual body
proportions.
d. in children of first-generation immigrants.
ANS: C
The upper-to-lower segment ratio is calculated when a child is suspected of having a growth
problem or unusual body proportions.

24. Which statement regarding female pubertal changes is true?

a. Most adolescent girls will develop breasts before they develop pubic hair.
b. Peak height velocity should occur after menarche.
c. Breast asymmetry is an abnormal finding.
d. Menarche should occur by NUTanner
RSINbreast
GTB.C M
stageO2.
ANS: A
In two-thirds of the population of girls, breasts begin to develop before pubic hair. Peak height
velocity actually occurs about 1 year before menarche, breast asymmetry is common, and
menarche occurs after Tanner breast stage 2. Peak height velocity will not occur after
menarche. Breast asymmetry is not an abnormal finding. Menarche does not generally occur
by Tanner breast stage 2.

25. What is the youngest age at which pubic hair growth in the male may be considered normal?
a. 7 years
b. 8 years
c. 9 years
d. 10 years
ANS: C
In males, sexual development before 9 years of age is precocious puberty and is considered an
abnormal finding; sexual development after 9 years of age is considered normal puberty.

NURSINGTB.COM
26. A pregnant woman of normal prepregnancy weight should be expected to gain how much
weight per week during the second and third trimesters of pregnancy?
a. 1 pound
b. 3 pounds
c. 2 pounds
d. 4 pounds
ANS: A
Expected weight gain in the first trimester is variable, between 1 and 2 kg (2 to 4 pounds);
however, in the second and third trimesters, weekly weight gain should be around 0.45 kg (1
pound) per week.

27. A prominent forehead, large nose, large jaw, and elongation of the facial bones and
extremities are signs of:
a. infantile hydrocephalus.
b. acromegaly.
c. Cushing syndrome.
d. achondroplasia.
ANS: B
A prominent forehead, large nose, large jaw, and elongation of the facial bones and
extremities are all prominent characteristics of acromegaly; a prominent forehead can also
occur with achondroplasia, but hypoplasia of the midface differentiates the two.
NURSI
DIF: Cognitive Level: Remembering
NGMSC:
TB.C
(Knowledge)
OM
OBJ: Nursing process—assessment Physiologic Integrity: Physiologic Adaptation
28. Round face, preauricular fat, hyperpigmentation, and “buffalo hump” in the posterior cervical
area are associated with:
a. infantile hydrocephalus.
b. acromegaly.
c. Cushing syndrome.
d. achondroplasia.
ANS: C
Round face, preauricular fat, hyperpigmentation, and a buffalo hump in the posterior cervical
area are all commonly associated with Cushing syndrome; the buffalo hump distinguishes
Cushing syndrome from the other choices.

29. Mrs. Raymonds is a 24-year-old patient who has presented for a routine concern over her
current weight. In your patient teaching with her, you explain the importance of
macronutrients. Which of the following is a macronutrient?
a. Iron
b. Thiamin
c. Calcium
d. Fat
NURSINGTB.COM
ANS: D
Carbohydrates, protein, and fat are referred to as macronutrients because they are required in
large amounts. Iron, thiamin, and calcium are minerals.

30. Which is the most vital nutrient?

a. Protein
b. Carbohydrate
c. Fat
d. Water
ANS: D
Water is the most vital nutrient. A person can exist without food for several weeks but without
water for only a few days.

31. Which of the following is the most accurate reflection of an individual’s food intake?
a. 24-hour diet recall
b. Food diary
c. Computerized nutrient analysis
d. Serum protein assay
ANS: B
The food diary is a record ofN URSas
intake INitGhappens,
TB.COmaking
M this method the most accurate
reflection of an individual’s food intake.

32. Mrs. Hartzell is a 34-year-old patient who has presented for nutritional counseling because
she is a vegetarian. Deficiency of which of the following is a concern in the vegetarian diet?
a. Ascorbic acid
b. Vitamin B12
c. Folate
d. Fiber
ANS: B
The nutrients that may be deficient in a vegetarian diet, if not carefully planned, include
proteins, calcium, iron, vitamin B12, and vitamin D.

33. Ms. Otten is a 45-year-old patient who presents with a complaint of weight gain. Which
medication is frequently associated with weight gain?
a. Diuretics
b. Oral hypoglycemics
NURSINGTB.COM
c. Laxatives
d. Steroids
ANS: D
Medications that contribute to weight gain include steroids, oral contraceptives,
antidepressants, and insulin.

34. Ms. Davis is a 27-year-old patient with a BMI of 33. Based on her BMI, your diagnosis would
be:
a. normal body weight.
b. overweight.
c. obese.
d. extremely obese.
ANS: C
An obese BMI is 30 to 39.9. A normal BMI is less than 24. An overweight BMI is 25 to 29.9.
An extremely obese BMI is greater than 40.

35. A 17-year-old girl presents to the clinic for a sports physical. Physical examination findings
reveal bradycardia, multiple erosions of tooth enamel, and scars on her knuckles. She appears
healthy otherwise. You should ask her if she:
a. binges and vomits. NURSINGTB.COM
b. has regular menstrual periods.
c. has constipation frequently.
d. is cold intolerant.
ANS: A
In young adults, usually female, bradycardia, knuckle scars, and tooth decay are signs of
chronic, self-induced vomiting characteristic of bulimia. Amenorrhea can occur from
increased physical activity or anorexia. Constipation and cold intolerance are usually
symptoms of anorexia nervosa.

MULTIPLE RESPONSE
1. Which are signs and symptoms of hydrocephalus? (Select all that apply.)
a. Early closed suture lines
b. Hyperreflexia Y
c. Irritable, poor feeding Y
d. Does not meet expected height and weight
e. Difficulty holding head up Y
f. Rapidly increasing head circumference Y
ANS: B, C, E, F
NURSINGTB.COM
Signs and symptoms of hydrocephalus include hyperreflexia, difficulty holding head up,
irritability, lack of energy, rapidly increasing head circumference, and poor feeding. Early
closed suture lines and inability to meet expected height and weight do not indicate
hydrocephalus.

COMPLETION
1. An 11-year-old boy is brought in for an annual physical examination by his mother. The boy’s
height is 60 inches. You suspect Marfan syndrome because the boy’s arm span is greater than
_______________ inches.
ANS:
60
Arm span that is greater than a child’s height is associated with Marfan syndrome. Children
with Marfan syndrome can have cardiovascular problems and should be thoroughly evaluated.

2. Infants normally increase their birth length by ____% during the first year of life.
ANS:
50 NURSINGTB.COM
Infant length generally increases by 50% in the first year of life.

3. The term large for gestational age (LGA) indicates that an infant is larger than ____% of
infants born at the same number of weeks’ gestation.
ANS:
90
LGA corresponds to an infant whose weight is classified as greater than the 90th percentile.

NURSINGTB.COM
Chapter 09: Skin, Hair, and Nails

MULTIPLE CHOICE
1. The skin repairs surface wounds by:

a. exaggerating cell replacement.
b. excreting lactic acid.
c. producing vitamins.
d. providing a mechanical barrier.
ANS: A
The skin’s tissue cells have a rapid rate of turnover and constant renewal, thereby enabling the
skin to repair damaged surfaces.

2. The adipose tissue in the hypodermis serves to:

a. provide sensory input.
b. generate heat and insulate.
c. create tensile strength.
d. secrete collagen.
ANS: B
The hypodermis layer consists of adipose tissue that serves to generate heat and provide
insulation, shock absorption,NURaSreserve
and INGTofB.C OM
calories.

3. The secretory activity of the sebaceous glands is stimulated by:

a. body heat.
b. ambient temperature.
c. sex hormones.
d. dietary protein.
ANS: C
The sebaceous glands, when stimulated by the sex hormones, produce a lipid-rich substance
that keeps the skin moist.

4. Mrs. Tuber is a 36-year-old patient who comes into the health center with complaints that her
fingernails are not growing. Which structure is the site of new nail growth?
a. Cuticle
b. Perionychium
c. Matrix
d. Nail bed
NURSINGTB.COM
ANS: C
The white crescent-shaped area beyond the proximal nail fold is called the matrix, which is
the site of new nail growth.

5. Mrs. Leonard brings her newborn infant into the pediatrician’s office for a first well-baby
visit. As the healthcare provider, you teach her that newborns are more vulnerable to
hypothermia because of:
a. the presence of coarse terminal hair.
b. desquamation of the stratum corneum.
c. their covering of vernix caseosa.
d. a poorly developed subcutaneous fat layer.
ANS: D
Newborns have a poorly developed subcutaneous fat layer and therefore have a reduced
ability to generate heat.

6. Mrs. Mulligan brings her 16-year-old son into the office for a sports physical examination. As
the healthcare provider, you explain that normal hormone-related changes of adolescence
include:
a. increased oil production.
b. slowed hair growth.
c. depleted apocrine glands.NURSINGTB.COM
d. decreased sebaceous gland activity.
ANS: A
During adolescence, the sebaceous glands increase sebum production, which causes the skin
to have an oily appearance and predisposes the individual to acne.

7. Expected hair distribution changes in older adults include:

a. increased terminal hair follicles on the scalp.
b. more prominent axillary and pubic hair production.
c. increased terminal hair follicles to the tragus of men’s ears.
d. more prominent peripheral extremity hair production.
ANS: C
The transition from a vellous to terminal hair pattern occurs in older men at the nares and
tragus.

8. Brittle nails are typical findings in:

a. adolescents.
NURSINGTB.COM
b. infants.
c. pregnant women.
d. older adults.
ANS: D
Older adults typically have decreased peripheral circulation to the nails, causing the nails to
develop longitudinal ridges that are more brittle and susceptible to splitting into layers.

9. Mrs. Franklin is a 68-year-old patient who presents to the office with a complaint that her
nails do not seem to be growing. As the healthcare provider, you explain to her that the nails
of older adults grow slowly because of:
a. decreased circulation.
b. dietary deficiencies.
c. fungal infections.
d. low hormone levels.
ANS: A
Decreased circulation to the nails of older adults causes nail growth retardation.

10. As part of your health promotion education for a new patient, you explain that the risk factors
for skin cancer include:
a. an olive complexion. NURSINGTB.COM
b. repeated trauma or irritation to skin.
c. history of allergic reactions to sunscreen.
d. dark eyes and hair.
ANS: B
Fair-skinned persons with light eyes with repeated trauma or skin irritation have higher risk
factors for skin cancer development.

11. The type and brand of grooming products used are important to the health history of:
a. adolescents.
b. everyone.
c. older adults.
d. persons with rashes.
ANS: B
Knowledge of exposure to environmental chemicals is valid health history data for all age
groups, not just adolescents, older adults, or persons with rashes.

NURSINGTB.COM
12. Mr. Donalds is a 45-year-old roofer. Your inspection to determine color variations of the skin
is best conducted:
a. using an episcope.
b. under fluorescent lighting.
c. with illumination provided by daylight.
d. using a Wood’s light.
ANS: C
Daylight provides the best illumination source for determining color variations of the skin.

13. Tangential lighting is best used for inspecting skin:

a. color.
b. contour.
c. exudates.
d. symmetry.
ANS: B
Tangential lighting—light shined laterally to the surface—is best for inspecting skin contour.

14. Unusual white areas on the skin may be caused by:

a. adrenal disease.
b. polycythemia. NURSINGTB.COM
c. vitiligo.
d. Down syndrome.
ANS: C
The absence of melanin produces unpigmented white areas known as vitiligo.

15. Which cultural group has the lowest incidence of nevi?

a. Native Americans
b. African Americans
c. Mexican Americans
d. Asians
ANS: B
Nevi are more common in persons who burn, rather than tan; therefore, African Americans
have the lowest rates of nevi.

16. You are inspecting the lower extremities of a patient and have noted pale, shiny skin of the
lower extremities. This may reflect:
NURSINGTB.COM
a. systemic disease.
b. a history of vigorous exercise.
c. peptic ulcer disease.
d. mental retardation.
ANS: A
Pale, shiny skin of the lower extremities may reflect peripheral changes that occur with
systemic disorders, such as diabetes mellitus and cardiovascular disease.

17. A 29-year-old white woman appears jaundiced. Liver disease as a cause has been excluded.
What history questions should the nurse ask?
a. Whether she had unprotected sex
b. Whether she has a history of diabetes mellitus
c. Whether she had unusual bleeding problems
d. Whether she eats a lot of yellow and orange vegetables
ANS: D
In the absence of liver disease, another cause of jaundice is increased carotene pigmentation.
Diets high in carrots, sweet potatoes, and squash are high in carotene and can make the skin
appear to be jaundiced. Whether she had unprotected sex, a history of diabetes mellitus, or
unusual bleeding problems would not be relevant when assessing the jaundiced skin.

N R I G B.C M
U Swho N has
T comeOto the office for a routine physical
18. Mrs. Bower is a 39-year-old patient
examination. As a healthcare provider, you know that the skin temperature is best assessed
with the:
a. dorsal surface of the examiner’s hand.
b. palmar surface of the examiner’s hand.
c. ulnar surface of the examiner’s hand.
d. pads of the examiner’s fingers.
ANS: A
The dorsal surface of the hand is best for estimating temperature variations.

19. You are examining a pregnant patient and have noted a vascular lesion. When you blanch over
the vascular lesion, the site blanches and refills evenly from the center outward. The nurse
documents this lesion as a:
a. telangiectasia.
b. spider angioma.
c. petechiae.
d. purpura.
ANS: B
NURSINGTB.COM
Spider angiomas are dilated arterioles. A network of dilated capillaries radiate from the center
arteriole, outward like a spider’s legs. Spider angiomas are often associated with high estrogen
levels, as occur in pregnancy. Blanching over the center is followed by a rapid return of
redness from the center outward. Telangiectasias refill erratically. Petechiae and purpura do
not blanch.

20. Small, minute bruises are called:

a. ecchymoses.
b. petechiae.
c. spider veins.
d. telangiectasias.
ANS: B
Petechiae are smaller than 0.5 cm in diameter. Ecchymoses are larger than 0.5 cm in diameter.
Spider veins and telangiectasias are vascular lesions.

21. A flat, nonpalpable lesion is described as a macule if the diameter is:

a. larger than 1 cm.
b. smaller than 1 cm.
c. 3 cm exactly.
d. too irregular to measure.
NURSINGTB.COM
ANS: B
A macule, by definition, is a flat, circumscribed area smaller than 1 cm in diameter and is
measurable. An example of a macular rash is measles.

22. Mrs. Britton is a 34-year-old patient who presents to the office with complaints of skin rashes.
You have noted a 4.3-cm, rough, elevated area of psoriasis. This is an example of a:
a. plaque.
b. patch.
c. macule.
d. papule.
ANS: A
A plaque, by definition, is an elevated, firm, rough lesion with a flat top surface larger than 1
cm in diameter, as seen in someone with, for example, psoriasis.

23. Skin turgor checks are performed to determine the:

a. temperature of the skin.
b. hydration status.
NURSINGTB.COM
c. actual age.
d. extent of an ecchymosis.
ANS: B
Skin will remain tented if the patient is dehydrated or will not tent if edema is present.

24. You have just completed a skin assessment on Mr. Baker. During your assessment, you have
transilluminated a skin lesion. During the physical examination, you know that skin lesions
are transilluminated to distinguish:
a. vascular from nonvascular lesions.
b. furuncles from folliculitis lesions.
c. fluid-filled lesions from solid cysts or masses.
d. herpes zoster from varicella.
ANS: C
Transillumination is used to determine the presence of fluid in cysts and masses. Fluid-filled
lesions will transilluminate with a red glow, and solid masses will not transilluminate.

25. Fluorescing lesions are best distinguished using a(n):

a. incandescent lamp.
b. magnifying glass.
c. transilluminator. NURSINGTB.COM
d. Wood’s lamp.
ANS: D
Fluorescing lesions (e.g., some tinea lesions) show a characteristic yellow-green color under a
Wood’s lamp.

26. Women with terminal hair growth in a male distribution pattern should receive further
evaluation for a(n):
a. circulation condition.
b. endocrine disorder.
c. inflammatory state.
d. nutritional deficit.
ANS: B
Hirsutism in women (growth of terminal hair in a male distribution) can be a clinical sign of
an endocrine disorder. Hair loss can be associated with poor circulation, inflammation, or
nutritional deficits.

NURSINGTB.COM
27. Which nail change found on examination would be most alarming?

a. Dark bands seen on all fingernails of a dark-skinned person
b. Yellow discoloration of the great toe of an older adult
c. Single dark band in a white adult
d. Pits in both index fingernails of an adult
ANS: C
Dark bands in a dark-skinned person are normal; yellow in the toe of an older adult can
represent a nail disease or a chronic respiratory condition; and pits are related to psoriasis. A
single dark band in a white adult indicates a more serious condition—melanoma.

28. Transient mottling of the patient’s skin in a cool room is a common finding in:
a. menopausal women.
b. newborn infants.
c. pregnant women.
d. sedentary adults.
ANS: B
Cutis marmorata, a mottled appearance, is part of the newborn’s response to changes in
temperature.

29. A single transverse line seenN

in the palm of a small child may imply:
a. Down syndrome. URSINGTB.COM
b. Turner syndrome.
c. systemic sclerosis.
d. profound dehydration.
ANS: A
The simian line, a single transverse crease, is seen on the palm of children with Down
syndrome.

30. Cafe au lait patches are numbered with each assessment of infants and young children
because:
a. the numbers are expected to increase each year.
b. coalescent lesions are a more serious finding.
c. the presence of six or more patches suggests neurofibromatosis.
d. decreasing numbers are expected with growth.
ANS: C
NURSINGTB.COM
The presence of six or more patches with diameters larger than 1 cm in children younger than
5 years of age suggests neurofibromatosis. Fewer than five patches is usually considered
harmless. The numbers of cafe au lait patches are not expected to increase each year.
Coalescent lesions are not a more serious finding. Decreasing numbers are not expected with
growth.

31. A Dennie-Morgan fold is probably caused by:

a. birth trauma.
b. high fever.
c. excess adipose tissue.
d. chronic rubbing.
ANS: D
Persons with chronic atopic or allergic conditions tend to rub the eyes sufficiently to cause an
extra crease or pleat of skin below the eye, called the Dennie-Morgan fold.

32. Linea nigra is commonly found on the abdomens of:

a. infants and children.
b. adolescents.
c. pregnant patients.
d. older adults.
NURSINGTB.COM
ANS: C
Pregnant patients commonly develop pigmentation of the abdomen from the symphysis pubis
to the top of the fundus in the midline.

33. Cherry angiomas are a common finding in:

a. adults older than 30 years.
b. newborns.
c. pregnant women.
d. sunbathers.
ANS: A
Cherry angiomas occur in almost everyone older than 30 years and increase numerically with
age.

34. Pigmented, raised, warty lesions over the face and trunk should be assessed by an experienced
practitioner who can distinguish:
a. cutaneous tags from lentigines.
b. furuncles from folliculitis.
NURSINGTB.COM
c. sebaceous hyperplasia from eczema.

d. seborrheic keratoses from actinic keratoses.
ANS: D
Actinic keratoses have malignant potential, and seborrheic keratoses do not. Because they can
look similar, an experienced practitioner should make the determination.

35. Age spots are also called:

a. seborrheic keratoses.
b. solar lentigines.
c. cutaneous horns.
d. acrochordon.
ANS: B
Solar lentigines are irregular, round, gray-brown lesions with a rough surface that occur in
sun-exposed areas and are referred to as age spots.

36. The most common inflammatory skin condition is:

a. cutis marmorata.
b. eczematous dermatitis.
c. intradermal nevus.
d. pityriasis rosea. N R I G B.C M
U S N T O
ANS: B
The most common inflammatory skin disorder is eczematous dermatitis.

37. Which is a noncandidal fungal infection?

a. Pityriasis rosea
b. Psoriasis
c. Tinea corporis
d. Rosacea
ANS: C
Tinea corporis is the only listed fungal infection (noncandidal); the others are not fungal in
origin.

38. The characteristic that best differentiates psoriasis from other skin abnormalities is the:
a. color of the scales.
b. formation of tiny papules.
c. general distribution over the body.
NURSINGTB.COM
d. recurrence.
ANS: A
Unlike other skin conditions, silvery papules and plaques characterize psoriasis.

39. Painful vesicles are associated with:

a. psoriasis.
b. pityriasis rosea.
c. paronychia.
d. herpes zoster.
ANS: D
Herpes zoster (shingles) produces painful itching or burning of the dermatome area.

40. A 17-year-old student complains of a “rash for 3 days.” You note pale, erythematous oval
plaques over the trunk. They have fine scales and are arranged in a fernlike pattern, with
parallel alignment. What is the nurse’s next action?
a. Teach infectious control measures.
b. Inquire about another recent skin lesion.
c. Inspect the palms and the soles.
d. Inform the patient that this will resolve within a week.
ANS: B NURSINGTB.COM
The described rash is the typical presentation of pityriasis rosea. The rash is not infectious or
contagious, does not involve the palms and soles, and usually lasts for several weeks.
Pityriasis rosea begins with a sudden primary (herald) patch, with generalized eruption to the
trunk and extremities following 1 to 3 weeks later.

41. Which of the following is an ABCDE characteristic of malignant melanoma?

a. Asymmetric borders
b. Borders well demarcated
c. Color of lesion is uniform
d. Diameter less than 6 mm
ANS: A
ABCD melanoma mnemonic includes asymmetry, borders that are irregular, color that is not
the same all over, diameter larger than 6 mm and growing, and evolution.

42. The most common cutaneous neoplasm is:

a. basal cell carcinoma.
NURSINGTB.COM
b. compound nevus.
c. seborrheic keratosis.
d. senile actinic keratosis.
ANS: A
Basal cell carcinoma is the most common form of skin cancer. It occurs more frequently on
sun-exposed parts of the body.

43. Soft, painless, bluish papules in persons who are HIV-positive are most likely:
a. Kaposi sarcoma.
b. malignant melanoma.
c. molluscum contagiosum.
d. pityriasis rosea.
ANS: A
Kaposi sarcoma is the more common malignant skin lesion of HIV-infected persons. The
lesions are soft, painless, bluish purple macules or papules.

44. A 5-year-old child presents with discrete vesicles on an erythematous base that began near her
scalp and are spreading to the trunk. The child has a low-grade fever and feels tired. What is
the nurse’s next action?
a. Teach infectious control Nmeasures.
R INGTB.COM
b. Inquire about other patternsUof Sphysical abuse.
c. Inspect the buccal mucosa for Koplik spots.
d. Inform the parent that this will resolve within a couple of days.
ANS: A
The description of this child’s complaint is a varicella rash, not physical abuse or rubeola.
Chickenpox is a highly communicable disease and can be prevented by immunization. The
period of communicability lasts from 1 or 2 days before onset of the rash until all the vesicles
have crusted over, which usually takes about 1 week. This is not physical abuse. Inspecting
the buccal mucosa for Koplik spots will not diagnose the problem. This will not resolve
within a couple of days.

45. During history taking, a mother states that her son awoke in the middle of the night
complaining of intense itching to his legs. Today, your inspection reveals a honey-colored
exudate from the vesicular rash on his legs. Which condition is consistent with these findings?
a. Exanthem
b. Impetigo
c. Solar keratoses
d. Trichotillomania
ANS: B
NURSINGTB.COM
Impetigo causes intense pruritus, regional lymphadenopathy, and honey-colored exudative

crusting as the vesicles or bullae rupture and dry.

46. You are conducting a preschool examination on a 5-year-old child. Which injury would most
likely raise your suspicion that the child is being abused?
a. Recent bruising over both knees
b. A healed laceration under the chin
c. A bruise on the right shin with associated abrasion of tissue
d. Bruises in various stages of resolution over body soft tissues
ANS: D
Toddlers and older children who bruise themselves accidentally do so over bony prominences,
like the knees, chin, and shin. Bruises over soft tissues are more consistent with abuse.

47. Assessment of poor hygiene, healed fractures with deformity, or unexplained trauma in older
adults indicates:
a. sexual abuse.
b. physical neglect.
c. psychological abuse.
d. violated rights.
Physical neglect is described asUtheSmost
N common
T Oform of elder abuse.
48. The nurse assesses the nail base angle using the Schamroth technique. Which nail bed shape
indicates a normal expected examination finding?
a. Flat
b. Convex
c. Concave
d. Bowed
ANS: C
The normal nail base angle should be 160 degrees, which results in a concave nail base that
produces a diamond-shaped window with the Schamroth technique.

MULTIPLE RESPONSE
1. Which identify the signs and symptoms of basal cell cancer? (Select all that apply.)
a. Itching
NURSINGTB.COM
b. Reddish patch
c. Starts from a nevi
d. Various clinical forms—cystic, nodular, pigmented
e. Macule type
ANS: A, B, D
Common signs and symptoms of basal cell carcinoma include a, pink, red, tan, white, black,
or brown shiny nodule, in a variety of clinical forms, which may be crusted and itching.

NURSINGTB.COM
NURSINGTB.COM
Chapter 10: Lymphatic System

MULTIPLE CHOICE
1. Which organ does not have lymphatic vessels?

a. Brain
b. Kidneys
c. Liver
d. Lungs
ANS: A
Lymphatic tissues are found abundantly throughout the body except in two places, the
placenta and the brain (central nervous system). Lymphatic tissues are found abundantly in
the kidneys, liver, and lungs.

2. Cells that line the lymph node sinuses perform the specific function of:
a. fat absorption.
b. fetal immunization.
c. hematopoiesis.
d. phagocytosis.
ANS: D
Lymph nodes defend againstNthe
URinvasion
SINGTofB.C OM
microorganisms by phagocytosis.

3. Lymph flows faster in response to:

a. increased metabolic activity.
b. decreased blood volume.
c. decreased metabolic rate.
d. decreased permeability of the capillary walls.
ANS: A
Lymph flow increases with mounting capillary pressure, greater permeability of the capillary
walls, or increased metabolic rate.

4. An organ that is essential to the development of protective immune function in the infant but
has little or no demonstrated function in the adult is the:
a. spleen.
b. liver.
c. thymus.
d. pancreas.
NURSINGTB.COM
ANS: C
In the adult, the thymus atrophies and, in the older adult, is replaced by fat and connective
tissue.

5. Mr. Shea is a 45-year-old patient who presents to the office for multiple complaints. The
examination of the upper left quadrant of the abdominal cavity is essential to the evaluation of
the immune system because of the location of which organ?
a. Spleen
b. Liver
c. Stomach
d. Pancreas
ANS: A
The spleen is the largest of the lymphatic organs. It is located in the upper left portion of the
abdomen.

6. Mrs. Farrel brings in her 6-year-old son with complaints of a sore throat and fever. As the
healthcare provider, you are concerned about his tonsils and adenoids. Enlarged tonsils and
adenoids may obstruct the:
a. thoracic duct.
b. esophagus.
c. nasopharyngeal passageway.NURSINGTB.COM
d. external auditory meatus.
ANS: C
The palatine tonsils are located on either side of the pharynx; the adenoids (pharyngeal
tonsils) are found on the posterior wall of the pharynx and superior to the soft palate. If these
structures become enlarged, they block the passage between the pharynx and nasal cavity.

7. Mrs. Sing is a 44-year-old patient who presents to the office with a complaint of enlarged
lymph nodes. When enlarged, which lymph nodes are most likely to be a sign of pathology
(e.g., malignancy)?
a. Occipital
b. Anterior cervical
c. Supraclavicular
d. Femoral
ANS: C
Supraclavicular nodal enlargement is of special concern because it suggests a malignancy,
even in children; an enlarged supraclavicular lymph node may be the sentinel node of
Hodgkin disease.
NURSINGTB.COM
8. As adults age, their ability to resist infection is reduced because of the lymphatic nodes
becoming more:
a. fibrotic.
b. mucoid.
c. porous.
d. profuse.
ANS: A
Older adults’ lymph nodes diminish in both number and size and are replaced with more
fibrotic and fatty tissues.

9. Equipment for examining the lymphatic system includes a:

a. caliper.
b. centimeter ruler.
c. goniometer.
d. syringe and needle.
ANS: B
The centimeter ruler and marking pencil are the only equipment needed for examination of the
lymphatic system. They are used to measure and outline the borders of the nodes.

N R I GMSC: B.C Physiologic
M Integrity: Physiologic Adaptation
U S N T O
10. Which nodes are most often associated with inflammation?
a. Shotty
b. Movable
c. Fixed
d. Tender
ANS: D
Tenderness is almost always indicative of inflammation. Shotty nodes (feel like the tip of an
eraser) that are fixed are of greater concern. Shotty, movable, or fixed nodes are not usually
associated with inflammation.

11. Which nodes are also called Virchow nodes?

a. Internal mammary
b. Anterior axillary
c. Deep cervical
d. Supraclavicular
ANS: D
The supraclavicular nodes are also referred to as Virchow nodes.
NURSINGTB.COM

12. The harder and more discrete a node, the more likely that there is a(n):
a. innocent cause.
b. infection.
c. malignancy.
d. metabolic disease.
ANS: C
Tender nodes almost always indicate the presence of an infection, whereas a hard, discrete,
and nontender node is more likely to represent a malignancy.

13. Which finding indicates that the examiner is assessing a blood vessel rather than a lymph
node?
a. A bruit
b. Inflammation
c. Tenderness
d. Redness
ANS: A
Pulsations and auscultation of bruits indicate a blood vessel and not a lymph node.

NURSINGTB.COM
14. When examining lymph nodes near a joint in the arm or leg, which of the following
maneuvers is likely to facilitate the examination?
a. Extension of the extremity
b. Circumduction of the extremity
c. Flexion of the extremity
d. Rotation of the extremity
ANS: C
Bending joint areas will ease taut tissues and allow for better accessibility to palpation.

15. To palpate the inguinal nodes, you should have the patient:
a. bend over a table and cough.
b. lie supine with knees slightly flexed.
c. lie supine with legs extended.
d. stand and cough vigorously.
ANS: B
To palpate the inguinal nodes, you should have the patient lie supine and slightly flex her or
his knees.
NURSINGTB.COM

16. The most important clue to the diagnosis of immunodeficiency disease in a child is:
a. family history.
b. illness in siblings.
c. previous hospitalizations.
d. serious recurring infections.
ANS: D
Although family history, illness in siblings, and previous hospitalizations are helpful clues to
discover an immunodeficiency in a child, it is most important to review the occurrence of
serious, uncommon infections, such as Pneumocystis jirovecii, or other fungal infections that
do not respond as expected to therapy.

17. A red streak that follows the course of the lymphatic collecting duct is a finding associated
with:
a. Hodgkin disease.
b. lymphangitis.
c. lymphedema.
d. lymphoma.
ANS: B
Lymphangitis—inflammation of the lymphatic vessels—is evident by a red streak that follows
the course of the inflamed lymphatic
NURSIduct. GTHodgkin
B.COMdisease and lymphoma refer to
N
malignancies manifested primarily by nodal enlargements; lymphedema is lymph swelling
that distinguishes itself from interstitial edema because it does not pit.

18. Which disorder is characterized by a single node that is chronically enlarged and nontender in
a patient with no other symptoms?
a. Retropharyngeal abscess
b. Streptococcal pharyngitis
c. Mononucleosis
d. Toxoplasmosis
ANS: D
Toxoplasmosis is characterized by a chronically enlarged, nontender, single node—usually in
the posterior cervical chain.

19. Initial signs and symptoms of Epstein-Barr virus mononucleosis usually include:
a. pharyngitis, fever, and malaise.
b. bleeding gums and spontaneous nosebleeds.
c. headache, visual disturbance, and rash.
NURSINGTB.COM
d. inguinal adenopathy and painful urination.

ANS: A
Presenting signs and symptoms of Epstein-Barr virus mononucleosis are pharyngitis, fever,
fatigue, malaise, often splenomegaly, and occasionally hepatomegaly and/or rash.

20. Tender nodes associated with cat scratch disease are usually found in which area?
a. Epitrochlear area
b. Popliteal area
c. Axilla
d. Inguinal area
ANS: C
Cat scratch disease usually results in enlargement of nodes in the head, neck, and axillae.
Although epitrochlear enlargement occurs most exclusively in cat scratch fever, its occurrence
is less common.

21. Serum sickness is usually characterized first by the appearance of:

a. lymph node enlargement.
b. joint pain.
c. urticaria.
d. fever. N R I G B.C M
U S N T O
ANS: C
Urticaria is the first sign of serum sickness, followed by lymphadenopathy, joint pain, fever,
and facial edema.

MULTIPLE RESPONSE
1. Which condition stimulates lymph node enlargement? (Select all that apply.)
a. Graves disease
b. Lymphangioma
c. Esophageal reflux
d. Parotid swelling
ANS: A, B, D
Lymph node enlargement is stimulated by Graves disease, lymphangioma, and parotid
swelling.

NURSINGTB.COM
Chapter 11: Head and Neck

MULTIPLE CHOICE
1. Which cranial nerves innervate the face?

a. II and V
b. III and VI
c. V and VII
d. VIII and IX
ANS: C
Facial nerves are controlled by cranial nerves V and VII; cranial nerves II, III, and VI control
the eyes, cranial nerve VIII deals with hearing, and cranial nerve IX deals with swallowing.

2. Mrs. Britton brings her 16-year-old son in with a complaint that he is not developing correctly
into adolescence. Which structures disproportionately enlarge in the male during adolescence?
a. Coronal sutures
b. Hyoid and cricoid cartilages
c. Mandible and maxilla bones
d. Nose and thyroid cartilages
ANS: D
In adolescent males, the noseNenlarges
URSINandGTthe
B.C OM cartilage becomes the largest
thyroid
component of the anterior larynx, known as the Adam’s apple.

3. Which of the following is an expected change in the assessment of the thyroid during
pregnancy?
a. Palpation of the gland becomes difficult.
b. A bruit is auscultated.
c. Inspection reveals a goiter.
d. The gland is tender on palpation.
ANS: B
During pregnancy, the thyroid gland hypertrophies (not to the point of a goiter), palpation is
easier and, because the gland also has increased vascularity, bruits are common. It is an
abnormal finding for the thyroid to feel fibrotic, tender, or smaller.

4. Mr. Mathews is a 47-year-old patient who presents for a routine physical examination. On
examination, you noted a bruit heard over the thyroid. This is suggestive of:
a. hypothyroidism.
b. hyperthyroidism.
NURSINGTB.COM
c. thyroid cancer.
d. thyroid cyst.
ANS: B
Because of hypermetabolic states such as hyperthyroidism, a bruit may be heard as a result of
the increased blood flow to the area. Auscultating a bruit is not symptomatic of
hypothyroidism, cancer, or a cyst. A nodule is more indicative of cancer.

5. Ms. Galvan is a 22-year-old secretary who comes to the clinic with headaches of 6 weeks’
duration. She tells the office assistant about her heavy schedule, including part-time work and
evening classes. Her vital signs are normal. Which information is most appropriate to Ms.
Galvan’s history?
a. Current medications
b. Elimination patterns
c. Immunization status
d. Previous pregnancies
ANS: A
Some current medications, such as birth control pills, nitroglycerin, antihypertensives,
antiseizure drugs, and some diabetic drugs, can be headache triggers. Withdrawal of headache
medication can also trigger headaches.

N R I G B.C M
U S N best
T wayOto examine for:
6. Observation during history taking is the
a. head position.
b. scalp lice.
c. thyroid size.
d. tracheal alignment.
ANS: A
Head position as well as facial features is best observed when talking to the patient during the
history. Scalp lice, thyroid size, and tracheal alignment are best assessed by palpation and
closer physical observation.

7. During a head and neck assessment of a neonate, it is important to screen for:

a. the presence of torticollis.
b. signs and symptoms of cerebral palsy.
c. uneven movement of the eyes.
d. unilateral movement of the tongue.
ANS: A
NURSINGTB.COM
Torticollis is usually caused by constraint of the newborn in utero or injury during vaginal
delivery. The other symptoms may be difficult to discern because of the infant’s lack of fine
motor skills and control of voluntary muscle groups. During a head and neck assessment of a
neonate, it is not important to screen for signs and symptoms of cerebral palsy, uneven
movement of the eyes, or unilateral movement of the tongue.

8. During a physical examination of a 30-year-old Chinese man, you notice a slight asymmetry
of his face. The cranial nerve examination is normal. Your best action is to:
a. ask the patient if this characteristic runs in his family.
b. perform monofilament testing on the face.
c. consult with the clinician regarding the laboratory tests needed.
d. record the finding in the patient’s chart.
ANS: D
It is not abnormal to have some slight asymmetry of the face that does not require further
questioning, tests, or unnecessary laboratory work, but it does require a notation in the chart
that could be referenced for future concerns.

9. Which is the best way to position a patient’s neck for palpation of the thyroid?
a. Flexed away from the side being examined
b. Flexed directly forward
NURexamined
c. Flexed toward the side being SINGTB.COM
d. Hyperextended directly backward
ANS: C
The patient should be positioned so that the sternocleidomastoid muscle is relaxed and the
thyroid is easier to palpate. This is done by having the patient flex the neck slightly forward
and laterally toward the side being examined.

10. The thyroid gland should:

a. be slightly left of midline.
b. have a clear vascular sound.
c. move when the patient swallows.
d. tug with each heartbeat.
ANS: C
It is a normal finding for the thyroid gland to move with swallowing; however, being off
center may indicate a nodular growth or enlargement. The thyroid gland should not be slightly
left of midline. Vascular sounds indicate hypermetabolic states such as hyperthyroidism, and a
tug with each heartbeat is a sign of an aortic aneurysm.

NURSINGTB.COM
11. You are palpating a patient’s thyroid and find that its broadest dimension measures 4 cm. The
right lobe is 25% larger than the left. These data would indicate:
a. a congenital anomaly.
b. a multinodular goiter.
c. a normal thyroid gland.
d. thyroiditis.
ANS: C
The situation described is most likely a normal finding; the right lobe of the thyroid gland is
typically 25% larger than the left and measures 4 cm. The other choices produce enlargements
beyond these normal findings.

12. The correct way to transilluminate an infant’s skull is to:

a. hold the light 18 inches from the skull.
b. move the light toward and then away from the head.
c. place the light firmly against the skull.
d. shine the light inside the infant’s mouth.
ANS: C
The correct technique for transillumination of the infant’s skull is to place the light source
tightly against the skull so that no light escapes.

N R I GMSC: Physiologic
B.C M Integrity: Physiologic Adaptation
U S N T O
13. Which of the following is true regarding a cephalohematoma?
a. It is bound by suture lines.
b. The affected part feels soft.
c. It is obvious at birth.
d. The margins are poorly defined.
ANS: A
The condition is subperiosteal, under the bone, and contained by the margins of the suture
lines; it does not cross the suture line. It is often unnoticed at birth and typically feels firm,
with its edges well defined.

14. Nuchal rigidity is most commonly associated with:

a. thyroiditis.
b. meningeal irritation.
c. Down syndrome.
d. cranial nerve V damage.
ANS: B
Stiffness and inability to flex the neck, or nuchal rigidity, constitute a classic symptom of
meningeal irritation.
NURSINGTB.COM

15. When noting a bulging fontanel with marked pulsations in a 6-month-old, you suspect:
a. normal development.
b. congenital anomaly.
c. increased intracranial pressure.
d. fever response to a viral infection.
ANS: C
A bulging fontanel with pulsations suggests increased intracranial pressure. A normal fontanel
feels slightly depressed, with mild pulsations.

16. Which type of headache usually occurs at night, is precipitated by alcohol consumption, and
occurs more often in men than in women?
a. Classic migraine
b. Temporal arteritis
c. Cluster
d. Hypertensive
ANS: C
Cluster headaches usually occur at night; they are associated with alcohol consumption and
occur more often in men.
N R I G B.C M
U S (Comprehension)
DIF: Cognitive Level: Understanding N T O
17. Mr. Johnson presents with a freely movable cystic mass in the midline of the high neck
region, at the base of the tongue. This is most likely a:
a. parotid gland tumor.
b. branchial cleft cyst.
c. Stensen duct stone.
d. thyroglossal duct cyst.
ANS: D
A thyroglossal duct cyst presents as a freely movable mass at the base of the tongue. A parotid
gland tumor occurs in the ear and cheek bone area. A branchial cleft cyst occurs in the lateral
neck area. A Stensen duct stone occurs in the parotid duct.

18. The premature union of cranial sutures that involves the shape of the head without mental
retardation is:
a. craniosynostosis.
b. encephalocele.
c. microcephaly.
d. myxedema.
NURSINGTB.COM
ANS: A
In patients with craniosynostosis, the cranial sutures fuse prematurely, causing a misshapen
head, but mental retardation is not involved. Encephalocele and microcephaly involve mental
retardation. Myxedema is a condition of hyperthyroidism.

19. Mr. Donaldson is a 64-year-old patient with complaints of headaches. As the examiner, you
are palpating his head during your physical examination. Which of the following would be
your first step?
a. Palpate the patient’s hair, noting texture, color, and distribution.
b. Palpate the temporomandibular joint.
c. Palpate the skull from front to back.
d. Palpate the temporal artery.
ANS: C
Palpate the skull in a gentle rotary movement first, progressing systematically from front to
back.

NURSINGTB.COM
NURSINGTB.COM
Chapter 12: Eyes

MULTIPLE CHOICE
1. Mrs. Alden is a 29-year-old pregnant patient in her third trimester. She tells you that her
vision has been a little blurred, and she thinks she needs to get new contact lenses. You should
advise her to:
a. get new lenses as soon as possible to avoid complications.
b. wait until several weeks after delivery to get new lenses.
c. go to the nearest emergency department for evaluation.
d. change her diet to include more yellow vegetables.
ANS: B
Because of the increased level of lysozyme in the tears during pregnancy, a blurred sensation
may occur but will subside several weeks after pregnancy. The blurred vision is a normal
occurrence during pregnancy. It is not an emergency, nor is it diet-dependent.

2. A condition that typically develops by the age of 45 years is:

a. presbyopia.
b. hyperopia.
c. myopia.
d. astigmatism.
NURSINGTB.COM
ANS: A
By 45 years of age, a condition known as presbyopia develops; presbyopia involves a
weakening of accommodation. Hyperopia occurs in early infancy. Myopia and astigmatism
can occur at any time.

3. Which finding, when seen in the infant, is ominous?

a. Difficulty tracking objects with the eyes
b. Appearing to have better peripheral than central vision
c. Blinking when bright light is directed at the face
d. White pupils on photographs
ANS: D
The absence of a red reflex, determined by physical examination or the appearance of white
pupils on a photograph, is indicative of retinoblastoma, a serious retinal tumor.

4. Mr. C’s visual acuity is 20/50. This means that he:

a. can see 50% of what the average person sees at 20 feet.
b. has perfect vision when tested at 50 feet.
NURSINGTB.COM
c. can see 20% of the letters on the chart’s 20/50 line.

d. can read letters while standing 20 feet from the chart that the average person could
read at 50 feet.
ANS: D
Visual acuity is measured as a fraction, in which the top number is the distance that the patient
is standing from the chart; the bottom number is the distance that an average person can stand
and still read the line.

5. The criterion for determining the adequacy of a patient’s visual field is:
a. the ability to discriminate primary colors.
b. the ability to discriminate details.
c. correspondence with the visual field of the examiner.
d. distance vision equal to that of an average person.
ANS: C
The examiner compares his or her own peripheral vision to that of the patient while
performing the confrontation test, so unless the examiner is aware of a problem with his or her
own vision, the examiner could assume that the fields are full if they match.

6. Mrs. S. is a 69-year-old woman who presents for a physical examination. On inspection of her
eyes, you note that the left upper
NUReyelid droops, covering more of the iris than does the right.
This is recorded as: SINGTB.COM
a. exophthalmos on the right.
b. ptosis on the left.
c. nystagmus on the left.
d. astigmatism on the right.
ANS: B
Ptosis is when one of the upper eyelids covers more of the iris than the other lid, possibly
extending over the pupil.

7. A condition in which the eyelids do not completely meet to cover the globe is called:
a. glaucoma.
b. lagophthalmos.
c. exophthalmos.
d. hordeolum.
ANS: B
Lagophthalmos is a term used to describe the condition in which eyelids do not completely
meet when closing. Glaucoma involves elevated pressure in the eye. Exophthalmus involves
bulging eyes. A hordeolum is better known as a stye.
NURSINGTB.COM

8. Mr. Morris is a 38-year-old patient who presents to the clinic with complaints of allergies. An
allergy can cause the conjunctiva to have a:
a. cobblestone pattern.
b. dry surface.
c. subconjunctival hemorrhage.
d. rust-colored pigment.
ANS: A
A red or cobblestone pattern, especially to the upper conjunctiva, indicates allergic
conjunctivitis. Allergies also cause itchy, watery eyes rather than dry surfaces, hemorrhage, or
rust-colored pigment.

9. A pterygium is more common in people heavily exposed to:

a. high altitudes.
b. tuberculosis.
c. ultraviolet light.
d. cigarette smoke.
ANS: C
Persons heavily exposed to ultraviolet light are more susceptible to the development of a
pterygium.
N R I G B.C M
U (Analysis)
S N T O
DIF: Cognitive Level: Analyzing
10. Mr. Brown was admitted from the emergency department, and you are completing his
physical examination. His pupils are 2 mm bilaterally, and you notice that they fail to dilate
when the penlight is moved away. This is characteristic in patients who are or have been:
a. in a coma.
b. taking sympathomimetic drugs (cocaine).
c. taking opioid drugs (morphine).
d. treated for head trauma.
ANS: C
Pupil constriction to less than 2 mm is called miosis. With miosis, the pupils fail to dilate in
the dark, a common result of opioid ingestion or the use of drops for glaucoma. Pupils are
usually dilated greater than 6 mm in a patient described in the other choices.

11. When testing corneal sensitivity controlled by cranial nerve V, you should expect the patient
to respond with:
a. brisk blinking.
b. copious tearing.
c. pupil dilation.
NURSINGTB.COM
d. reflex smiling.
ANS: A
Brisk blinking is an expected response to corneal sensitivity testing, which involves gently
touching the cornea with a piece of cotton.

12. You observe pupillary response as the patient looks at a distant object and then at an object
held 10 cm from the bridge of the nose. You are assessing for:
a. confrontation reaction.
b. accommodation.
c. pupillary light reflex.
d. nystagmus.
ANS: B
Testing for accommodation involves asking the patient to look at an object at a distance
(pupils dilate) and then to look at another, much closer object (pupils constrict).

13. When inspecting the region of the lacrimal gland, palpate:

a. the lower orbital rim, near the inner canthus.
b. in the area between the arch of the eyebrow and upper lid.
c. beneath the lower lid, adjacent to the inner canthus.
d. adjacent to the lateral aspect
N R of the
I eye, just beneath
G B.C M the upper lid.
U S N T O
ANS: A
The lacrimal gland is located at the lower orbital rim near the inner canthus of the eye.

14. Examination to assess for extraocular muscle imbalance is conducted by:

a. comparing pupillary responses to different shapes.
b. having the patient follow your finger through planes.
c. inspecting slightly closed lids for fasciculations.
d. transilluminating the cornea with tangential light.
ANS: B
The test for extraocular muscle function is to have the patient follow an object as you move it
through planes of vision while observing for nystagmus.

15. Mr. Older is a 40-year-old patient who presents to the office for a follow-up eye examination
after the diagnosis of myopia. To see retinal details in a myopic patient, you will need to:
a. adjust your ophthalmoscope into the plus lens.
b. move your ophthalmoscope backward.
NURSINGTB.COM
c. move your hand farther forward.

d. turn your ophthalmoscope to a minus lens.
ANS: D
The myopic patient (nearsighted) has longer eyeballs, so that light rays focus in front of the
retina. To see the retina, use the minus (red) numbers by moving the diopter wheel
counterclockwise; to assess a hyperopic patient, use a plus lens.

16. Ask the patient to look directly at the light of the ophthalmoscope when you are ready to
examine the:
a. retina.
b. optic disc.
c. retinal vessels.
d. macula.
ANS: D
The macula is the site of central vision and is observed when the patient looks directly at the
ophthalmoscope light.

17. Opacities of the red reflex may indicate the presence of:
a. hypertension.
b. hydrocephalus. NURSINGTB.COM
c. cataracts.
d. myopia.
ANS: C
Opacities or dark spots of the red reflex may indicate the presence of congenital cataracts in
the newborn.

18. If a patient has early papilledema, using an ophthalmoscope, the examiner will be able to
detect:
a. dilated retinal veins.
b. retinal vein pulsations.
c. sharply defined optic discs.
d. visual defects.
ANS: A
Papilledema is caused by increased intracranial pressure along the optic nerve, pushing the
vessels forward (cup protrudes forward) and dilating the retinal veins. Retinal vein pulsations
and visual defects are not visible with an ophthalmoscope. On examination, papilledema is
characterized by loss of definition of the optic disc.
NURSINGTB.COM
19. Cupping of the optic disc may be a result of:

a. migraine headaches.
b. diabetes.
c. glaucoma.
d. dehydration
ANS: C
Cupping is seen with causes of increased intraocular pressure, such as glaucoma. Migraine
headaches, diabetes, and dehydration do not cause cupping of the optic disc. Diabetes results
in cotton wool patches and hemorrhages.

20. When drusen bodies are noted to be increasing in number or in intensity of color, the patient
should be further evaluated with a(n):
a. Amsler grid.
b. Snellen E chart.
c. litmus test.
d. confrontation test.
ANS: A
Drusen bodies, when they increase in number or intensity of color, may indicate a precursor
state of macular degeneration. When this happens, the patient’s central vision should be
assessed using the Amsler grid. The Snellen E chart measures visual acuity, the litmus test is
used for testing pH, and a confrontation
N R I GtestB.C examines
M peripheral vision.
U S N T O
21. Cotton wool spots are most closely associated with:

a. glaucoma.
b. normal aging processes.
c. hypertension.
d. eye trauma.
ANS: C
Cotton wool spots actually represent infarcts of the retina and are associated with
hypertension or diabetes.

22. Which may be suggestive of Down syndrome?

a. Drusen bodies
b. Papilledema
c. Narrow palpebral fissures
d. Prominent epicanthal folds
ANS: D
NURSINGTB.COM
Prominent epicanthal folds, or slanting of the eyes, may be normal in Asian infants, but in
other ethnic groups it may indicate Down syndrome.

23. To differentiate between infants who have strabismus and those who have pseudostrabismus,
use the:
a. confrontation test.
b. corneal light reflex.
c. E chart.
d. Amsler grid.
ANS: B
The corneal light reflex is used with infants to differentiate between strabismus and
pseudostrabismus by noting an asymmetric versus symmetric light reflex.

24. You are attempting to examine the eyes of a newborn. To facilitate eye opening, you would
first:
a. dim the room lights.
b. elicit pain.
c. place him in the supine position.
d. shine the penlight in his or her eyes.
ANS: A N R I G B.C M
The best way to assess the eyesUof S N T is toOstart by dimming the lights because it
a newborn
encourages infants to open their eyes.

25. Dot hemorrhages, or microaneurysms, in the retina and the presence of hard and soft exudates
are most commonly seen in those with:
a. Down syndrome.
b. diabetic retinopathy.
c. systemic lupus.
d. glaucoma.
ANS: B
Dot hemorrhages or tiny aneurysms are characteristics of background retinopathy. A trapping
of lipids within incompetent capillaries causes the hemorrhages.

26. Which maneuver can be done to reduce the systemic absorption of cycloplegic and mydriatic
agents when examining a pregnant woman if the examination is mandatory?
a. Have the woman keep her eyes closed for several minutes.
b. Instill half the usual dosage.
NURSINGTB.COM
c. Keep the patient supine, with her head turned and flexed.
d. Use nasolacrimal occlusion after instillation.
ANS: D
To reduce absorption systemically, the examiner may use nasolacrimal occlusion after
applying, which involves pinching the upper bridge of the nose.

27. Changes seen in proliferative diabetic retinopathy are the result of:
a. anoxic stimulation.
b. macular damage.
c. papilledema.
d. minute hemorrhages.
ANS: A
New vessels are a characteristic seen in proliferative retinopathy resulting from anoxic
stimulation. An insufficient blood supply from failing capillaries causes new vessel growth.

MULTIPLE RESPONSE
1. Which are the signs and symptoms of infant retinoblastoma? (Select all that apply.)
a. White reflex
b. Red reflex NURSINGTB.COM
c. Corneal light reflex
d. Absence of a blink reflex
e. Autosomal dominant trait
f. Drainage from the affected eye
g. Visual acuity of 20/500
ANS: A, E
Retinoblastoma in an infant is marked by a characteristic white reflex, also called cat’s eye
reflex or leukocoria. Red reflex and corneal light reflex are expected findings. Absence of the
blink reflex is not associated with retinoblastoma.

NURSINGTB.COM
Chapter 13: Ears, Nose, and Throat

MULTIPLE CHOICE
1. Mr. Sprat is a 21-year-old patient who complains of nasal congestion. He admits to using
recreational drugs. On examination, you have noted a septal perforation. Which of the
following recreational drugs is commonly associated with nasal septum perforation?
a. Heroin
b. Cocaine
c. PCP
d. Ecstasy
ANS: B
Long-term cocaine snorting causes ischemic necrosis of the septal cartilage and leads to
perforation of the nasal septum.

2. A 5-year-old child presents with nasal congestion and a headache. To assess for sinus
tenderness, you should palpate over the:
a. sphenoid and frontal sinuses.
b. maxillary and frontal sinuses.
c. maxillary sinuses only.
d. sphenoid sinuses only.
NURSINGTB.COM
ANS: C
Only the maxillary and the frontal sinuses are accessible for physical examination; however,
the young child does not develop frontal sinuses until 7 to 8 years of age.

3. Mr. and Mrs. Johnson have presented to the office with their infant son with complaints of ear
drainage. When examining an infant’s middle ear, the nurse should use one hand to stabilize
the otoscope against the head while using the other hand to:
a. pull the auricle down and back.
b. hold the speculum in the canal.
c. distract the infant.
d. stabilize the chest.
ANS: A
The nurse should use the other hand to pull the auricle down and back in an effort to
straighten the upward curvature of the canal.

4. Mrs. Donaldson is a 31-year-old patient who is pregnant. In providing Mrs. Donaldson with
healthcare information, you will explain that she can expect to experience:
NURSINGTB.COM
a. more nasal stuffiness.

b. a sensitive sense of smell.
c. drooling.
d. enhanced hearing.
ANS: A
Physiologic changes of pregnancy include nasal stuffiness, a decreased sense of smell,
impaired hearing, epistaxis, and a sense of fullness in the ears.

5. You are performing hearing screening tests. Who would be expected to find difficulty in
hearing the highest frequencies?
a. A 7-year-old
b. An 18-year-old
c. A 30-year-old
d. A 50-year-old
ANS: D
Sensorineural hearing loss begins after 50 years of age, initially with losses of high-frequency
sounds and then progressing to tones of lower frequency.

6. Mr. Spencer presents with the complaint of hearing loss. You specifically inquire about
current medications. Which medications,
NURSINGifTB.Clisted, are likely to contribute to his hearing loss?
a. Chlorothiazide OM
b. Acetaminophen
c. Salicylates
d. Cephalosporins
ANS: C
Ototoxic medications include aminoglycoside, salicylates, furosemide, streptomycin, quinine,
ethacrynic acid, and cisplatin.

7. To approximate vocal frequencies, which tuning fork should be used to assess hearing?
a. 100 to 300 Hz
b. 200 to 400 Hz
c. 500 to 1000 Hz
d. 1500 to 2000 Hz
ANS: C
Use of a 500- to 1000-Hz tuning fork approximates vocal frequencies.

NURSINGTB.COM
8. You are using a pneumatic attachment on the otoscope while assessing tympanic membrane
movement. You gently squeeze the bulb but see no movement of the membrane. Your next
action should be to:
a. remove all cerumen from the canal.
b. change to a larger speculum.
c. squeeze the bulb with more force.
d. insert the speculum to a depth of 2 cm.
ANS: B
To see tympanic movement when using the pneumatic attachment, there should be a seal
around the speculum to block outside air. In this manner, the normal tympanic membrane
moves as a result of pressure changes from the insufflator bulb. A soft rubber speculum is
recommended to establish the seal.

9. When conducting an adult otoscopic examination, you should:

a. position the patient’s head leaning toward you.
b. grasp the handle of the otoscope as you would a baseball bat.
c. select the largest speculum that will fit in the canal.
d. ask the patient to keep his or her eyes closed.
ANS: C
When conducting an adult otoscopic examination, select the largest speculum that will
comfortably fit in the patient’s ear. When you are conducting an adult otoscopic examination,
the patient’s head should be positioned toward the opposite shoulder. Hold the handle of the
otoscope between the thumb N URindex
and SINfinger,
GTB.C OM it on the middle finger. There is no
supporting
reason for the patient to keep her or his eyes shut.

10. Bulging of an amber tympanic membrane without mobility is usually associated with:
a. middle ear effusion.
b. healed tympanic membrane perforation.
c. impacted cerumen in the canal.
d. repeated and prolonged crying cycles.
ANS: A
An amber color, with bulging of the tympanic membrane and without mobility or redness,
usually indicates the presence of fluid in the middle ear.

11. When hearing is evaluated, which cranial nerve is being tested?

a. III
b. IV
c. VIII
d. XII
NURSINGTB.COM
ANS: C
Cranial nerve VIII, the vestibulocochlear nerve, is associated with hearing.

12. Speech with a monotonous tone and erratic volume may indicate:
a. otitis externa.
b. hearing loss.
c. serous otitis media.
d. sinusitis.
ANS: B
Speech with a monotonous tone and erratic volume may indicate hearing loss.

13. You are performing Weber and Rinne hearing tests. For the Weber test, the sound lateralized
to the unaffected ear; for the Rinne test, air conduction-to-bone conduction ratio is less than
2:1. You interpret these findings as suggestive of:
a. a defect in the inner ear.
b. a defect in the middle ear.
c. otitis externa.
d. impacted cerumen.
ANS: A
These results are consistent with
N RaSsensorineural
INGTB.Chearing loss, a defect in the inner ear. Otitis
externa and impacted cerumenU are conditions OMexternal ear that can cause conductive
of the
hearing problems.

14. Nasal symptoms that imply an allergic response include:

a. purulent nasal drainage.
b. bluish gray turbinates.
c. small, atrophied nasal membranes.
d. firm consistency of turbinates.
ANS: B
Nasal symptoms that imply an allergic response include bluish gray or pale pink nasal
turbinates that are swollen and boggy and a transverse crease at the junction between the
cartilage and bone of the nose.

15. You are interviewing a parent whose child has a fever, is pulling at her right ear, and is
irritable. You ask the parent about the child’s appetite and find that the child has a decreased
appetite. This additional finding is more suggestive of:
a. acute otitis media.
NURSINGTB.COM
b. otitis externa.
c. serous otitis media.
d. middle ear effusion.
ANS: A
Anorexia is an initial symptom of acute otitis media.

16. A hairy tongue with yellowish brown to black elongated papillae on the dorsum:
a. is indicative of oral cancer.
b. is sometimes seen following antibiotic therapy.
c. usually indicates vitamin deficiency.
d. usually indicates anemia.
ANS: B
Recent antibiotic use can turn the tongue yellow-brown to black and make it appear hairy.
Oral cancer involves lesions. A smooth red tongue with a slick appearance may indicate a
niacin or vitamin B12 deficiency. Pallor usually indicates anemia.

17. To inspect the lateral borders of the tongue, you should:

a. ask the patient to extend the tongue outward.
b. insert the tongue blade obliquely against the tongue.
c. lift the tongue upward with
NUgloved
RSINfingers.
G B.C M
d. pull the gauze-wrapped tongue to eachTside. O
ANS: D
To inspect the lateral borders of the tongue, you should wrap the tongue with a piece of gauze
and then pull the tongue to each side for inspection.

18. For best results, an otoscopic and oral examination in a child should be:
a. conducted at the beginning of the assessment.
b. done after inspection.
c. performed at the end of the examination.
d. performed before palpation.
ANS: C
Because young children often resist an otoscopic and oral examination, it may be wise to
postpone these procedures until the end, after you have gained some trust.

MULTIPLE RESPONSE
NURSINGTB.COM
1. Mr. Akins is a 78-year-old patient who presents to the clinic with complaints of hearing loss.
Which are changes in hearing that occur in older adults? (Select all that apply.)
a. Results from cranial nerve VII
b. Slow progression
c. Loss of high frequency
d. Bone conduction heard longer than air conduction
e. Sounds may be garbled, difficult to localize
f. Unable to hear in a crowded room
ANS: C, E, F
Age-related hearing loss is associated with degeneration of hair cells in the organ of Corti,
loss of cortical and organ of Corti auditory neurons, degeneration of the cochlear conductive
membrane, and decreased vascularity in the cochlea. Sensorineural hearing loss first occurs
with high-frequency sounds and then progresses to tones of lower frequency. Loss of
high-frequency sounds usually interferes with the understanding of speech and localization of
sound. Conductive hearing loss may result from an excess deposition of bone cells along the
ossicle chain, causing fixation of the stapes in the oval window, cerumen impaction, or a
sclerotic tympanic membrane.

2. Which signs and symptoms occur with a sensorineural hearing loss? (Select all that apply.)
a. Air conduction shorter than bone conduction
b. Lateralization to the affected ear
c. Loss of high-frequency sounds
d. Speaks more loudly
N R I G B.COM
e. Disorder of the inner ear U S N T
f. Air conduction longer than bone conduction
ANS: C, D, E, F
The signs and symptoms of sensorineural hearing loss include loss of high-frequency sounds,
speaks more loudly, disorder of the inner ear, air conduction longer than bone conduction, and
lateralization to the unaffected ear.

COMPLETION
1. When you ask the patient to identify smells, you are assessing cranial nerve __.
ANS:
I
The first cranial nerve, the olfactory nerve, is tested when you ask a patient to identify
different smells.

NURSINGTB.COM
Chapter 14: Chest and Lungs

MULTIPLE CHOICE
1. A 44-year-old male patient who complains of a cough has presented to the emergency
department. He admits to smoking one pack per day. During your inspection of his chest, the
most appropriate lighting source to highlight chest movement is:
a. bright tangential lighting.
b. daylight from a window.
c. flashlight in a dark room.
d. fluorescent ceiling lights.
ANS: A
Bright tangential light is best for visualizing chest movements.

2. When auscultating the apex of the lung, you should listen at a point:
a. even with the second rib.
b. 4 cm above the first rib.
c. higher on the right side.
d. on the convex diaphragm surface.
ANS: B
The apex of the lung is 4 cm NURSthe
above INfirst
GTB.Crib. OM

3. To count the ribs and the intercostal spaces, you begin by palpating the reference point of the:
a. distal point of the xiphoid.
b. manubriosternal junction.
c. suprasternal notch.
d. acromion process.
ANS: B
The angle of Louis, the junction of the manubrium and the sternum, corresponds to the second
rib, the reference point for counting ribs and intercostal spaces.

4. Mr. Curtis is a 44-year-old patient who has presented to the emergency department with
shortness of breath. During the history, the patient describes shortness of breath that gets
worse when he sits up. To document this, you will use the term:
a. platypnea.
b. orthopnea.
c. tachypnea.
d. bradypnea.
NURSINGTB.COM
ANS: A
Dyspnea that increases in the upright posture is called platypnea. Orthopnea is dyspnea that
worsens when the person lies down. Tachypnea is an increased respiratory rate. Bradypnea is
a decreased respiratory rate.

5. Which finding suggests a minor structural variation?

a. Barrel chest
b. Clubbed fingers
c. Pectus carinatum
d. Chest wall retractions
ANS: C
Pectus carinatum (pigeon chest) is a minor structural variation. Barrel chest, clubbing of the
fingers, and chest wall retractions result from compromised respirations.

6. Ms. Rudman, age 74 years, has no known health problems or diseases. You are doing a
preventive healthcare history and examination. Which symptom is associated with
intrathoracic infection?
a. Barrel chest
b. Cor pulmonale
c. Funnel chest
d. Malodorous breath
NURSINGTB.COM
ANS: D
Intrathoracic infections may make the breath malodorous.

7. The best time to observe and count respirations is while:

a. the patient is answering questions.
b. weighing the patient.
c. palpating the pulse.
d. the patient is sleeping.
ANS: C
Counting respirations while you palpate the pulse does not make the patient self-conscious
because the patient expects you to be counting the pulse. Respiratory patterns change as the
patient speaks. Attempting to count during weighing would make the patient self-conscious
and affect the respiratory rate. Respiratory patterns change as the patient sleeps.

NURSINGTB.COM
8. As you take vital signs on Mr. Barrow, age 78 years, you note that his respirations are 40
breaths/min. He has been resting, and his mucosa is pink. In regard to Mr. Barrow’s
respirations, you would:
a. document his rate as normal.
b. do nothing because his color is pink.
c. note that his rate is below normal.
d. report that he has an above-average rate.
ANS: D
The normal adult respiratory rate is 12 to 20 breaths/min, and the ratio of breaths to heartbeats
is 1:4. A respiratory rate of 40 breaths/min is not within the normal range and should be
documented as above average.

9. In which patient situation would you expect to assess tachypnea?

a. Patient who is depressed
b. Patient who abuses narcotics
c. Patient with metabolic acidosis
d. Patient with myasthenia gravis
ANS: C
In metabolic acidosis, the body compensates by increasing the respiratory rate to blow off the
excess carbon dioxide. A patient who is depressed, abuses narcotics, or has myasthenia gravis
would have respiratory depression.
NU(Application)
10. Which site of chest wall retractions indicates a more severe obstruction in the asthmatic
patient?
a. Lower chest
b. Along the anterior axillary line
c. Above the clavicles
d. At the nipple line
ANS: C
Asthma usually causes retractions of the lower chest. The more severe the obstruction, the
greater the negative pressure produced in the chest during inspiration, and retractions are
manifested in the upper thorax.

11. You would expect to document the presence of a pleural friction rub for a patient being treated
for:
a. pneumonia.
b. atelectasis.
c. pleurisy.
d. emphysema.
NURSINGTB.COM
ANS: C
A pleural friction rub is caused by inflammation of the pleural surfaces and would be expected
to be auscultated with pleurisy.

12. Which type of apnea requires immediate action?

a. Primary apnea
b. Secondary apnea
c. Sleep apnea
d. Periodic apnea of the newborn
ANS: B
Secondary apnea is a grave condition, and unless resuscitative measures are instituted
immediately, breathing will not resume spontaneously. Primary apnea is self-limiting. Sleep
apnea should be evaluated but does not require immediate action. Periodic apnea of the
newborn is a normal condition.

13. With consolidation in the lung tissue, the breath sounds are louder and easier to hear, whereas
healthy lung tissue produces softer sounds. This is because:
a. consolidation echoes in the chest.
b. consolidation is a poor conductor of sound.
c. air-filled lung sounds are from smaller spaces.
d. air-filled lung tissue is anNinsulator
URSINofGT B.COM
sound.
ANS: D
Air is a poor conductor of sound. Denser consolidation promotes louder sounds and is a better
conductor of sound. Consolidation is a better conductor of sound than air. Breath sounds are
easier to hear when the lungs are consolidated; the mass surrounding the tube of the
respiratory tree promotes sound transmission better than air-filled alveoli.

MULTIPLE RESPONSE
1. Which lung sounds are associated with atelectasis? (Select all that apply.)
a. Wheezes
b. Ronchi
c. Crackles
d. Crepitus
e. Rales
ANS: A, B, C
Wheezes, ronchi, and crackles in varying amounts are associated with atelectasis.
NURSINGTB.COM
COMPLETION
1. An Apgar score of __________ is given to the infant who demonstrates irregular respiratory
effort.
ANS:
1
The Apgar score of 1 in an infant reflects slow or irregular breathing.

NURSINGTB.COM
NURSINGTB.COM
Chapter 15: Heart

MULTIPLE CHOICE
1. Mr. O, age 50 years, comes for his annual health assessment, which is provided by his
employer. During your initial history-taking interview, Mr. O mentions that he routinely
engages in light exercise. At this time, you should:
a. ask if he makes his own bed daily.
b. have the patient describe his exercise.
c. make a note that he walks each day.
d. record “light exercise” in the history.
ANS: B
When Mr. O says that he engages in light exercise, have him describe his exercise. To qualify
his use of the term light, ask him the type, length of time, frequency, and intensity of his
activities.

2. Which of the following information belongs in the past medical history section related to heart
and blood vessel assessment?
a. Adolescent inguinal hernia
b. Childhood mumps
c. History of bee stings
NURSINGTB.COM
d. Previous unexplained fever
ANS: D
Previous unexplained fever should be included in the past medical history of a heart and blood
vessel assessment. This incidence may be related to acute rheumatic fever, with potential heart
valve damage.

3. A patient you are seeing in the emergency department for chest pain is believed to be having a
myocardial infarction. During the health history interview of his family history, he relates that
his father had died of “heart trouble.” The most important follow-up question you should pose
is which of the following?
a. “Did your father have coronary bypass surgery?”
b. “Did your father’s father have heart trouble also?”
c. “What were your father’s usual dietary habits?”
d. “What age was your father at the time of his death?”
ANS: D
A family history of sudden death, particularly in young and middle-aged relatives,
significantly increases one’s chance of a similar occurrence.

NURSINGTB.COM
4. Which one of the following is a common symptom of cardiovascular disorders in the older
adult?
a. Fatigue
b. Joint pain
c. Poor night vision
d. Weight gain
ANS: A
Common symptoms of cardiovascular disorders in older adults include confusion, dizziness,
blackouts, syncope, palpitations, coughs and wheezes, hemoptysis, shortness of breath, chest
pains or tightness, impotence, fatigue, and leg edema.

5. In the adult, the apical impulse should be most visible when the patient is in what position?
a. Supine
b. Upright
c. Lithotomy
d. Right lateral recumbent
ANS: B
In most adults, the apical impulse should be visible at about the midclavicular line in the fifth
left intercostal space, but it is easily obscured by obesity, large breasts, or muscularity. The
apical impulse may become visible only when the patient sits upright and the heart is brought
closer to the anterior wall. A visible and palpable impulse when the patient is supine suggests
NURS
an intensity that may be the result ofIaNproblem.
GTB.CInOmost
M adults, the apical impulse will not be
visible in the upright, lithotomy, or right lateral recumbent positions.

6. If the apical impulse is more vigorous than expected, it is called a:

a. lift.
b. thrill.
c. bruit.
d. murmur.
ANS: A
If the apical impulse is more vigorous than expected, it is referred to as a lift or heave. A thrill
is a palpable murmur. A bruit is an auscultated arterial murmur. A murmur is an auscultated
sound caused by turbulent blood flow into, through, or out of the heart.

7. A palpable rushing vibration over the base of the heart at the second intercostal space is called
a:
a. heave.
b. lift.
c. thrill.
NURSINGTB.COM
d. thrust.
ANS: C
A thrill is a fine, palpable, rushing vibration—a palpable murmur. Cardiac thrills generally
indicate a disruption of the expected blood flow related to some defect in the closure of one of
the semilunar valves (generally aortic or pulmonic stenosis), pulmonary hypertension, or atrial
septal defect. A heave or lift is a more vigorous apical impulse. A lift is another term for a
heave, which is a more vigorous apical impulse. A thrust is sudden, forcible forward
movement.

8. An apical PMI palpated beyond the fifth intercostal space may indicate:
a. decreased cardiac output.
b. obesity.
c. left ventricular hypertrophy.
d. hyperventilation.
ANS: C
An apical impulse that is more forceful and widely distributed, fills systole, or is displaced
laterally and downward may be indicative of left ventricular hypertrophy. Obesity, large
breasts, and muscularity can obscure the visibility of the apical impulse.

9. A lift along the left sternal border

NURisSImost likely the result of:
a. aortic stenosis. NGTB.COM
b. atrial septal defect.
c. pulmonary hypertension.
d. right ventricular hypertrophy.
ANS: D
A lift along the left sternal border may be caused by right ventricular hypertrophy. A thrill
indicates a disruption of the expected blood flow related to a defect in the closure of one of
the semilunar valves, which is seen in aortic or pulmonic stenosis, pulmonary hypertension, or
atrial septal defect.

10. To estimate heart size by percussion, you should begin tapping at the:
a. anterior axillary line.
b. left sternal border.
c. midclavicular line.
d. midsternal line.
ANS: A
Estimating the size of the heart can be done by percussion. Begin tapping at the anterior
axillary line, moving medially along the intercostal spaces toward the sternal border. The
change from a resonant to a dull note marks the cardiac border.
NURSINGTB.COM

11. To hear diastolic heart sounds, you should ask patients to:
a. lie on their back.
b. lie on their left side.
c. lie on their right side.
d. sit up and lean forward.
ANS: B
Left lateral recumbent is the best position to hear the low-pitched filling sounds in diastole
with the bell of the stethoscope. Sitting up and leaning forward is the best position in which to
hear relatively high-pitched murmurs with the diaphragm of the stethoscope. The right lateral
recumbent position is the best position for evaluating the right rotated heart of dextrocardia.

12. You are listening to a patient’s heart sounds in the aortic and pulmonic areas. The sound
becomes asynchronous during inspiration. The prevalent heart sound in this area is most
likely:
a. S1.
b. S2.
c. S3.
d. S4.
U S valves,
S2 marks the closure of the semilunar N T which O indicates the end of systole; it is best
heard in the aortic and pulmonic areas. It is higher pitched and shorter than S1. S2 typically
splits during inspiration.

13. Chest pain with an organic cause in a child is most likely the result of:
a. cardiac disease.
b. asthma.
c. esophageal reflux.
d. arthritis.
ANS: B
Unlike chest pain in adults, chest pain in children and adolescents is seldom caused by a
cardiac problem. More likely, the case is related to trauma, exercise-induced asthma, or
cocaine use.

14. A condition that is likely to present with dizziness and syncope is:
a. bacterial endocarditis.
b. hypertension.
NURSINGTB.COM
c. sick sinus syndrome.

d. pericarditis.
ANS: C
Sick sinus syndrome (SSS) is a sinoatrial dysfunction that occurs secondary to hypertension,
arteriosclerotic heart disease, or rheumatic heart disease. SSS causes dysrhythmia with
subsequent syncope, transient dizzy spells, light-headedness, seizures, palpitations, angina, or
congestive heart failure (CHF). Bacterial endocarditis presents with prolonged fever, signs of
neurologic dysfunction, and sudden onset of CHF. Chest pain is an initial symptom in acute
pericarditis, along with a triphasic friction rub.

15. Your patient, who abuses intravenous (IV) drugs, has a sudden onset of fever and symptoms
of congestive heart failure. Inspection of the skin reveals nontender erythematic lesions to the
palms. These findings are consistent with the development of:
a. rheumatic fever.
b. cor pulmonale.
c. pericarditis.
d. endocarditis.
ANS: D
Endocarditis is a bacterial infection of the endothelial layer of the heart. It should be suspected
with at-risk patients (e.g., IV drug abusers) who present with fever and sudden onset of
congestive heart symptoms. The lesions described are Janeway lesions.
NU(Application)
16. The most helpful finding in determining left-sided heart failure is:
a. dyspnea.
b. orthopnea.
c. jugular vein distention.
d. an S3 heart sound.
ANS: C
Evidence-based research has shown that the most helpful clinical examination finding
supportive of left-sided heart failure is jugular vein distention.

MULTIPLE RESPONSE
1. Your patient has been diagnosed with pericarditis. Which are signs and symptoms, or a
precipitating factor? (Select all that apply.)
a. Sharp pain
b. Pain relieved by sitting up
c. Pain relieved by resting
d. Friction rub heard to right of sternum
NURSINGTB.COM
e. History of kidney failure

f. Result of viral infection
g. Result of medications such as procainamide
ANS: A, B, E, F, G
Pericarditis may be seen with a viral infection, kidney failure, or medications such as
procainamide. Symptoms include pain relieved by sitting up or leaning forward. A friction rub
is heard at the left of the sternum, at the third or fourth intercostal space.

NURSINGTB.COM
NURSINGTB.COM
Chapter 16: Blood Vessels

MULTIPLE CHOICE
1. Induration, edema, and hyperpigmentation are common associated findings with which of the
following?
a. Peripheral arterial disease
b. Venous ulcer
c. Arterial embolic disease
d. Venous thrombus
ANS: B
A venous ulcer also results from chronic venous insufficiency and demonstrates induration
edema and hyperpigmentation. Peripheral arterial edema results in ischemia, in which the foot
or leg is painful and cold; nonulceration is common as the muscles atrophy. Arterial embolic
disease includes occlusion of the small arteries, resulting in blue toe syndrome and splinter
hemorrhages in the nail bed. A venous thrombus presents with minimal ankle edema,
low-grade fever, tachycardia, and possibly a positive Homan sign.
DIF: Cognitive Level: Applying (Application) OBJ: Nursing process—diagnosis

MSC: Physiologic Integrity: Reduction of Risk Potential
2. The most prominent component of the jugular venous pulse is the:

a. a wave.
b. c wave.
c. v wave. NURSINGTB.COM
d. x slope.
ANS: A
The a wave is the first and most prominent component of the jugular venous pulse. The a
wave represents a brief backflow of blood into the vena cava during right atrial contraction.

3. During a routine prenatal visit, Ms. T was noted as having dependent edema, varicosities of
the legs, and hemorrhoids. She expressed concern about these symptoms. You explain to Ms.
T that her enlarged uterus is compressing her pelvic veins and her inferior vena cava. You
would further explain that these findings:
a. are usual conditions during pregnancy.
b. indicate a need for hospitalization.
c. indicate the need for amniocentesis.
d. suggest that she is having twins.
ANS: A
Explain to the patient that these are usual conditions during pregnancy. Blood in the lower
extremities tends to pool in later pregnancy because of the occlusion of the pelvic veins and
inferior vena cava from pressure created by the enlarged uterus. This occlusion results in an
increase in dependent edema, varicosities of the legs and vulva, and hemorrhoids.
NURSINGTB.COM

4. Vascular changes expected in the older adult include:

a. loss of vessel elasticity.
b. decreased peripheral resistance.
c. decreased pulse pressure.
d. constriction of the aorta and major bronchi.
ANS: A
With age, the walls of the arteries become calcified and they lose their elasticity and
vasomotor tone; therefore, they lose their ability to respond appropriately to changing body
needs. Increased peripheral vascular resistance occurs, causing an increase in blood pressure.

5. You are examining Mr. S, a 79-year-old diabetic man complaining of claudication. Which of
the following physical findings is consistent with the diagnosis of peripheral arterial disease?
a. Thick, calloused skin
b. Ruddy, thin skin
c. Warmer temperature of extremity in contrast to other body parts
d. Loss of hair over the extremities
ANS: D
An individual with peripheral artery disease or claudication will have thin skin with localized
pallor and cyanosis, a loss ofNbody warmth in the affected area, and loss of hair over the
extremities. URSINGTB.COM
6. You are performing a physical examination on a 46-year-old male patient. His examination
findings include the following: positive peripheral edema, holosystolic murmur in the
tricuspid region, and a pulsatile liver. His diagnosis is:
a. an aortic aneurysm.
b. an arteriovenous fistula.
c. tricuspid stenosis.
d. tricuspid regurgitation.
ANS: D
An aneurysm is a localized isolation that results in a pulsatile swelling and a thrill or bruit. An
arteriovenous fistula is a pathologic communication between an artery and vein resulting in a
thrill or bruit and edema or ischemia in the involved extremity. Tricuspid regurgitation results
in a holosystolic murmur in the tricuspid region, a pulsatile liver, and peripheral edema.

7. A characteristic distinguishing primary Raynaud phenomenon from secondary Raynaud

phenomenon includes which of the following?
NURSINGTB.COM
a. Vasospasm
b. Digital ischemia with pain
c. Triphasic demarcated skin
d. Cold and achy improving with warming
ANS: B
In primary Raynaud phenomenon, there is triphasic demarcation of the skin—white, cyanotic,
and reperfused—and vasospasm that lasts a minutes to less than an hour, areas of cold, and an
achy feeling that improves with rewarming. In secondary Raynaud phenomenon, there is
intense pain from digital ischemia.

8. In children, coarctation of the aorta should be suspected if you detect:

a. a delay between the radial and femoral pulses.
b. a simultaneous radial and femoral pulse.
c. an absent femoral pulse on the left.
d. bilateral absence of femoral pulses.
ANS: A
Coarctation of the aorta is a congenital stenosis or narrowing seen most commonly in the
descending aortic arch, near the origin of the left subclavian artery and ligamentum
arteriosum. Ordinarily, the radial and femoral pulses are palpated simultaneously. When there
is a delay and/or a palpable diminution of amplitude of the femoral pulse, coarctation must be
suspected. Differences in blood pressure taken in the arms and legs should confirm the
suspicion. Coarctation of the aorta should not be suspected if the radial and femoral pulses are
NUfemoral
palpated simultaneously, if the RSINpulseGTB.C OMleft is absent, or if there is bilateral
on the
absence of femoral pulses.

9. Which of the following statements is true regarding the development of venous ulcers in older
adults?
a. The major symptom is severe leg pain, especially when walking.
b. The affected leg is commonly pale and hairless, and pulses are difficult to palpate.
c. Diabetes, peripheral neuropathy, and nutritional deficiencies are causative factors.
d. The ulcers are generally located on the tips of toes.
ANS: C
Venous ulcers are generally found on the medial or lateral aspects of the lower limbs, most
often in older adults. Induration, edema, and hyperpigmentation are common. Heart failure,
hypoalbuminemia, peripheral neuropathy, diabetes mellitus, nutritional deficiencies, and
arterial disease cause the venous ulcers to develop. The major symptom of venous ulcers is
not severe leg pain. In patients with venous ulcers, the affected leg is not commonly pale and
hairless, and pulses are not difficult to palpate. Venous ulcers are not generally located on the
tips of toes.

NURSINGTB.COM
10. When examining arterial pulses the thumb may be used:

a. especially if vessels have a tendency to move.
b. never for palpating pulses.
c. checking the jugular venous pressure.
d. during the Allen test.
ANS: A
The thumb may be used, especially if the vessels have a tendency to move when probed by
the fingers. The thumb is particularly useful in fixing the brachial and even the femoral pulses.
You cannot palpate for jugular venous pressure waves. The Allen test is used to ensure ulnar
patency prior to radial artery puncture.

11. To assess a patient’s jugular veins, the patient should first be placed in which position?
a. Supine
b. Semi-Fowler
c. Upright
d. Left lateral recumbent
ANS: A
To assess jugular veins, place the patient in the supine position. This causes engorgement of
the jugular veins. Then gradually raise the head of the bed until the pulsations of the jugular
vein become visible between the angle of the jaw and the clavicle. Jugular veins cannot be
palpated.
NURSI(Comprehension)
DIF: Cognitive Level: Understanding
NGMSC:
TB.C OM
OBJ: Nursing process—assessment Physiologic Integrity: Reduction of Risk Potential
12. Observation of hand veins can facilitate the assessment of:

a. mitral valve competency.
b. a heart murmur.
c. right heart pressure.
d. left heart pressure.
ANS: C
Hand veins can be used as an auxiliary manometer of right heart pressure. Assess the hand
veins while the hand is at the patient’s side. Then raise the hand until the veins collapse, and
use a ruler to measure the vertical distance between the midaxillary line (level of the heart)
and the level of the collapsed hand veins.

13. You are assessing Mr. Z’s fluid volume status as a result of heart failure. If your finger
depresses a patient’s edematous ankle to a depth of 6 mm, you should record this pitting as:
a. 1+.
b. 2+.
c. 3+.
d. 4+.
NURSINGTB.COM
ANS: C
Pitting edema to 6 mm represents a 3+ rating. This edema is noticeably deep and may last
more longer a minute; the dependent extremity looks fuller and swollen. Edema is graded on a
scale of mild (1+) through worse (4+).

14. A bounding pulse in an infant may be associated with:

a. patent ductus arteriosus.
b. coarctation of the aorta.
c. decreased cardiac output.
d. peripheral vaso-occlusion.
ANS: A
A bounding pulse is associated with a large left-to-right shunt produced by a patent ductus
arteriosus. A weaker or thinner pulse represents diminished cardiac output or peripheral
vasoconstriction. A difference in pulse amplitude between the upper extremities or between
the femoral and radial pulses, and absence of the femoral pulse, suggests a coarctation of the
aorta.

15. In infants or small children, a capillary refill time of 4 seconds:

a. is normal.
b. indicates hypervolemia.
NURSINGTshock.
c. indicates dehydration or hypovolemic B.COM
d. indicates renal artery stenosis.
ANS: C
Capillary refill time represents the time it takes the capillary bed to refill after being occluded
by pressure to the nail bed for several seconds. Observe the time it takes for the nail to regain
its full color, which should be less than 2 seconds for an intact system. The capillary refill
time will be longer than 2 seconds during arterial occlusion, hypovolemic shock, hypothermia,
and dehydration.

16. A venous hum heard over the internal jugular vein of a child:
a. usually signifies untreatable illness.
b. usually has no pathologic significance.
c. usually requires surgical intervention.
d. must be monitored until the child is grown.
ANS: B
A venous hum is caused by the turbulence of blood flow in the internal jugular veins. It is
common in children and usually has no pathologic significance. To detect a venous hum,
auscultate over the right supraclavicular space at the medial end of the clavicle and along the
anterior border of the sternocleidomastoid muscle. It is louder during diastole.
NURSINGTB.COM

17. You are palpating bilateral pedal pulses and cannot feel one of the pulses. The feet are equally
warm. You find that both great toes are pink, with a capillary refill within 2 seconds. Which
of the following statements is correct?
a. Immediate emergency surgery is indicated.
b. Pedal pulses are not always palpable.
c. Unilateral pulses are never normal.
d. Venogram studies will be needed.
ANS: B
Dorsalis pedis and posterior tibia pulses may be difficult to palpate or may not be palpable in
some well persons. The feet are warm and capillary refill is less than 2 seconds; there is
adequate circulation to the feet. Immediate emergency surgery is not indicated. Unilateral
pulses may be normal. Venogram studies will not be needed.

MULTIPLE RESPONSE
1. When palpating the carotid artery, which of the following is most important? (Select all that
apply.)
a. Rotate the patient’s head to the side being examined to relax the
sternocleidomastoid.
b. Excessive carotid sinus massage
NURSIcan compromise blood flow to the brain.
c. Excessive carotid sinus massage NGcause
can TB.C OM of the pulse.
slowing
d. Palpate both sides simultaneously.
ANS: A, B, C
When palpating the carotid arteries, never palpate both sides simultaneously. Excessive
carotid sinus massage can cause slowing of the pulse and a drop in blood pressure and can
compromise blood flow to the brain, leading to syncope. If you have difficulty feeling the
pulse, rotate the patient’s head to the side being examined to relax the sternocleidomastoid
muscle.

2. Which are risk factors for varicose veins? (Select all that apply.)
a. Gender
b. Alcohol use
c. Lower extremity trauma
d. Increased body mass
e. Hypertension
f. Diabetes
ANS: A, C, D
NURSINGTB.COM
Gender (women are four times more likely than men to have varicose veins—genetic
predisposition), tobacco use, increased body mass, age, and history of lower extremity trauma
are all risk factors for varicose veins.

NURSINGTB.COM
NURSINGTB.COM
Chapter 17: Breasts and Axillae

MULTIPLE CHOICE
1. Montgomery tubercles are most prominent in the breasts of:

a. adult males.
b. patients with lung disease.
c. pregnant women.
d. pubertal females.
ANS: C
Montgomery tubercles undergo hypertrophy and become more prominent in the breasts of
pregnant and lactating women.

2. Most women with breast cancer:

a. possess the BRCA1 or BRCA2 gene.
b. risk increases with aging.
c. have a mother who had breast cancer.
d. continue to menstruate after age 52.
ANS: B
Of all breast cancers, 77% occur in women older than 50 years. Most women with breast
NURor
cancer do not possess the BRCA1 SIBRCA2
NGTB.C M 5% to 10% of women with breast
gene.OOnly
cancer are known to have either gene. Most women with breast cancer do not have a mother
who had breast cancer. Familial breast cancers occur in 10% to 20% of breast cancer
populations. Most women with breast cancer do not continue to menstruate after age 52.
Having a later start of menopause does not overshadow the 77% of all breast cancers that
occur in women older than 50 years.

3. A 50-year-old woman presents as a new patient. Which finding in her personal and social
history would increase her risk profile for developing breast cancer?
a. Drinking three glasses of wine per week
b. Early menopause
c. Nulliparity
d. Late menarche
ANS: C
Nulliparity, or late age at the birth of the first child (after 30 years old), is a risk factor for
breast cancer. Other risk factors include late menopause, early menarche, and drinking more
than one alcoholic drink daily.

NURSINGTB.COM
4. If your patient has nipple discharge, you will most likely need a:
a. Vacutainer tube.
b. glass slide and fixative.
c. specimen jar with formaldehyde.
d. tape strip to test pH.
ANS: B
A glass slide and fixative are used for microscopic examination of the discharge to identify its
cellular makeup.

5. While examining a 30-year-old woman, you note that one breast is slightly larger than the
other. In response to this finding, you should:
a. note the finding in the patient’s record.
b. ask the patient if she has ever had breast cancer.
c. tell the patient to get a mammogram as soon as possible.
d. tell the patient to get a mammary sonogram as soon as possible.
ANS: A
Often one breast is slightly larger than the other. This is a normal variation and no further
intervention is required.

6. A 23-year-old white woman N

has R
come
I toGtheB.C
clinic M
because she has missed two menstrual
U ShaveN enlarged
periods. She states that her breasts T O
and that her nipples have turned a darker
color. Your response to this finding is to:
a. instruct her that this is a side effect of birth control injection therapy.
b. suggest pregnancy testing.
c. question her use of tanning beds.
d. schedule an appointment with a surgeon.
ANS: B
In light-skinned women, pregnancy produces enlarged breasts with a darker areola. Neither
hormonal injections nor the use of tanning beds will change the color of the areola as does
pregnancy. Surgical consultation is not necessary.

7. In patients with breast cancer, peau d’orange skin is often first evident:
a. in the axilla.
b. in the upper inner quadrant.
c. on or around the nipple.
d. at the inframammary ridge.
ANS: C
The areola is the most common initial site for visualization of peau d’orange skin.
NURSINGTB.COM

8. A firm, transverse ridge of compressed tissue is felt bilaterally along the lower edge of a
40-year-old patient’s breast. You should:
a. ask the patient if she has a history of breast cancer.
b. refer the patient to a surgeon.
c. ask the patient to have a mammogram as soon as possible.
d. record the finding in the patient’s record.
ANS: D
The inframammary ridge thickens and can be felt more easily with age. It is an expected,
normal finding, without indications for further action.

9. When examining axillary lymph nodes, the patient’s arm is:

a. raised fully above the head.
b. extended at the side.
c. flexed at the elbow.
d. crossed over the chest.
ANS: C
To examine the axilla, support the patient’s lower arm with the elbow flexed with one of your
hands and use your other hand to palpate the axilla.
DIF: Cognitive Level: Applying

NU(Application)
RSINGMSC:
OBJ: Nursing process—assessment TB.COM
Physiologic Integrity: Reduction of Risk Potential
10. Male gynecomastia associated with illicit or prescription drug use can be expected to:
a. lessen when the body becomes accustomed to the drug.
b. resolve after the drug is discontinued.
c. leave permanent breast enlargement when the drug is discontinued.
d. cause purulent drainage if left untreated.
ANS: B
Gynecomastia associated with illicit or prescription drug use (e.g., antihypertensive drugs,
estrogens, steroids) usually resolves after the offending drug is discontinued and does not
require further intervention.

11. A nursing mother complains that her breasts are tender. You assess hard, shiny, and erythemic
breasts bilaterally. You should advise the patient to:
a. massage gently and continue nursing.
b. apply warm compresses and stop nursing.
c. monitor her temperature and restrict fluids.
d. sleep wearing a bra and wash her breasts with antibacterial soap.
ANS: A
NURSINGTB.COM
This patient has mastitis. The aim of treatment is to promote breast drainage. You should not
advise the patient to apply warm compresses and stop nursing. Applying warm compresses
will not encourage breast milk flow, and stopping nursing will increase the risk of a breast
infection turning into a breast abscess. Monitoring her temperature and restricting fluids do
not encourage breast milk flow. Sleeping with a bra and washing the breasts with antibacterial
soap do not encourage breast milk flow. Only mild soaps are advised; harsh soaps can dry and
crack the nipple and compound infection.

12. You are conducting a clinical breast examination for your 30-year-old patient. Her breasts are
symmetric, with bilateral, multiple tender masses that are freely movable and with
well-defined borders. You recognize that these symptoms and assessment findings are
consistent with:
a. fibroadenoma.
b. Paget disease.
c. cancer.
d. fibrocystic changes.
ANS: D
Fibrocystic changes are tender masses, usually bilateral, with multiple round, mobile,
well-delineated borders. A fibroadenoma is usually nontender. Paget disease is an eczema-like
condition of the nipple that signals an underlying cancer. Cancer is usually nontender.

OBJ: Nursing process—assessment MSC: Health Promotion and Maintenance
NURSINGTB.COM
13. Your patient is a nursing mother who asks you to look at a mole she has under her left breast
at the inframammary fold. The mole is nontender and soft and has grown in size since she
started nursing. There are no other changes to the mole. This mole probably represents an
undiagnosed:
a. Montgomery tubercle.
b. case of Paget disease.
c. supernumerary nipple.
d. fat necrosis.
ANS: C
Supernumerary nipples usually resemble moles and occur, as this one does, along the milk
line. Those that have glandular tissue may enlarge under hormonal influences. They may not
be recognized as extra nipples in infants because they are usually small and not well formed.

14. When conducting a clinical breast examination, the examiner should:

a. forgo the examination if the patient has had a recent mammogram.
b. keep the patient’s breasts completely covered to respect modesty.
c. dim the lights to minimize anxiety.
d. inspect both breasts simultaneously.
ANS: D
NURSINGTB.COM
Simultaneous observation of both breasts is essential to detect differences between breast size,
symmetry, contour, and skin color.

MULTIPLE RESPONSE
1. Mrs. Weber is a 65-year-old patient who has presented at the clinic with a complaint of a
tender breast mass that she discovered during breast self-examination. You have completed a
physical examination on Mrs. Weber and have palpated a mass of the right breast in the lower
outer quadrant. When providing patient education to Mrs. Weber regarding the breast mass,
you will explain that the characteristics of a cancerous mass would be which of the following?
(Select all that apply.)
a. Immobile and firm
b. Pain on palpation
c. Irregular border edges
d. Mobile and rubbery
e. Nontender
ANS: A, C, E
Characteristics of cancerous breast masses are irregular or stellate, hard, fixed, nontender, and
poorly delineated.

N R I G B.C M
U S whoN presents
T Ofor a routine annual examination. During
2. Ms. Lawson is a 41-year-old patient
her breast examination, you are also completing a lymphatic examination. Which of the
following lymph nodes are examined during a breast examination? (Select all that apply.)
a. Supraclavicular
b. Lateral axillary nodes
c. Anterior cervical nodes
d. Anterior axillary nodes
e. Posterior cervical nodes
ANS: A, B, D DIF: Cognitive Level: Remembering (Knowledge)
NURSINGTB.COM
Chapter 18: Abdomen

MULTIPLE CHOICE
1. Mrs. James is 7 months’ pregnant and states that she has developed a problem with
constipation. She eats a well-balanced diet and is usually regular. You should explain that
constipation is common during pregnancy because of changes in the colorectal areas, such as:
a. decreased movement through the colon and increased water absorption from the
stool.
b. increased movement through the colon and increased salt taken from foods.
c. looser anal sphincter and fewer nutrients taken from foods.
d. tighter anal sphincter and less iron eliminated in the stool.
ANS: A
Constipation and flatus are more common during pregnancy because the colon is displaced,
peristalsis is decreased, and water absorption is increased. Movement through the colon is
decreased during pregnancy. The colon does not absorb nutrients. A tighter sphincter tone is
not related to pregnancy.

2. The family history of a patient with diarrhea and abdominal pain should include inquiry about
cystic fibrosis because it is:
a. a common genetic disorder.
b. one cause of malabsorption NUsyndrome.
RSINGTB.COM
c. a curable condition with medical intervention.
d. the most frequent cause of diarrhea in general practice.
ANS: B
Cystic fibrosis is an uncommon, chronic genetic disorder affecting multiple systems. In the
gastrointestinal tract, it causes malabsorption syndrome because of pancreatic lipase
deficiency. Steatorrhea and abdominal pain from increased gas production are frequent
complaints.

3. When assessing abdominal pain in a college-age woman, one must include:

a. history of interstate travel.
b. food likes and dislikes.
c. age at completion of toilet training.
d. the first day of the last menstrual period.
ANS: D
NURSINGTB.COM
Exploring abdominal pain complaints in a young woman can reveal multiple causes related to
the menstrual cycle, including menstrual pain, ovulation discomfort, and abnormal menses.
Asking the patient to tell you the first day of her last menstrual period can help discriminate
among these factors. History of international travel and traveler’s diarrhea can be related to
abdominal pain, but interstate travel usually does not. Food preferences and age at completion
of toilet training are not relevant.

4. Infants born weighing less than 1500 g are at higher risk for:
a. hepatitis A.
b. necrotizing enterocolitis.
c. urinary urgency.
d. pancreatitis.
ANS: B
Necrotizing enterocolitis is a gastrointestinal disease that mostly affects premature infants. It
involves infection and inflammation that cause destruction of the bowel, and it becomes more
apparent after feedings.

5. You are completing a general physical examination on Mr. Rock, a 39-year-old man with
complaints of constipation. When examining a patient with tense abdominal musculature, a
helpful technique is to have the patient:
a. hold his or her breath. NURSINGTB.COM
b. sit upright.
c. flex his or her knees.
d. raise his or her head off the pillow.
ANS: C
To help relax the abdominal musculature, it is helpful to place a small pillow under the
patient’s head and under slightly flexed knees. The other techniques are not helpful because
they increase muscle flexion.

6. Mrs. Little is a 44-year-old patient who presents to the office with abdominal pain and fever.
During your examination, you ask the patient to raise her head and shoulders while she lies in
a supine position. A midline abdominal ridge rises. You document this observation as a(n):
a. small inguinal hernia.
b. large epigastric hernia.
c. abdominal lipoma.
d. diastasis recti.
ANS: D
A diastasis recti occurs when the abdominal contents bulge between two abdominal muscles
to form a midline ridge as the head is lifted. It has little clinical significance and usually
occurs in women who have had repeated pregnancies and in obese patients.
NURSINGTB.COM

MSC: Integrated Process: Communication and Documentation
7. Mr. Robins is a 45-year-old man who presents to the emergency department with a complaint
of constipation. During auscultation, you note borborygmi sounds. This is associated with:
a. gastroenteritis.
b. peritonitis.
c. satiety.
d. paralytic ileus.
ANS: A
Borborygmi are prolonged loud gurgles that occur with gastroenteritis, early intestinal
obstruction, or hunger. Peritonitis and paralytic ileus result in hypoactive bowel sounds. Food
satiety does not stimulate growling sounds as does hunger.

8. To document absent bowel sounds correctly, one must listen continuously for:
a. 30 seconds.
b. 1 minute.
c. 3 minutes.
d. 5 minutes.
ANS: D
Absent bowel sounds are confirmed
N R IafterGlistening
B.C to M each quadrant for 5 minutes.
U S N T O
9. Percussion of the abdomen begins with establishing:

a. liver dullness.
b. spleen dullness.
c. gastric bubble tympany.
d. overall dullness and tympany in all quadrants.
ANS: D
Percussion begins with a general establishment over all quadrants for areas of dullness and
tympany and then proceeds to specific target organs.

10. When percussing a spleen, Traube’s space is a:

a. semilunar region.
b. splenic percussion sign.
c. left-sided pleural effusion.
d. solid mass.
ANS: A
NURSINGTB.COM
Percussion of the spleen is more difficult because percussion tones elicited may be caused by
other conditions. Traube’s space is a semilunar region defined by the sixth ribs superiorly, the
midaxillary line laterally, and the left costal margin inferiorly.

11. Your patient is complaining of acute, intense, sharp epigastric pain that radiates to the back
and left scapula, with nausea and vomiting. Based on this history, your prioritized physical
examination should be to:
a. percuss for ascites.
b. assess for rebound tenderness.
c. inspect for ecchymosis of the flank.
d. auscultate for abdominal bruits.
ANS: C
Abdominal pain that radiates to the back could be caused by pancreatitis or a gastric ulcer,
gallbladder pain usually radiates to the right or left scapula but not to the back, pancreatitis
pain can radiate to the left shoulder or scapula, and nausea and vomiting usually occur with
gallbladder, pancreas, or appendix conditions. Pancreatitis is a differential diagnosis for all
these symptoms, so begin the examination by inspecting the flanks for the Grey Turner sign,
an indication of pancreatitis.

12. To assess for liver enlargement in the obese person, you should:
a. use the hook method. NURSINGTB.COM
b. have the patient lean over at the waist.
c. auscultate using the scratch technique.
d. attempt palpation during deep exhalation.
ANS: C
If the abdomen is obese or distended, or if the abdominal muscles are tight, you should plan
on auscultating the liver using the scratch method to estimate the lower border of the liver.

13. An umbilical assessment in the newborn that is of concern is:

a. a thick cord.
b. umbilical hernia.
c. one umbilical artery and two veins.
d. pulsations superior to the umbilicus.
ANS: C
Expect two arteries and one vein. A single umbilical artery indicates the possibility of
congenital anomalies. A thick cord suggests a well-nourished fetus, an umbilical hernia will
generally close spontaneously by 2 years, and pulsations to the abdomen in the epigastric area
are common.
NURSINGTB.COM
14. Your patient presents with symptoms that lead you to suspect acute appendicitis. Which
assessment finding is least likely to be associated with this condition?
a. Positive psoas sign
b. Positive McBurney sign
c. Consistent right lower quadrant (RLQ) pain
d. Rebound tenderness
ANS: C
A positive psoas sign, McBurney point pain, rebound tenderness, and periumbilical pain that
migrates to the RLQ are signs of appendicitis. The absence of pain migration makes
appendicitis less likely.

15. When using the bimanual technique for palpating the abdomen, you should:
a. push down with the bottom hand and the other hand on top.
b. push down with the top hand and concentrate on sensation with the bottom hand.
c. place the hands side by side and push equally.
d. place one hand anteriorly and the other hand posteriorly, squeezing the hands
together.
ANS: B
The bimanual technique uses one hand on top of the other. Exert pressure with the top hand
while concentrating on sensation with the other hand.
N R I G B.C M
U (Analysis)
S N T O
16. Flatulence, diarrhea, dysuria, and tenderness with abdominal palpation are findings usually
associated with:
a. diverticulitis.
b. pancreatitis.
c. ruptured ovarian cyst.
d. splenic rupture.
ANS: A
Only diverticulitis has all these presenting symptoms.

17. A 51-year-old woman calls with complaints of weight loss and constipation. She reports
enlarged hemorrhoids and rectal bleeding. You advise her to:
a. use a topical, over-the-counter hemorrhoid treatment for 1 week.
b. exercise and eat more fiber.
c. come to the laboratory for a stool guaiac test.
d. eat six small meals a day.
ANS: C
NURSINGTB.COM
Blood in the stool is an abnormal finding that should never be ignored, even if it can be
explained by conditions other than colon cancer. She should have her stool checked for blood
now as well as annually because she is older than 50 years.

18. Costovertebral angle tenderness should be assessed whenever you suspect that the patient may
have:
a. cholecystitis.
b. pancreatitis.
c. pyelonephritis.
d. ulcerative colitis.
ANS: C
Pyelonephritis is characterized by flank pain and costovertebral angle tenderness.

19. A mother brings her 2-year-old child for you to assess. The mother feels a lump whenever she
fastens the child’s diaper. Nephroblastoma is a likely diagnosis for this child when your
physical examination of the abdomen reveals a(n):
a. fixed mass palpated in the hypogastric area.
b. tender, midline abdominal mass.
c. olive-sized mass of the right upper quadrant.
d. nontender, slightly movable, flank mass.
NURSINGTB.COM
ANS: D
A Wilms tumor (nephroblastoma) is the most common intraabdominal tumor of childhood. It
presents with hypertension, fever, malaise, and a firm nontender mass deep within the flank
that is only slightly movable and is usually unilateral.

20. In older adults, overflow fecal incontinence is commonly caused by:

a. malabsorption.
b. parasitic diarrhea.
c. fecal impaction.
d. fistula formation.
ANS: C
Constipation with overflow occurs when the rectum contains hard stool and soft feces above a
leak around the mass of stool.

MULTIPLE RESPONSE
NURSINGTB.COM
1. Your patient is a 48-year-old woman with complaints of severe cramping pain in the abdomen
and right flank. Her past medical history includes a history of bladder calculi. You diagnose
her with renal calculi at this time. Which of the following symptoms would you expect with
her diagnosis? (Select all that apply.)
a. Abdominal pain on palpation
b. Blumberg sign
c. Cullen sign
d. CVA tenderness
e. Fever
f. Grey Turner sign
g. Hematuria
h. Nausea
ANS: A, D, E, G
Abdominal pain on palpation, CVA tenderness, fever, hematuria, and nausea are all signs and
symptoms of renal calculi. The Cullen sign is ecchymosis around the umbilicus, the Blumberg
sign is rebound tenderness for appendicitis, the Grey Turner sign is ecchymosis in the flanks,
and the McBurney sign is rebound tenderness at McBurney’s point.

2. Your patient returns to the office with multiple complaints regarding her abdomen. Which of
the following are objective findings? (Select all that apply.)
a. Nausea
b. Dullness on percussion
c. Rebound tenderness
d. Vomiting
NURSINGTB.COM
e. Diarrhea
f. Burning pain in epigastrium
ANS: B, C, E, F
Nausea, vomiting and diarrhea, and burning pain in epigastrium are subjective signs. Dullness
on percussion and rebound tenderness are objective findings.

NURSINGTB.COM
Chapter 19: Female Genitalia

MULTIPLE CHOICE
1. Posteriorly, the labia minora meet as two ridges that fuse to form the:
a. fourchette.
b. vulva.
c. clitoris.
d. perineum.
ANS: A
The labia minora join posteriorly to form the fourchette.

2. A cervical polyp usually appears as a:

a. grainy area at the ectocervical junction.
b. bright red, soft protrusion from the endocervical canal.
c. transverse or stellate scar.
d. hard granular surface at or near the os.
ANS: B
Cervical polyps are bright red, soft, and fragile. They usually protrude from the endocervical
canal.
NURSINGTB.COM
3. Which structure is located posteriorly on each side of the vaginal orifice?

a. Skene glands
b. Clitoris
c. Perineum
d. Bartholin glands
ANS: D
Bartholin glands are found posteriorly on each side of the vaginal orifice.

4. During sexual excitement, how is the vaginal introitus lubricated?

a. The Bartholin glands secrete mucus.
b. The clitoris produces moisture.
c. The Skene glands drain fluid.
d. The urethral surfaces secrete water.
ANS: A
The Bartholin glands secrete mucus into the introitus for lubrication during sexual stimulation.
NURSINGTB.COM

5. The vaginal mucosa of a woman of childbearing years should appear:

a. smooth and pink.
b. moist and excoriated.
c. dry and papular.
d. transversely rugated.
ANS: D
Between puberty and menopause, the vagina is transversely rugated; after menopause, it loses
its rugation.

6. The adnexa of the uterus are composed of the:

a. corpus and cervix.
b. fallopian tubes and ovaries.
c. uterosacral and broad ligaments.
d. vagina and fundus.
ANS: B
The fallopian tubes and ovaries are collectively referred to as the adnexa of the uterus.

N R I G B.C M
U Spregnancy
7. A bluish color to the cervix during N T is called
O (the):
a. McDonald sign.
b. Spinnbarkeit.
c. Goodell sign.
d. Chadwick sign.
ANS: D
The Chadwick sign is a bluish color to the cervix during pregnancy. The Goodell sign is an
increase in vascularity and softening of the cervix. Spinnbarkeit refers to the quality of elastic
mucus during mittelschmerz, and the McDonald sign is fundal flexing on the cervix.

8. The pelvic joint that separates most appreciably during late pregnancy is the:
a. sacroiliac.
b. symphysis.
c. sacrococcygeal.
d. iliofemoral.
ANS: B
Of the four pelvic joints, the one that moves appreciably later in pregnancy is the symphysis
pubis.
NURSINGTB.COM

9. Pregnancy-related cervical changes include:

a. flattening and lengthening.
b. thinning and reddening.
c. hardening and pallor.
d. softening and bluish coloring.
ANS: D
During pregnancy, the cervix softens (Goodell sign) and then appears bluish (Chadwick sign).

10. Mrs. Robinson, a 49-year-old patient, presents to the office complaining of missing her
menstrual period. She asks about menopause. You explain to her that the conventional
definition of menopause is:
a. the first day of the last menstrual period.
b. 1 year with no menses.
c. the last day of the last menstrual period.
d. the cessation of ovulation.
ANS: B
Menopause is defined as 1 year without menses.

NURSINGTB.COM
11. Which systemic feature is related to the effects of menopause?
a. Increased abdominal fat distribution
b. Decreased LDL levels
c. Cold intolerance
d. Decreased cholesterol levels
ANS: A
Systemic effects of menopause include increased intraabdominal body fat, increased LDL and
cholesterol levels, and hot flashes.

12. Ms. A, age 32, states that she has a recent history of itchy vaginal discharge. Ms. A has never
been pregnant. Her partner uses condoms and she uses spermicide for birth control. Which of
the following data are most relevant to Ms. A’s problem?
a. Bowel habits
b. Douching routines
c. Menstrual flow
d. Nutritional factors
ANS: B
NURSINGTB.COM
When obtaining history of present illness information for the woman with a vaginal discharge,
you should inquire about her douching habits. Douching is not only medically unnecessary
but it can also mask, or even worsen, conditions such as bacterial vaginosis or a yeast
infection.

13. Which risk factor is associated with cervical cancer?

a. Endometriosis
b. Low parity
c. Multiple sex partners
d. Obesity
ANS: C
Cervical cancer is associated with certain HPV strains. Multiple sex partners increase the risk
of HPV infection.

14. The risk of ovarian cancer is increased by:

a. the use of oral contraceptives.
b. cigarette smoking.
c. age between 35 and 50 years.
d. early age at first intercourse.
ANS: A N R I G B.C M
There is a relationship betweenUtheSnumber
N Tof menstrual
O cycles and risk of ovarian cancer.
Early menarche and menopause after 50 years of age increase the risk.

15. The form of gynecologic cancer that is increased in obese women is:
a. vaginal.
b. cervical.
c. ovarian.
d. endometrial.
ANS: D
Obesity increases a woman’s chance of developing endometrial cancer by twofold to fivefold.

16. The mother of an 8-year-old child reports that she has recently noticed a discharge stain on her
daughter’s underwear. Both the mother and daughter appear nervous and concerned. You
would need to ask questions to assess the child’s:
a. drug ingestion.
b. fluid intake.
c. risk for sexual abuse.
NURSINGTB.COM
d. hormone responsiveness.
ANS: C
Vaginal discharge in a child could be related to a chemical irritation from soaps, lotions, or
powders or to urinary tract infections. Concerned parents and children should be assessed for
the risk of sexual abuse.

17. The female patient should ideally be in which position for the pelvic examination?
a. Fowler
b. Prone
c. Lateral supine
d. Lithotomy
ANS: D
Ideally, the woman should be in a lithotomy position for a pelvic examination.

18. When you plan to obtain cytologic studies, speculum introduction may be facilitated by:
a. lubrication with gel.
b. lubrication with warm water.
c. use of a plastic speculum.
d. opening the blades completely.
It is generally thought that gel lubrication may interfere with cytologic studies; therefore, most
clinicians lubricate the speculum with warm water. Although gel lubrication would facilitate
speculum introduction, the gel could interfere with cytologic studies. Use of a plastic
speculum or opening the blades completely would not facilitate speculum introduction.

19. Which one of the following is a proper technique for the use of a speculum during a vaginal
examination?
a. Allow the labia to spread, and insert the speculum slightly open.
b. Insert one finger, and insert the opened speculum.
c. Press the introitus downward, and insert the closed speculum obliquely.
d. Spread the labia, and insert the closed speculum horizontally.
ANS: C
Use two fingers of one hand to push the introitus down to relax the pubococcygeal muscle.
Then hold the closed speculum with the other hand, and insert the speculum past your fingers
obliquely.

NURSINGTB.COM
20. When collecting specimens, which sample should be obtained first?

a. Chlamydial swab
b. Gonococcal culture
c. Pap smear
d. Wet mount
ANS: C
A Pap smear is obtained first and then other samples to test for gonorrhea, chlamydia,
Trichomonas, bacterial vaginosis, or candidiasis are obtained. Pap smear results are affected
by the presence of blood, and vaginal infections result in more friable tissues; therefore, the
Pap smear should be obtained first.

21. The presence of a fishy odor after adding potassium hydroxide to a wet mount slide
containing vaginal mucus suggests:
a. bacterial vaginosis.
b. yeast infection.
c. chlamydial infection.
d. pregnancy.
ANS: A
A positive whiff test suggests bacterial vaginosis.

N R I G B.C M
U Sis not
N part
T of the
O bimanual examination?
22. The assessment of which structure
a. Cervix
b. Bladder
c. Uterus
d. Ovaries
ANS: B
The bimanual examination consists of assessing the cervix, uterus, adnexa, and ovaries.

23. Mrs. Reilly brings her 6-year-old daughter in with complaints of a foul vaginal discharge
noted in her underpants. The most common cause of a foul vaginal discharge in children is
a(n):
a. accident.
b. foreign body.
c. infection.
d. ruptured hymen.
ANS: B
A foul vaginal discharge in the preschool-age girl is most likely indicative of the presence of a
foreign body.
NURSINGTB.COM

24. A 3-year-old girl is being seen because of a foul vaginal odor. To inspect the vaginal vault,
you should first:
a. insert a pediatric vaginal speculum.
b. place the child prone and in the fetal position.
c. insert a cotton-tipped applicator and press down.
d. pull the labia forward and slightly to the side.
ANS: D
Applying anterior labial traction allows the hymenal opening and the interior of the vagina to
become visible, almost to the cervix. The presence of a foreign body will be visible with this
maneuver.

25. A mother brings her 8-year-old daughter to the clinic because the child says it hurts to urinate
after she fell while riding her bicycle. On inspection, you find posterior vulvar and gross
perineum bruising. These findings are consistent with:
a. chronic masturbation.
b. congenital defects.
c. acute urinary tract infection.
d. sexual abuse.
ANS: D
A straddle injury from a bicycle
NUR seatIis usually
GTB.C evident
M over the symphysis pubis; injuries
S N O
resulting from sexual molestation are generally more posterior and may involve the perineum
grossly.

26. What accommodations should be used for the position of a hearing-impaired woman for a
pelvic examination?
a. The patient should assume the M or V position.
b. Her legs should be farther apart.
c. The head of the table should be elevated.
d. The lithotomy position with obstetric stirrups should be used.
ANS: C
The woman with a hearing impairment will need to see the clinician and/or an interpreter
during the examination; therefore, her head should be elevated.

27. Asking the woman to close the introitus during a pelvic examination is a test for:
a. endometriosis.
b. rectocele.
c. cervical polyps.
NURSINGTB.COM
d. sphincter tone.
ANS: D
The test for sphincter tone is to have the woman squeeze the vaginal opening around your
finger. A rectocele can be seen as a bulge on the posterior wall. Endometriosis is suggested
with tender nodules along the uterosacral ligaments. Cervical polyps can be inspected without
squeezing.

28. Itchy, painful, small red vesicles are typical of:

a. condyloma acuminatum.
b. condyloma latum.
c. herpes simplex lesions.
d. syphilitic chancre.
ANS: C
Herpetic lesions are painful, itchy red vesicles; condyloma acuminatum are warty lesions on
the genitalia; condyloma latum are secondary syphilis lesions that appear as flat, round, or
oval papules covered by a gray exudate; and a chancre is a painless ulcer.

MSC: Physiologic Integrity: Physiologic Adaptation
29. A young, sexually active woman comes to the urgent care clinic complaining of suprapubic
abdominal pain. She is afebrile with rebound tenderness to the right side. There is no dysuria
and no vaginal discharge or odor.
NURASIpelvic
GTexamination
B.COM is done. She has pain with cervical
motion, and you palpate a painful massNover the left adnexal area. Your prioritized action is
to:
a. swab for gonococcal infection and then dip her urine.
b. obtain a surgical consult immediately.
c. remove the foreign body.
d. dip her urine and then swab for Chlamydia.
ANS: B
The presenting symptoms of a tubal pregnancy are a surgical emergency. The only diagnostic
test should be a pregnancy test.

NURSINGTB.COM
Chapter 20: Male Genitalia

MULTIPLE CHOICE
1. While examining an 18-year-old man, you note that his penis and testicles are more darkly
pigmented than the body skin. You should consider this finding to be:
a. within normal limits.
b. suggestive of a skin fungus.
c. suggestive of psoriasis.
d. caused by excessive progesterone.
ANS: A
Darker pigmentation on the penis and testicles, as compared with other body skin, is a normal
finding and is not suggestive of a skin fungus, psoriasis, or excessive progesterone.

2. In an uncircumcised male, retraction of the foreskin may reveal a cheesy white substance.
This is usually:
a. evidence of a fungal infection.
b. a collection of sebaceous material.
c. indicative of penile carcinoma.
d. suggestive of diabetes.
In the uncircumcised male, smegma is formed by the secretion of sebaceous material by the
glans and the desquamation of epithelial cells from the prepuce. It appears as a cheesy white
substance on the glans and in the fornix of the foreskin. Smegma lubricates the cavity between
the foreskin of the penis and the glans, allowing smooth movement between them during
intercourse. It is not usually evidence of a fungal infection, penile carcinoma, or diabetes.

3. Inspection of the scrotum should reveal:

a. lightly pigmented skin.
b. two testes per sac.
c. smooth scrotal sacs.
d. the left scrotal sac lower than the right.
ANS: D
The left cord is longer than the right; consequently, the left testis hangs somewhat lower. The
skin of the scrotum is more darkly pigmented. The scrotum has one testis per sac. The
scrotum has small epidermoid cysts that give it a lumpy appearance.

4. Expected genitalia changes that occur as men age include that:
NURSINGTB.COM
a. the ejaculatory volume decreases with age.

b. erections develop more quickly.
c. the viability of sperm increases.
d. the scrotum becomes more pendulous.
ANS: D
Ejaculatory volume increases with age, erections develop more slowly, sperm viability
decreases, and the scrotum becomes more pendulous with age.

5. Inspection of the male urethral orifice requires the examiner to:

a. ask the patient to bear down.
b. insert a small urethral speculum.
c. press the glans between the thumb and forefinger.
d. transilluminate the penile shaft.
ANS: C
Inspection of the urethral orifice is accomplished by pressing the glans between the
examiner’s thumb and forefinger. This maneuver opens the slitlike orifice for further
inspection.

6. You are inspecting the genitalia of an uncircumcised adult male. The foreskin is tight and
cannot be easily retracted. You
NUshould:
RSINGTB.COM
a. chart the finding as paraphimosis.
b. inquire about previous penile infections.
c. retract the foreskin firmly.
d. transilluminate the glans.
ANS: B
This condition is phimosis and is usually congenital, or it may be related to recurrent
infections or poorly controlled diabetes. You should not chart this finding as paraphimosis.
Retracting the foreskin forcibly would lead to further adhesion formation and worsening
phimosis. Transillumination is indicated for masses of the scrotum.

7. Which type of hernia lies within the inguinal canal?

a. Umbilical
b. Direct
c. Indirect
d. Femoral
ANS: C
Hernias found within the inguinal canal are called indirect hernias.
NURSINGTB.COM
8. Which condition is of minor consequence in an adult male?

a. Adhesions of the foreskin
b. Continuous penile erection
c. Lumps in the scrotal skin
d. Venous dilation in the spermatic cord
ANS: C
Lumps in the scrotal skin are related to numerous sebaceous cysts and are within normal
limits.

9. Mr. L has an unusually thick scrotum, with edema and pitting. He has a history of cardiac
problems. The appearance of his scrotum is most likely a(n):
a. congenital defect that has worsened.
b. indication of general fluid retention.
c. normal consequence of aging.
d. complication of the development of mumps.
ANS: B
General fluid retention can cause scrotal thickening and pitting edema, and is usually seen as a
result of cardiac, renal, or hepatic disease. This swelling does not imply a condition of the
genitalia, but rather a condition of these related systems.
DIF: Cognitive Level: Applying

NU(Application)
RSINGTB.COM
10. A characteristic related to syphilis or diabetic neuropathy is testicular:

a. dropping, with asymmetry.
b. enlargement.
c. insensitivity to painful stimulation.
d. recession into the abdomen.
ANS: C
Diabetic neuropathy or syphilis can cause a marked reduction of tactile perceptions.
Asymmetry is a normal finding; enlargement and recession are not related to diabetes or
syphilis.

11. On palpation, a normal vas deferens should feel:

a. beaded.
b. smooth.
c. ridged.
d. spongy.
ANS: B
NURSINGTB.COM
The vas deferens should feel smooth and discrete as it is palpated from the testicle to the
inguinal ring. A beaded or lumpy vas deferens might indicate diabetes or the presence of old
inflammatory changes.

12. A premature infant’s scrotum will appear:

a. bifid.
b. loose.
c. ridged.
d. smooth.
ANS: D
The premature male scrotum will appear underdeveloped, smooth, without rugae, and without
testes; the full-term infant should have a loose, pendulous scrotum, with rugae and a midline
raphe.

13. An enlarged painless testicle in an adolescent or adult male may indicate:

a. epididymitis.
b. testicular torsion.
c. a tumor.
d. an undescended testicle.
ANS: C N R I G B.C M
U S
A hard, enlarged, painless testicle can N T a tumor
indicate O in the adolescent or adult male.
Epididymitis and torsion are painful; an undescended testicle is common in infants and is
usually resolved by 12 months.

14. You palpate a soft, slightly tender mass in the right scrotum of an adult male. You attempt to
reduce the size of the mass, and there is no change in the mass size. Your next assessment
maneuver is to:
a. use two fingers to attempt to reduce the mass.
b. palpate the left scrotum simultaneously.
c. lift the right testicle and then compare pain level.
d. transilluminate the mass.
ANS: D
A soft mass is a hernia or hydrocele. If the mass can be reduced, it is probably a hernia; a
nonreducible mass should be transilluminated to determine whether it contains fluid and is
possibly caused by a hydrocele. Lifting the scrotum should be done when epididymitis is
suspected.

NURSINGTB.COM
15. The most common cancer in young men ages 15 to 30 years is:
a. testicular.
b. penile.
c. prostate.
d. anal.
ANS: A
Because testicular tumors are the most common cancer occurring in young adults,
self-examination is encouraged.

16. The most emergent cause of testicular pain in a young male is:
a. testicular torsion.
b. epididymitis.
c. tumor.
d. hydrocele.
ANS: A
Testicular torsion is a surgical emergency. If surgery is performed within 12 hours after the
onset of symptoms, the testis can be saved in about 90% of cases. Delayed treatment results in
a much lower salvage rate.

17. An adolescent male is being N

seenRforIacute
G onset
B.CofMleft testicular pain. The pain started 3
U SandNdenies
hours ago. He complains of nausea T dysuria
O or fever. Your priority action should be
to:
a. obtain urine and DNA probe urethral samples.
b. lift the left scrotum to confirm epididymitis.
c. establish absent cremasteric reflex.
d. transilluminate the left and right scrotum.
ANS: C
The patient is displaying symptoms of testicular torsion. An absent cremasteric reflex is a
supporting finding to differentiate torsion from epididymitis.

18. The most common type of hernia occurring in young males is:
a. hiatal.
b. incarcerated femoral.
c. indirect inguinal.
d. umbilical.
ANS: C
The most common type of hernia in children and young males is an indirect inguinal hernia.
NURSINGTB.COM
19. Difficulty replacing the retracted foreskin of the penis to its normal position is called:
a. paraphimosis.
b. Peyronie disease.
c. phimosis.
d. priapism.
ANS: A
Paraphimosis refers to the inability to replace the foreskin to its original position after it has
been retracted behind the glans.

20. Which genital virus infection is known to have a latent phase followed by the production of
viral DNA capsids and particles?
a. Condyloma acuminatum
b. Molluscum contagiosum
c. Herpetic lesions
d. Lymphogranuloma venereum
ANS: A
Condyloma acuminatum (genital warts) are soft, reddish lesions commonly present on the
prepuce, glans penis, and shaft. These lesions can undergo latency, followed by viral DNA
capsids and particles, which are produced in the host cells.

NUR(Analysis)
OBJ: Nursing process—assessment SINGMSC:
TB.COM
Physiologic Integrity: Physiologic Adaptation
21. Pearly gray, smooth, dome-shaped, often umbilicated lesions of the glans penis are probably:
a. herpetic lesions.
b. condylomata.
c. molluscum contagiosum.
d. chancres.
ANS: C
Smooth, dome-shaped lesions with an umbilicated center of a pearly gray color are indicative
of molluscum contagiosum.

22. A 12-year-old boy relates that his left scrotum has a soft swollen mass. The scrotum is not
painful on palpation. The left inguinal canal is without masses. The mass transilluminates with
a penlight. This collection of symptoms is consistent with:
a. orchitis.
b. a hydrocele.
c. a rectocele.
d. a scrotal hernia.
ANS: B
NURSINGTB.COM
A hydrocele is a soft scrotal mass that occurs as a result of fluid accumulation and therefore
transilluminates. Orchitis results in a swollen, tender testis. A rectocele does not result in
scrotal swelling. A scrotal hernia would also be palpable along the inguinal canal.

MSC: Physiologic Integrity: Physiologic Adaptation
23. Which condition is a complication of mumps in the adolescent or adult?

a. Cystitis
b. Epididymitis
c. Orchitis
d. Paraphimosis
ANS: C
Orchitis is uncommon unless seen as a complication of mumps in the adolescent or adult.

24. Parents of a 6-year-old boy should be asked if he has:

a. erections.
b. nocturnal emissions.
c. rapid detumescence.
d. scrotal swelling.
ANS: D
Scrotal swelling, especially with crying or with bowel movements, signals the presence of a
hernia. The questions about erections
NURSIand GTrapid
B.Cdetumescence are for the older male. The
question about nocturnal emissions is N
asked OM
of adolescents.

25. The male with Peyronie disease will usually complain of:
a. painful, inflamed testicles.
b. deviation of the penis during erection.
c. lack of sexual interest.
d. painful lesions of the penis.
ANS: B
Peyronie disease is characterized by a fibrous band in the corpus cavernous. It results in
unilateral deviation of the penis during erection.

26. A cremasteric reflex should result in:

a. testicular and scrotal rise on the stroked side.
b. penile deviation to the left side.
c. bilateral elevation of the scrotum.
d. immediate erection of the penis.
NURSINGTB.COM
ANS: A
On stroking the inner thigh with a blunt instrument or finger, the testicle and scrotum should
rise on the stroked side.

NURSINGTB.COM
NURSINGTB.COM
Chapter 21: Anus, Rectum, and Prostate

MULTIPLE CHOICE
1. Baby Sue is born with an imperforate anus. However, her outward anal appearance is normal.
Which sign would indicate to the healthcare provider that she has a closed anal passageway?
a. Development of a scaphoid abdomen
b. Vomiting after her first feeding
c. Bleeding from the rectum
d. Failure to pass meconium stool
ANS: D
Failure to pass meconium stool indicates that a newborn has an imperforate anus.

2. In males, which surface of the prostate gland is accessible by digital examination?

a. Median lobe
b. Posterior
c. Superior
d. Anterior
ANS: B
The posterior surface of the prostate gland lies close to the anterior wall of the rectum and is
NU
palpable through digital rectal RSINGTB.COM
examination.

3. The prostatic sulcus:

a. divides the right and left lateral lobes.
b. is the site of the seminal vesicle emergence.
c. refers to the anterior aspect of the prostate.
d. secretes clear viscous mucus.
ANS: A
The prostatic sulcus divides the two lateral lobes and is palpated as a shallow groove.

4. The rectal past medical history of all patients should include inquiry about:
a. bowel habits.
b. dietary habits.
c. hemorrhoid surgery.
d. laxative use.
ANS: C
NURSINGTB.COM
Past medical history should include inquiry about hemorrhoids, spinal cord injury, benign
prostatic hypertrophy (BPH), prostate, colorectal, breast, ovarian, or endometrial cancers, and
episiotomies of fourth-degree lacerations during delivery. Habits are part of the personal and
social history; the use of laxatives is part of the history of the present illness.

5. The effects of aging on the gastrointestinal system lead to more frequent experiences of:
a. constipation.
b. prolonged satiety.
c. diarrhea.
d. prostate glandular atrophy.
ANS: A
Older adults experience an elevated pressure threshold for the sensation of rectal distention
and are therefore susceptible to constipation. They also experience early satiety, fecal
incontinence, and prostate glandular hypertrophy.

6. Factors associated with increased risk of prostate cancer include:

a. African descent.
b. cigarette smoking.
c. a low-fat diet.
d. alcoholism.
NURSINGTB.COM
ANS: A
The incidence rate of prostate cancer is 50% higher for African American men compared with
white American men. African American men also have a higher mortality rate.

7. The caliber of the urinary stream is routine information in the history of:
a. adolescents.
b. infants.
c. older adults.
d. sexually active young men.
ANS: C
Routine questions about the caliber of the urinary stream and dribbling are directed toward
older men because hypertrophy of the prostate gradually impedes urine flow.

8. Equipment for examination of the anus, rectum, and prostate routinely includes gloves and:
a. a hand mirror and gauze.
b. a lubricant and penlight.
c. slides and normal saline.
NURSINGTB.COM
d. swabs and culture medium.

ANS: B
Equipment for the examination includes a penlight, lubricating jelly, gloves, and fecal occult
blood testing materials.

9. Which is a risk factor for colorectal cancer?

a. High-fiber diet
b. Diet low in animal fats and proteins
c. Irish descent
d. Inherited BRAC2 mutation
ANS: D
History of intestinal polyps is considered a risk factor for colorectal cancer, as are diets low in
fiber and high in animal fats and an ethnic background of Ashkenazi Jewish descent.

10. Nodules found in the peritoneum through the anterior rectal wall:
a. are found with bidigital palpation.
b. are called shelf lesions.
c. are chronic fibrosis.
d. are found by having the patient bear down.
Because the anterior rectal wall is in contact with the peritoneum, you may be able to detect
the tenderness of peritoneal inflammation and the nodularity of peritoneal metastasis. The
nodules called shelf lesions are palpable just above the prostate in males and in the cul-de-sac
of females.

11. Perianal abscesses, fissures, or pilonidal cysts will cause the patient to experience:
a. bulging and wrinkling.
b. constipation and pallor.
c. diarrhea and redness.
d. tenderness and inflammation.
ANS: D
Tenderness and inflammation to the perianal area may be related to an abscess, fistula, fissure,
pilonidal cyst, or pruritus ani.

12. Palpation of the anal ring is done by:

a. bidigital palpation with the thumbs.
NURSINGTB.COM
b. inserting the smallest finger into the anus.

c. pressing a gauze pad over the anus.
d. rotation of the forefinger inside the anus.
ANS: D
The anal muscular ring is palpated by rotating the examination finger.

13. The posterior surface of the prostate can be located by palpation of the:
a. anal canal and perineum.
b. anterior wall of the rectum.
c. lateral wall of the anus.
d. lower abdomen and perineum.
ANS: B
Palpation of the rectal anterior wall facilitates posterior prostate location.

14. The cervix may be palpated through the:

a. anterior rectal wall.
b. internal umbilical wall.
c. lateral urethral meatus.
d. posterior uterine surface.
In women, the cervix can be palpated through the anterior rectal wall. It feels like a small,
round mass.

15. Your patient’s chief complaint is repeated, pencil-like stools. Further examination should
include:
a. a stool culture.
b. parasite testing.
c. a digital rectal examination (DRE).
d. a prostate examination.
ANS: C
Persistent pencil-shaped stools are indicative of stenosis from scarring or pressure from a
mass. DRE should be performed to assess for a mass.

16. Very light tan or gray stools may indicate:

a. upper gastrointestinal bleeding.
b. obstructive jaundice.
NURSINGTB.COM
c. lower gastrointestinal bleeding.

d. polyposis.
ANS: B
Very light tan or gray stools suggest obstructive jaundice.

17. Tarry black stools should make you suspect:

a. internal hemorrhoids.
b. rectal fistula.
c. upper intestinal tract bleeding.
d. prostatic cancer.
ANS: C
Upper intestinal tract bleeding results in tarry black stools.

18. Prostate-specific antigen (PSA) screening is controversial because:

a. there are many false-negative results.
b. PSA is produced by many other tissues.
c. it is less sensitive than digital rectal examination.
d. no data have proved that it decreases mortality.
ANS: D
There are no data confirmingNthat
URPSA
SINscreening
GTB.CO M
decreases mortality from prostate cancer.

19. Which finding in an infant may indicate lower spinal deformities?

a. Perirectal redness
b. Shrunken buttocks
c. Rectal prolapse
d. Dimpling in the pilonidal area
ANS: D
Sinuses, tufts of hair, and dimpling in the pilonidal area may indicate lower spinal deformities
such as a pilonidal cyst.

20. A lower spinal cord lesion may be indicated by which finding?

a. Lack of an anal wink
b. Rectal prolapse
c. Anal fistula
d. Small flaps of anal skin
ANS: A
NURSINGTB.COM
Lightly touching the anal opening of an infant should produce a contraction referred to as an
anal wink. A negative wink may indicate a lower spinal cord lesion.

21. Pinworms and Candida may both cause:

a. constipation.
b. hemorrhoids.
c. perirectal irritation.
d. perirectal protrusion.
ANS: C
Pinworms and Candida both cause perirectal irritation and itching.

22. Thrombosed hemorrhoids are:

a. flabby skin sacs.
b. red, inflamed, and painful.
c. fluctuant soft papules.
d. blue, shiny, painful masses.
ANS: D
Thrombosed hemorrhoids appear as blue shiny masses at the anus; they contain clotted blood
and are edematous and painful.
N R I G B.C M
DIF: Cognitive Level: ApplyingU(Application)
S N T O
23. Palpation of a normal prostate in an older adult is likely to feel:

a. cool.
b. grainy.
c. polypoid.
d. rubbery.
ANS: D
Older men are more likely to experience prostate hypertrophy, which when palpated feels
smooth, rubbery, and symmetric.

24. Mr. Dunn is a 62-year-old man who has presented for a routine annual examination. On
examination of the prostate you note a hard, irregular, painless nodule and obliteration of the
median sulcus. These are signs of:
a. benign prostatic hypertrophy.
b. cancer of the prostate.
c. long-standing prostatitis.
d. swelling as a result of aging.
NURSINGTB.COM
ANS: B
Obliteration of the median sulcus is consistent with organ enlargement; however, the
associated findings of a hard, irregular, and painless nodule indicate a cancerous growth.

25. The mother brings her 4-year-old to the clinic because the child complains of perianal itching.
As part of your examination you complete a cellulose tape test. The cellulose tape test is used
for the detection of:
a. enterobiasis.
b. carcinoma.
c. amebiasis.
d. steatorrhea.
ANS: A
Enterobiasis (pinworm infestation) is detected by the cellulose tape test. Pinworms are
collected by applying tape to the perianal folds and then pressing the tape on a glass slide.

MULTIPLE RESPONSE
1. Mr. Sweeney is a 58-year-old man who has presented for a routine annual prostate
examination. On examination, you note a normal prostate gland. Which of the following
characteristics should describe the normal prostate? (Select all that apply.)
a. Rubbery consistency
NURSINGTB.COM
b. About 4 cm in diameter
c. Fluctuant softness
d. Gland protruding 1 cm into the rectum
e. Firm, smooth, and slightly movable
ANS: B, D, E
The gland should feel like a pencil eraser, firm, smooth, and slightly movable and should be
nontender. It has a diameter of 4 cm, with a 1-cm protrusion into the rectum.

NURSINGTB.COM
Chapter 22: Musculoskeletal System

MULTIPLE CHOICE
1. The type of joint that has the widest range of motion in all planes is the:
a. ball-and-socket.
b. condyloid.
c. gliding.
d. saddle.
ANS: A
The ball-and-socket joint is the joint that has the widest range of motion (e.g., the hip joint). A
condyloid joint may only move in two planes. A gliding joint is only able to glide. A saddle
joint has no axial rotation.

2. Spinal vertebrae are separated from each other by:

a. bursae.
b. tendons.
c. disks.
d. ligaments.
ANS: C
NUspinal
Except for sacral vertebrae, the RSINvertebrae
GTB.Care
OMseparated from one another by disks.
Spinal movement is achieved by paraspinous muscles, tendons, and ligaments. Bursae are
located in the knee, elbow, shoulder, and hip.

3. The joint where the humerus, radius, and ulna articulate is the:
a. wrist.
b. elbow.
c. shoulder.
d. clavicle.
ANS: B
The elbow is the site where the humerus, radius, and ulna meet. The wrist is made up of the
radius and the carpal bones of the hand. The shoulder is made up of the humerus and scapula.
The clavicle connects to the scapula but not to the humerus.

4. The articulation of the radius and carpal bones is the:

a. wrist.
b. elbow.
c. shoulder.
NURSINGTB.COM
d. clavicle.
ANS: A
The joint comprising the radius and carpal bones is called the wrist.

5. The tibia, fibula, and talus articulate to form the:

a. ankle.
b. knee.
c. hip.
d. pelvis.
ANS: A
The tibia, fibula, and talus (or heel) join to form the ankle.

6. Long bones in children have growth plates known as:

a. epiphyses.
b. epicondyles.
c. synovium.
d. fossae.
ANS: A
Epiphyses are the growth plates found in long bones in children.
NURSINGTB.COM
7. The elasticity of pelvic ligaments and softening of cartilage in a pregnant woman are the result
of:
a. decreased mineral deposition.
b. increased hormone secretion.
c. uterine enlargement.
d. gait changes.
ANS: B
Increased hormone secretion during pregnancy is responsible for the elasticity of pelvic
ligaments and softening of the cartilage. These changes help accommodate the growing fetus.

8. Skeletal changes in older adults are the result of:

a. increased bone deposition.
b. increased bone resorption.
c. decreased bone deposition.
d. decreased bone resorption.
ANS: B
NURSINGTB.COM
With age, the skeletal system changes. One of the dramatic changes in skeletal equilibrium is
that bone resorption dominates bone deposition.

9. The family history for a patient with joint pain should include information about siblings with:
a. trauma to the skeletal system.
b. chronic atopic dermatitis.
c. genetic disorders.
d. obesity.
ANS: C
An important history to obtain for a patient with joint pain would be family history of genetic
disorders, such as osteogenesis imperfecta, dwarfing syndrome, rickets, hypophosphatemia,
and hypercalciuria.

10. Risk factors for sports-related injuries include:

a. competing in colder climates.
b. previous fracture.
c. history of recent weight loss.
d. failure to warm up before activity.
ANS: D
Failure to warm up before exercise
N RSisIone G risk
B.CfactorMfor sports-related injuries. Climate,
previous fractures, and weight U
loss areNnotTas strong
O risk factors for sports-related injuries.
11. Light skin and thin body habitus are risk factors for:
a. rheumatoid arthritis.
b. osteoarthritis.
c. congenital bony defects.
d. osteoporosis.
ANS: D
People with light skin and a thin body frame are at greater risk for developing osteoporosis.
Rheumatoid arthritis, osteoarthritis, and bony defects are not found to have a correlation with
light skin and small frame.

12. Inquiry about nocturnal muscle spasms would be most significant when taking the
musculoskeletal history of:
a. adolescents.
b. infants.
c. older adults.
NURSINGTB.COM
d. middle-age adults.
ANS: C
History taking of older adults should consist of symptoms of nocturnal muscle spasms.
Pregnant women and older adults commonly experience nocturnal leg cramps resulting from
imbalances of fluids, hormones, minerals, or electrolytes or dehydration. A particular concern
with the older adults is that this may be a sign of intermittent claudication.

13. The musculoskeletal examination should begin when:

a. the patient enters the examination room.
b. during the collection of subjective data.
c. when height is measured.
d. when joint mobility is assessed.
ANS: A
When the patient first walks in the room, the examiner should be observing his or her gait and
posture as part of the musculoskeletal examination.

14. Fasciculation occurs after injury to a muscle’s:

a. venous return.
b. motor neuron.
c. strength. NURSINGTB.COM
d. tendon.
ANS: B
Fasciculations can often be visualized as muscle twitching or dimpling under the skin, but
they usually do not generate sufficient force to move a limb. They may represent a benign
condition or occur as a manifestation of motor neuron disease or peripheral nervous system
diseases.

15. The physical assessment technique most frequently used to assess joint symmetry is:
a. inspection.
b. palpation.
c. percussion.
d. the use of joint calipers.
ANS: A
The assessment technique most commonly used to assess joint symmetry is inspection.

16. A goniometer is used to assess:
NURSINGTB.COM
a. bone maturity.
b. joint proportions.
c. range of motion.
d. muscle strength.
ANS: C
The angle of a joint can be accurately measured by using a goniometer. A goniometer is used
when the joint range of motion is beyond normal limits.

17. When palpating joints, crepitus may occur when:

a. irregular bony surfaces rub together.
b. supporting muscles are excessively spastic.
c. joints are excessively lax.
d. there is excess fluid within the synovial membrane.
ANS: A
Crepitus is felt or heard when irregular bony surfaces rub together.

18. The temporomandibular joint is palpated:

a. under the mandible, anterior to the sternocleidomastoid muscle.
b. above the mandible at midline.
c. anterior to the tragus. NURSINGTB.COM
d. at the mastoid process.
ANS: C
The temporomandibular joint is palpated just anterior to the tragus of the ear; the fingertips
are placed inside the joint space as the patient opens and closes the mouth.

19. The temporalis and masseter muscles are evaluated by:

a. having the patient shrug his or her shoulders.
b. having the patient clench his or her teeth.
c. asking the patient to fully extend his or her neck.
d. passively opening the patient’s jaw.
ANS: B
Having the patient to bite down and clench their teeth is the method for evaluating the
strength of the temporalis and masseter muscles. Cranial nerve V is tested with this same
maneuver.

20. The strength of the trapezius muscle is evaluated by having the patient:
NURSINGTB.COM
a. clench his or her teeth during muscle palpation.

b. push his or her head against the examiner’s hand.
c. straighten his or her leg with examiner opposition.
d. uncross his or her legs with examiner resistance.
ANS: B
Having the patient apply opposite force with differing head motions, against the examiner’s
hand, assesses the sternocleidomastoid and trapezius muscles.

21. Expected normal findings during the inspection of spinal alignment include:
a. asymmetric skin folds at the neck.
b. slight right-sided scapular elevation.
c. concave lumbar curve.
d. the head positioned superiorly to the gluteal cleft.
ANS: D
Spinal alignment is considered within normal limits when the patient’s head is positioned
directly over the gluteal cleft. The skin folds should be symmetric, the scapulae are at even
heights, and both the cervical and lumbar curves are convex.

22. A common finding in markedly obese patients and pregnant women is:
a. kyphosis. NURSINGTB.COM
b. lordosis.
c. paraphimosis.
d. scoliosis.
ANS: B
Bowing of the back, or lordosis, is more commonly found in pregnant women or obese
patients because of an altered center of gravity. Kyphosis is more commonly seen in older
adults. Paraphimosis is a penile condition. Scoliosis is more commonly seen in teenagers.

23. A wheelchair-dependent older woman would most likely develop skin breakdown at:
a. C7.
b. the iliac crests.
c. L4.
d. the gibbus.
ANS: D
This older woman, most likely kyphotic from osteoporosis, would have the greatest friction
point at the gibbus. The gibbus results from collapsed vertebrae, resulting in a sharp, pointy
deformity of the back. C7 and L4 remain as concave curves, with less friction. The iliac crests
would not protrude as far as the gibbus.
NURSINGTB.COM

24. When the patient flexes forward at the waist, which spinal observation would lead you to
suspect scoliosis?
a. Prominent lumbar hump
b. Prominent cervical concave curve
c. Lateral curvature of the spine
d. Restricted ability to flex at the hips
ANS: C
Scoliosis is suspected when there is a noticeable lateral curvature of the spine, or rib hump, as
the patient bends forward at the waist.

25. When a patient abducts an arm and the ipsilateral scapula becomes more prominent (winged),
this usually means that:
a. there has been an injury to the nerve of the anterior serratus muscle.
b. one of the clavicles has been fractured.
c. there is a unilateral trapezius muscle separation.
d. one shoulder is dislocated.
ANS: A
If the long thoracic nerve is damaged or bruised, it can cause paralysis of the serratus anterior
muscle and winging of the scapula, or shoulder blade. This is not a symptom of a fractured
clavicle or trapezius muscle separation.
NURSING A dislocated
B.COMshoulder would result in a hollowing
effect. T
26. When the shoulder contour is asymmetric and one shoulder has hollows in the rounding
contour, you would suspect:
a. kyphosis.
b. fractured scapula.
c. a dislocated shoulder.
d. muscle wasting.
ANS: C
Asymmetric contours to the shoulder with a hollowing in the socket are symptoms of a
shoulder dislocation. Kyphosis is a condition of the back; muscle wasting and a scapular
fracture do not present with these symptoms.

27. Ulnar deviation and swan neck deformities are characteristics of:
a. rheumatoid arthritis.
b. osteoarthritis.
c. osteoporosis.
NURSINGTB.COM
d. congenital defects.
ANS: A
Deviation of the fingers toward the ulnar side and swan neck deformities are classic
symptoms of rheumatoid arthritis. Osteoarthritis, congenital defects, and osteoporosis do not
present with these symptoms.

28. A finding that is indicative of osteoarthritis is (are):

a. swan neck deformities.
b. Bouchard nodes.
c. ganglions.
d. Heberden nodes.
ANS: D
Heberden nodes are bony overgrowths of the distal end of the fingers and are associated with
osteoarthritis. When the overgrowths are concentrated in the proximal interphalangeal joint,
they are known as Bouchard nodes and are associated with rheumatoid arthritis, as are swan
neck deformities; ganglions are present in nerve conditions.

29. Carpal tunnel syndrome would result in:

a. a negative Tinel sign.
b. a negative Phalen test. N R I G B.C M
U S N T
c. reduced abduction of the thumb. O
d. palm tingling.
ANS: C
Median nerve compression, as in carpal tunnel syndrome, results in a positive Tinel sign,
positive Phalen test, reduced abduction of the thumb, and sparing of palm tingling.

MULTIPLE RESPONSE
1. Cardinal signs for rheumatoid disorders include which of the following? (Select all that
apply.)
a. Gradual onset
b. Weakness that is usually localized and not severe
c. Coarse crepitus on motion
d. Joint tenderness
e. Sleep disturbance
ANS: A, D, E
Hallmark signs of rheumatoid arthritis are gradual onset of stiffness for 1 hour after rising,
sleep disturbance, joint tenderness, and medium to fine crepitus.
NURSINGTB.COM

2. The wrist moves in: (Select all that apply.)

a. eversion and inversion.
b. proximal radius and ulna articulation.
c. flexion and extension
d. adduction and abduction.
ANS: C, D
The wrist movement is in two planes, flexion and extension or radial and ulnar rotation.
Adduction and abduction are for shoulder and hip joints, and eversion and inversion are for
ankle movement.

NURSINGTB.COM
NURSINGTB.COM
Chapter 23: Neurologic System

MULTIPLE CHOICE
1. The autonomic nervous system coordinates which of the following?

a. High-level cognitive function
b. Balance and affect
c. Internal organs of the body
d. Balance and equilibrium
ANS: C
The autonomic nervous system coordinates the internal environment of the body by the
sympathetic and parasympathetic nervous systems. The other options are associated with the
cerebral cortex; its function consists of determining intelligence, personality, and motor
function.

2. The major function of the sympathetic nervous system is to:

a. orchestrate the stress response.
b. coordinate fine motor movement.
c. determine proprioception.
d. perceive stereognosis.
Stimulation of the sympathetic branch of the autonomic nervous system prepares the body for
emergencies for fight or flight (stress response). The cerebellum plays a key role in the
coordination of fine motor movements. Recognition of body parts and awareness of body
position (proprioception) are dependent on the parietal lobe. Stereognosis is the ability to
perceive the weight and form of solid objects by touch and is not under sympathetic control.

3. The parasympathetic nervous system maintains the day-to-day function of:

a. digestion.
b. response to stress.
c. lymphatic supply to the brain.
d. lymphatic drainage of the brain.
ANS: A
The parasympathetic division functions in a complementary and counterbalancing manner to
conserve body resources and maintain day-to-day body functions, such as digestion and
elimination.

4. Cerebrospinal fluid serves as a:
NURSINGTB.COM
a. nerve impulse transmitter.

b. red blood cell conveyer.
c. shock absorber.
d. mediator of voluntary skeletal movement.
ANS: C
Cerebrospinal fluid circulates between an interconnecting system of ventricles in the brain and
around the brain and spinal cord, serving as a shock absorber.

5. Diabetic peripheral neuropathy will likely produce:

a. hyperactive ankle reflexes.
b. diminished pain sensation.
c. exaggerated vibratory sense.
d. hypersensitive temperature perception.
ANS: B
Peripheral neuropathy is a disorder of the peripheral nervous system that results in motor and
sensory loss in the distribution of one or more nerves, usually in the hands and feet. Patients
may have sensations of numbness, tingling, burning, and cramping. In moderate to severe
diabetic neuropathy, there is wasting of the foot muscles, absent ankle and knee reflexes,
decreased or no vibratory sensation below the knees, and/or loss of pain or sharp touch
sensation to the midcalf level.

N R I GMSC: Physiologic
B.C M Integrity: Physiologic Adaptation
U S N T O
6. The thalamus is the major integration center for the perception of:
a. speech.
b. olfaction.
c. pain.
d. thoughts.
ANS: C
The thalamus is the major integrating center for the perception of various sensations such as
pain and temperature, serving as the relay center between the basal ganglia and cerebellum.
The reception of speech and interpretation of speech are located in the Wernicke area. The
olfactory sense is processed in the parietal lobe. The cerebrum holds memories, allows you to
plan, and enables you to imagine and think.

7. The awareness of body position is known as:

a. proprioception.
b. graphesthesia.
c. stereognosis.
d. two-point discrimination.
ANS: A
NURSINGTB.COM
Recognition of body parts and awareness of body position are known as proprioception. This
is dependent on the parietal lobe. The other options are assessment techniques that test for
sensory impairment.

8. Which area of the brain maintains temperature control?

a. Epithalamus
b. Thalamus
c. Abducens
d. Hypothalamus
ANS: D
The hypothalamus is the major processing center of internal stimuli for the autonomic nervous
system. It maintains temperature control, water metabolism, body fluid osmolarity, feeding
behavior, and neuroendocrine activity. The epithalamus houses the pineal body and is
responsible for sexual development and behavior. The thalamus conveys all sensory impulses,
except olfaction, to and from the cerebrum before their distribution to appropriate associative
sensory areas. The abducens is the sixth cranial nerve with motor function responsible for
lateral eye movement.

9. If a patient cannot shrug his or her shoulders against resistance, which cranial nerve (CN)
requires further evaluation?
a. CN I, olfactory NURSINGTB.COM
b. CN V, trigeminal
c. CN IX, glossopharyngeal
d. CN XI, spinal accessory
ANS: D
CN XI is responsible for the motor ability to shrug the shoulders. CN I is associated with
smell reception and interpretation. CN V is associated with opening of the jaw, chewing, and
sensation of the cornea, iris, conjunctiva, eyelids, forehead, nose, teeth, tongue, ear, and facial
skin. CN IX is associated with swallowing function, sensation of the nasopharynx, gag reflex,
taste, secretion of salivary glands, carotid reflex, and swallowing.

10. Motor maturation proceeds in an orderly progression from:

a. peripheral to central.
b. head to toe.
c. lateral to medial.
d. pedal to cephalic.
ANS: B
Motor maturation proceeds in a cephalocaudal direction. Motor control of the head and neck
develops first, followed by the trunk and extremities. The other choices are incorrect because
they relate the maturation sequence inappropriately, from outward to central.
NURSINGTB.COM

11. Normal changes of the aging brain include:

a. increased velocity of nerve conduction.
b. diminished perception of touch.
c. increased total number of neurons.
d. diminished intelligence quotient.
ANS: B
Sensory perceptions of touch and pain are diminished by aging. The velocity of nerve impulse
conduction declines, so responses to stimuli take longer. The number of cerebral neurons is
thought to decrease by 1% a year, beginning at 50 years of age; however, the vast number of
reserve cells inhibits the appearance of clinical signs.

12. The area of body surface innervated by a particular spinal nerve is called a:
a. dermatome.
b. nerve pathway.
c. spinal accessory area.
d. cutaneous zone.
ANS: A
The sensory and motor fibers of each spinal nerve supply and receive information to a
segment of skin known as a dermatome.
NURSINGNerve pathway
M and spinal accessory area refer to
nerve routes. Cutaneous zone refers TB.C
to a skin areaOthat transmits fine mechanical information
and normal exogenous thermal information at the same time.

13. A neurologic past medical history should include data about:

a. allergies.
b. circulatory problems.
c. educational level.
d. immunizations.
ANS: B
The neurologic past medical history should include data concerning neurovascular problems
such as stroke, aneurysm, and brain surgery. The other answers are not pertinent medical
information for the neurologic past medical history.

14. Which is the technique most often used for evaluating the neurologic system?
a. Auscultation
b. Inspection
c. Palpation
NURSINGTB.COM
d. Percussion
ANS: B
The evaluation tool of inspection is used most often. Inspection of gait and response to
questions can provide data concerning neurologic system function.

15. When assessing superficial pain, touch, vibration, and position perceptions, you are testing:
a. cerebellar function.
b. emotional status.
c. sensory function.
d. tendon reflexes.
ANS: C
Superficial pain, touch, vibration, and position perceptions are sensory functions.

16. You are initially evaluating the equilibrium of Ms. Q. You ask her to stand, with her feet
together and arms at her sides. She loses her balance. Ms. Q has a positive:
a. Kernig sign.
b. Homan sign.
c. McMurray test.
d. Romberg sign.
ANS: D NURSINGTB.COM
The Romberg test has the patient stand with the eyes closed, feet together, and arms at the
sides. A slight swaying movement of the body is expected, but not to the extent of falling.
Loss of balance results in a positive Romberg test. The Kernig sign indicates meningeal
irritation, the Homan sign indicates venous thrombosis, and the McMurray test is a rotation
test for demonstrating a torn meniscus.

17. The finger to nose test allows assessment of:

a. coordination and fine motor function.
b. point location.
c. sensory function.
d. stereognosis.
ANS: A
To perform the finger to nose test, the patient closes both eyes and touches his or her nose
with the index finger, alternating hands while gradually increasing the speed. This tests
coordination and fine motor skills. All the other choices test sensory function without motor
function.

NURSINGTB.COM
18. You are performing a two-point discrimination test as part of a well physical examination.
The area with the ability to discern two points in the shortest distance is the:
a. back.
b. palms.
c. fingertips.
d. upper arms.
ANS: C
The fingertips can discern two points with a minimal distance of 2 to 8 mm, the back, 40 to 70
mm, the palms, 8 to 12 mm, and the upper arms, 75 mm.

19. As Mr. B enters the room, you observe that his gait is wide-based and he staggers from side to
side while swaying his trunk. You would document Mr. B’s pattern as:
a. dystonic ataxia.
b. cerebellar ataxia.
c. steppage gait.
d. tabetic stamping.
ANS: B
A cerebellar gait (cerebellar ataxia) occurs when the patient’s feet are wide-based, with a
staggering gait, lurching from side to side, often accompanied by swaying of the trunk.
Dystonic ataxia is jerky dancing movements that appear nondirectional. Steppage gait is noted
when the hip and knee are elevated excessively high to lift the plantar-flexed foot off the
NURS
ground. The foot is brought down INaGslap
with TB.C M patient is unable to walk on the heels.
andOthe
Tabetic stamping occurs when the legs are positioned far apart, lifted high, and forcibly
brought down with each step; in this case, the heel stamps on the ground.

OBJ: Nursing process—assessment MSC: Safe and Effective Care: Management of Care
20. Deep pressure tests are used mostly for patients who are experiencing:
a. absent superficial pain sensation.
b. gait and stepping disturbances.
c. lordosis, osteoporosis, or arthritis.
d. tonic neck or torso spasms.
ANS: A
Deep pressure sensation is tested by squeezing the trapezius, calf, or biceps muscle, thus
causing discomfort. When superficial pain sensation is not intact, further assessments of
temperature and deep pressure sensation are performed.

21. Vibratory sensory testing should be routinely done for the patient with:
a. Parkinson disease.
b. diabetes.
c. cerebral palsy.
NURSINGTB.COM
d. Guillain-Barré syndrome.
ANS: B
Diabetic neuropathy must be routinely assessed in all diabetic patients. In moderate to severe
cases, decreased or absent vibratory sensation occurs below the knees, which should be
assessed with a tuning fork. The other choices do not result in sensation deficits.

22. To assess a cremasteric reflex, the nurse strokes the:

a. sole of the foot and observes whether the toes fan down and out.
b. abdomen and observes whether the umbilicus moves away from the stimulus.
c. inner thigh and observes whether the testicle and scrotum rise on the stroked side.
d. palm and observes whether the fingers attempt to grasp.
ANS: C
Stroking the inner thigh of a male patient (proximal to distal) will elicit the cremasteric reflex.
The testicle and scrotum rise on the stroked side. Stroking the sole of the foot elicits a
Babinski sign. Stroking the abdomen elicits an abdominal reflex. Stroking the palm elicits a
palmar grasp.

23. When you ask a patient to close his or her eyes and identify an object placed in the hand, you
are evaluating:
a. stereognosis. NURSINGTB.COM
b. graphesthesia.
c. vibratory sensation.
d. extinction phenomenon.
ANS: A
Stereognosis is the ability to recognize an object through touch and manipulation. Tactile
agnosia, an inability to recognize objects by touch, suggests a parietal lobe lesion.
Graphesthesia tests the patient’s ability to identify the figure being drawn on the palm. The
vibratory sense uses a tuning fork placed on a bony prominence, and the extinction
phenomenon tests sensation by simultaneously touching bilateral sides of the body with a
sterile needle.

24. The ability to recognize a number traced on the skin is called:

a. stereognosis.
b. graphesthesia.
c. an extinction phenomenon.
d. two-point discrimination.
ANS: B
NURSINGTB.COM
The ability to recognize a number traced on the skin is called graphesthesia. Stereognosis is
the ability to recognize an object through touch and manipulation. The extinction phenomenon
test and two-point discrimination assess a person’s ability to discern the number of pinpoints
and their location.

25. Which condition is consistent with Brown-Séquard syndrome?

a. Central sensory loss that is generalized
b. Motor paralysis on the lesion side of the body
c. Multiple peripheral neuropathy of the joints
d. Spinal root paralysis below the umbilicus
ANS: B
Parietal spinal sensory syndrome (Brown-Séquard syndrome) is noted when pain and
temperature sensation occur one to two dermatomes below the lesion on the opposite side of
the body from the lesion. Proprioceptive loss and motor paralysis occur on the lesion side of
the body.

26. To assess spinal levels L2, L3, and L4, which deep tendon reflex should be tested?
a. Triceps
b. Patellar
c. Biceps
d. Achilles NURSINGTB.COM
ANS: B
To assess spinal levels L2-4, the patellar reflex should be tested. The patellar tendon is the
only deep tendon that assesses the lumbar spinal level. The triceps and biceps tendon are
tested to assess the cervical spine, whereas the Achilles tendon is tested to assess the sacral
spine.

27. When using a monofilament to assess sensory function, the nurse:

a. uses two simultaneous monofilaments on similar bilateral points and then
compares results.
b. applies both a monofilament and a pin on similar bilateral points and then
compares results.
c. applies pressure to the monofilament until the filament bends.
d. strokes the monofilament along the skin from proximal to distal areas.
ANS: C
The monofilament is placed on several smooth spots of the patient’s plantar foot for seconds.
Adequate pressure applied by the monofilament is measured by the bend of the monofilament.

NURSINGTB.COM
28. Visible or palpable extension of the elbow is caused by reflex contraction of which muscle?
a. Achilles
b. Biceps
c. Patellar
d. Triceps
ANS: D
The triceps tendon, when directly hit with the reflex hammer just above the elbow, will cause
contraction of the triceps muscle and extension of the elbow.

29. It is especially important to test for ankle clonus if:

a. deep tendon reflexes are hyperactive.
b. deep tendon reflexes are hypoactive.
c. the Romberg sign is positive.
d. the patient has peripheral neuropathy.
ANS: A
Test the ankle clonus when reflexes are hyperactive. Support the patient’s knee in a flexed
position and briskly dorsiflex the foot with your other hand. If clonus is present, there is
recurrent ankle plantar flexion movement as long as the examiner retains the foot in
dorsiflexion. Sustained clonus signifies the hypertonia of an upper motor neuron lesion.

N R I GMSC: SafeMand Effective Care: Management of Care
B.C
U S N T O
30. On a scale of 1+ to 4+, which deep tendon reflex score is appropriate for a finding of clonus in
a patient?
a. 1+
b. 2+
c. 3+
d. 4+
ANS: D
1+ indicates a sluggish or diminished reflex. 2+ indicates an active or expected response. 3+
indicates more brisk than expected, slightly hyperactive. 4+ indicates brisk, hyperactive, with
intermittent or transient clonus.

31. Which sign is associated with meningitis and intracranial hemorrhage?

a. Babinski sign
b. Asymmetric tonic neck reflex
c. Doll’s eye movement
d. Nuchal rigidity
ANS: D
NURSINGTB.COM
A stiff neck or nuchal rigidity is a sign associated with meningitis and intracranial
hemorrhage. Test this by lifting the head of the patient to touch the chin while the patient lies
in a supine position. Pain and resistance to neck motion are associated with nuchal rigidity.

32. Cranial nerve XII may be assessed in an infant by:

a. watching the infant’s facial expressions when crying.
b. observing the infant suck and swallow.
c. clapping hands and watching the infant blink.
d. observing the infant’s rooting reflex.
ANS: B
Cranial nerve (CN) XII may be assessed in an infant by observing the infant suck and
swallow, by pinching the nose, and then observing for the mouth to open and the tip of the
tongue to rise in a midline position. Watching the infant’s facial expressions when crying
assesses CN VII. Clapping hands and watching the infant blink tests CN VIII. Observing the
rooting reflex assesses CN V.

33. You are most concerned for the infant who has a:
a. weak palmar grasp at 3 months.
b. strong stepping reflex at 2 months.
c. weak plantar reflex at 9 months.
NURSINGTB.COM
d. strong tonic neck at 6 months.
ANS: D
The tonic neck reflex must disappear before the infant can roll over or bring his or her hands
to their face; it should disappear by 6 months. The other choices are within expected ranges.

34. At what age should the infant begin to transfer objects from hand to hand?
a. 2 months
b. 4 months
c. 7 months
d. 10 months
ANS: C
Transferring objects hand to hand begins at 7 months. Purposeful release of objects is noted as
a normal finding by 10 months. Purposeful movements, such as reaching and grasping for
objects, begin at about 2 months of age. The progress of taking objects with one hand begins
at 6 months. There should be no tremors or constant overshooting of movements.

NURSINGTB.COM
35. An acute polyneuropathy that commonly follows a nonspecific infection occurring 10 to 14

days earlier and that primarily affects the motor and autonomic peripheral nerves in an
ascending pattern is:
a. cerebral palsy.
b. HIV encephalopathy.
c. Guillain-Barré syndrome.
d. Rett syndrome.
ANS: C
Guillain-Barré syndrome—acute idiopathic polyneuritis—is an acute polyradiculoneuropathy
that commonly follows a nonspecific infection that occurred 10 to 14 days earlier. It is
characterized by ascending symmetric weakness with sensation preserved. An increase in
severity occurs over days or weeks. A decrease in or absent strength and sensory loss may
result, along with motor paralysis and respiratory muscle failure.

36. Which is a concern, rather than an expected finding, in older adults?

a. Reduced ability to differentiate colors
b. Bilateral pillrolling of the fingers
c. Absent plantar reflex
d. Reduction in upward gaze
ANS: B
Bilateral pillrolling is indicative of Parkinson disease; the other choices are expected findings
with aging.
NURSINGTB.COM
37. Which condition is potentially life-threatening if not treated expeditiously with antibiotics?
a. HIV encephalopathy
b. Dementia
c. Parkinson disease
d. Bacterial meningitis
ANS: D
Meningitis is an inflammatory process in the meninges. Bacterial meningitis is a
life-threatening illness if not rapidly treated with appropriate antibiotics. All the other diseases
are neurologic disorders not treatable by antibiotics.

38. Ipsilateral Horner syndrome indicates a cerebrovascular accident (CVA) occurring in the:
a. anterior portion of the pons.
b. internal or middle cerebral artery.
c. posterior inferior cerebellar artery.
d. vertebral or basilar arteries.
ANS: C
NURSINGTB.COM
The posterior inferior cerebellar artery supplies the lateral and posterior portion of the
medulla. A CVA involving this artery can produce a neurologic sign of ipsilateral Horner
syndrome in the eye.

39. The immune system attacks the synaptic junction between the nerve and muscle fibers,
blocking acetylcholine receptor sites in:
a. myasthenia gravis.
b. encephalitis.
c. multiple sclerosis.
d. cerebral palsy.
ANS: A
Myasthenia gravis is a chronic autoimmune neuromuscular disease involving the lower motor
neurons and muscle fibers. The immune system of infected individuals produces antibodies
that destroy acetylcholine receptor sites at the neuromuscular junction. This blocks the nerve
impulse from reaching the muscle and produces muscle fatigue. Encephalitis is acute
inflammation of the brain and spinal cord involving the meninges. It is often caused by a
virus, such as the herpes simplex virus. Multiple sclerosis is a progressive autoimmune
disorder characterized by a combination of inflammation and degeneration of the myelin in
the brain’s white matter, leading to obstructed transmission of nerve impulses and decreased
brain mass. Cerebral palsy is a permanent disorder of movement and posture development
associated with nonprogressive (static) disturbances that occurred in the developing fetal or
infant brain.
NURSI(Comprehension)
DIF: Cognitive Level: Understanding NGTB.COM
40. Persons with Parkinson disease have an altered gait characterized by:
a. short shuffling steps.
b. the trunk in a backward position.
c. exaggerated swinging of the arms.
d. lifting the legs in a high-stepping fashion.
ANS: A
The altered gait of Parkinson disease has short shuffling steps, the posture is stooped forward,
and the arms have limited swing.

MULTIPLE RESPONSE
1. The tests for cortical sensory function include which of the following? (Select all that apply.)
a. Two-point discrimination
b. Extinction phenomenon
c. Superficial pain
d. Stereognosis
e. Touch
NURSINGTB.COM
ANS: A, B, D
The following tests are tests for cortical sensory function—stereognosis, two-point
discrimination, extinction phenomenon, graphesthesia, and point location.

NURSINGTB.COM
NURSINGTB.COM
Chapter 24: Sports Participation Evaluation

MULTIPLE CHOICE
1. The goals of preparticipation sports evaluation include:

a. screening for steroid use or abuse.
b. determining the best fit for positions in each sport.
c. determining the risk of injury or death during sports participation.
d. securing a legal contract before recommending limiting participation.
ANS: C
The ultimate goal of preparticipation physical evaluation is to ensure safe participation in an
appropriate sports activity.

2. The checkout station for preparticipation physical evaluation is critical because at this point:
a. all completed forms are distributed.
b. parental signatures are obtained.
c. the relevant history is obtained.
d. the coordination of follow-ups is reviewed.
ANS: D
At the checkout station, data collected during the evaluation are reviewed and necessary
follow-up actions are shared N URthe
with SIathlete
NGTB.C OMparents. In addition, the written report is
and/or
distributed.

3. You are conducting a preparticipation physical examination for a 10-year-old girl with Down
syndrome who will be playing basketball. She has slight torticollis and mild ankle clonus.
Which additional diagnostic test would be required for her?
a. Cervical spine radiography
b. Visual acuity
c. Mini-Mental State Examination
d. Nerve conduction studies
ANS: A
This girl is experiencing symptoms of atlantoaxial joint instability and should therefore have
cervical spine radiography with neurologic consultation before beginning sports activities.

4. Part of the screening orthopedic component of the examination includes evaluating the person
while he or she is:
a. performing push-ups.
b. duck walking.
NURSINGTB.COM
c. twisting at the waist.

d. crossing the arms over the chest.
ANS: B
Duck walking for four steps assesses hip, knee, and ankle range of motion, strength, and
balance.

5. Your 15-year-old patient is athletic and thin. Radiography of an ankle injury reveals a stress
fracture. You should question this patient about her:
a. sleep patterns.
b. salt intake.
c. aerobic workouts.
d. menstrual cycles.
ANS: D
The lean body encourages a hypoestrogenic state that can lead to menstrual dysfunction and
osteopenia or osteoporosis. This state increases the risk of stress fractures. The patient should
be questioned about amenorrhea.

6. One of the most important aspects to consider in the orthopedic screening examination is:
a. muscle contraction.
b. flexibility. NURSINGTB.COM
c. symmetry.
d. balance.
ANS: C
The most important aspects to consider when conducting an orthopedic examination are
symmetry of muscle, stature, and joint movement.

7. Which medical condition would exclude a person from sports participation?

a. Asthma
b. Fever
c. Controlled seizures
d. HIV-positive status
ANS: B
Fever can increase cardiopulmonary effort and impair exercise capacity; fever can indicate
myocarditis or other infections that make exercise dangerous.

NURSINGTB.COM
8. A parent is advised to restrict contact sports participation for their child. An example of a
sport in which this child could participate is:
a. hockey.
b. roller skating.
c. riflery.
d. skateboarding.
ANS: C
Riflery is a noncontact sport. Hockey is considered a collision sport. Roller skating and
skateboarding are considered to be limited contact sports.

9. A child has a poorly controlled seizure disorder. He has restricted sports participation but
would be able to engage in:
a. archery.
b. swimming.
c. weight lifting.
d. badminton.
ANS: D
Badminton does not pose an added risk to self or others if the child experiences a seizure
during participation.

N R I G B.C M
U asSpartNofTa sportsOphysical examination. You hear a murmur
10. You are auscultating heart tones
at the right second intercostal space (aortic area). The murmur increases in intensity when this
teenager goes from a sitting to standing position. The subsequent recommendation should be
to:
a. consult a cardiologist as soon as possible.
b. have a stress test before completion of the form.
c. participate in low-static, high-dynamic sports.
d. limit contact sports and have an echocardiogram.
ANS: A
The murmur of aortic stenosis is indicative of hypertrophic cardiomyopathy, which may be
the cause of sudden death in children and adolescents at rest or during exercise. Therefore, a
cardiology consult should be requested as soon as possible.

MULTIPLE RESPONSE
1. Why should the preparticipation sports examination take place well in advance of the planned
sports activity? (Select all that apply.)
a. To allow completion of therapy for identified problems
b. Because routine health maintenance needs to be addressed
NURSINGTB.COM
c. Because it should be 6 weeks prior to the planned sports event

d. To allow completion of follow-up testing
ANS: A, D
The preparticipation sports examination should be completed well enough in advance of the
planned sports activity so that rehabilitation or therapy for any problems can be completed, as
well as any follow-up testing or referrals.

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NURSINGTB.COM
Chapter 25: Putting it All Together

MULTIPLE CHOICE
1. Which is true regarding the relationship between the examiner and patient?
a. It is the examiner’s responsibility to help the patient understand that he or she is
qualified to make decisions regarding health care.
b. The patient must trust the examiner completely.
c. The examiner-patient relationship is enhanced by ignoring cultural issues.
d. The patient is a full partner with the examiner.
ANS: D
The patient is a full partner with the examiner. The examiner should keep the patient informed
and should develop a relationship to ensure trust. Cultural issues should be acknowledged, not
ignored. The examiner should keep the patient informed, but it is not the examiner’s
responsibility to help the patient understand that he or she is qualified to make healthcare
decisions. The examiner should develop a relationship to ensure trust, but it is not necessary
for the patient to trust the examiner completely.

OBJ: Nursing process—assessment MSC: Physiologic Integrity: Basic Care and Comfort
2. Which examiner behavior would help minimize your patient’s dissatisfaction?

a. Assume a busy and rushed attitude.
b. Convey your own feelings of discomfort.
c. Keep the patient waiting N UR
for SIN
more
G B.COM
thanT30 minutes.
d. Seek information about the patient’s problem.
ANS: D
When performing an examination, you are seeking information about the patient and the
problem that brings the patient to you. This process teaches you about the patient and teaches
the patient about your personal discipline, professional composure, and respect for others.

3. An examiner might be able to help a patient who seems uncomfortable with close contact
during an examination by:
a. acknowledging the discomfort.
b. backing away from the patient.
c. joking about the patient’s discomfort.
d. moving briskly to completion.
ANS: A
Acknowledging the patient’s discomfort during the examination will help the patient feel
more relaxed. Your professional concern can be reassuring to the patient. You should explain
what you are doing to the patient before the assessment and what the patient will experience;
if not, you will run the risk of losing trust. The other choices would make the patient more
uneasy.
NURSINGTB.COM

4. When performing a history and physical assessment, the examiner should:

a. change the sequence of observation with each interview.
b. develop a sequence of standard observations.
c. develop a preliminary diagnosis at the onset.
d. direct patient responses to fit the history sequence.
ANS: B
When performing a history and physical assessment, you should develop an approach that is
comfortable to you and ensures comfort for the patient. Part of the history can be obtained
while you are doing the physical examination.

5. The examiner should develop a demeanor that is exemplified by which one of the following
behaviors?
a. Exhibits visible distaste about the condition.
b. Gives immediate reassurances to the patient.
c. Gives patient unsolicited advice.
d. Validates the patient’s justified concerns.
ANS: D
The examiner needs to learn a gentle and balanced demeanor. By showing concern for the
patient’s feelings, you gain the
N patient’s
R I Gtrust;
B.C giving unsolicited advice can cause the patient
to lose trust in the relationship.U S N T OM
6. At your first meeting with a patient, it is usually best to say:

a. “Let’s get to the point.”
b. “I hope you will learn to trust me.”
c. “Let me tell you what I can do for you.”
d. “Tell me about yourself.”
ANS: D
Take the time to ask open-ended questions to ensure that the patient has the opportunity to
report accurately. Too great an adherence to routine may prevent the true story from
emerging. The other statements are not open-ended, which would not allow the patient to
elaborate. In addition, they are not comforting statements and would make the patient feel
uncomfortable at the initial meeting.

7. Which patient characteristic is most likely to limit patient reliability during history taking?
a. The patient’s measured IQ is above average.
b. The patient is alert and oriented to time and place.
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c. The patient is depressed.

d. The patient speaks the same language as examiner.
ANS: C
Emotional constraints can limit a patient’s reliability as a historian. Language barriers,
cultural barriers, and an unresponsive or comatose patient can all affect a patient’s ability to
be a thorough historian. All the other options would not limit a patient’s reliability.

8. The reliability of health-related findings and observations is the responsibility of the:

a. patient.
b. professional and medical assistants.
c. attending clinician.
d. professional and the patient.
ANS: D
It is the responsibility of the health professional and patient to present reliable findings and
observations. They work as a team.

9. Which is most likely to enhance examiner reliability?

a. The examiner who seeks input from others.
b. The examiner is uncomfortable with his or her own skills.
c. The examiner believes that
N heRS
orIsheGmust always be correct.
d. The examiner prejudges theUpatientNandTB.C OM
family.
ANS: A
As the examiner, you may not always be correct, but questioning yourself and seeking
confirmation from others when necessary will serve to assure your reliability. Showing that
you are uncomfortable with your skills can make the patient feel uncomfortable and see you
as unreliable. Believing that you must always be correct will not enhance your reliability as an
examiner. A person should never be prejudged, because this can interfere with the
examination and findings.

10. Which statement accurately reflects the sensitivity and specificity of laboratory tests?
a. The gold standard test has 100% sensitivity and specificity.
b. Sensitivity and specificity are inversely correlated.
c. Sensitivity and specificity are directly correlated.
d. No test has 100% sensitivity and specificity.
ANS: D
No test has 100% sensitivity and specificity.

NURSINGTB.COM
11. As you greet the patient, which examination technique is first implemented?
a. Auscultation
b. Inspection
c. Measurement
d. Palpation
ANS: B
Begin to inspect the patient as you greet him or her as you look for signs of distress or disease.
Inspect the appearance, gait, orientation, and difficulty in hearing or speech.

12. Which data is not part of your general inspection?

a. Dress and habitus
b. Sinus tenderness
c. Gait
d. Facial expression
ANS: B
On meeting the patient, the facial expression, gait, dress, and habitus should be inspected.
Inspecting for sinus tenderness is performed afterward, if indicated.

13. The sequence of the physicalNexamination

I G should
B.C beMindividualized to:
URS
a. minimize the number of times thatNtheTpatientOmust change positions.
b. maximize the convenience of the examiner.
c. improve patient flow.
d. minimize the time that the patient is in the room.
ANS: A
There is no one right way to put together the parts of the physical examination. The sequence
should be individualized to minimize the number of times the patient has to change positions
to conserve the patient’s energy.

14. According to the usual examination procedure, you would first assist your patient to assume
which position?
a. Lithotomy
b. Prone
c. Sitting
d. Supine
ANS: C
On entering the examination room, you should assist the patient in the sitting position on the
examining table. In the sitting position, you can examine the patient’s anterior and posterior
upper trunk and head, which comprise most of the focused assessments.
NURSINGTB.COM

15. An ophthalmoscopic eye examination involves:

a. lens inspection.
b. near vision evaluation.
c. sclera observation.
d. visual field assessment.
ANS: A
Ophthalmoscope eye examination involves testing the red reflex and inspecting the lens, disc,
cup margins, vessels, and retinal surface. The other assessments do not involve the use of the
ophthalmoscope.

16. Palpation of the epitrochlear nodes is part of the:

a. examination of the upper extremities.
b. assessment of the chest and thorax.
c. palpation of the abdomen.
d. examination of the head and neck.
ANS: A
Palpation of the epitrochlear nodes is part of the examination of the upper extremities. To
palpate the epitrochlear nodes, support the elbow in one hand and palpate in the depression
above and posterior to the medial
N Rcondyle
I G ofB.C the humerus.
M
U S N T O
17. Which are examined with the patient in a reclining 45-degree position?
a. Bilateral hips and popliteal angles
b. Facial bones and cranial nerves V and VII
c. Jugular venous pulsation and pressure
d. Oropharynx and thyroid gland placement
ANS: C
With the patient in a reclining 45-degree position, you can examine jugular venous pulsations
and measure jugular venous pressure. All the other choices can be examined with the patient
in a sitting position.

18. Which patient position facilitates inspection of the chest and shoulders?
a. Sitting
b. Supine
c. Trendelenburg
d. Prone
NURSINGTB.COM
ANS: A
With the patient in the sitting position, the examiner can inspect the chest and shoulders. The
area being inspected is exposed for the examiner to do a thorough assessment. The other
positions are not used to assess the chest and shoulders.

19. When assessing the abdomen, the examiner needs to expose the patient:
a. from the waist down.
b. from the pubis to the epigastrium.
c. in entirety.
d. at no point during the examination.
ANS: B
While the patient is in the supine position, the examiner can assess the abdomen. Arrange
draping to expose the abdomen from the pubis to epigastrium, ensuring that the private areas
of the patient are covered.

20. To inspect the abdominal muscles, ask the:

a. supine patient to raise their head.
b. standing patient to bend forward.
c. prone patient to raise their lower legs.
d. standing patient to stand on tiptoes.
NURSINGTB.COM
ANS: A
Asking the supine patient to raise his or her head will contract the rectus abdominis muscles,
which produces muscle prominence, making abdominal wall masses visible.

21. Proprioception should be assessed while the patient is:

a. prone.
b. supine.
c. seated.
d. standing.
ANS: D
The proprioception examination involves the Romberg test, heel to toe walking, standing on
one foot and then the other with the eyes closed, hopping in place, and deep knee bends. The
standing position is required to conduct these examinations.

22. Examination of the patient in the lithotomy, or knee-chest, position includes:

a. inspection for inguinal hernias.
b. palpation of anal sphincter tone.
NURSINGTB.COM
c. percussion of pelvic structures.

d. stereognosis testing.
ANS: B
With the patient in the lithotomy position, the examiner can inspect the external and internal
female genitalia and perform a rectal examination to assess and palpate anal sphincter tone.
The other choices require the patient to be in the supine or standing position.

23. Which portion of the physical examination is best done with the patient standing?
a. Spinal
b. Rectal
c. Neurologic
d. Musculoskeletal
ANS: A
With the patient in the standing position, the examiner can inspect and palpate the spine as the
patient bends over at the waist and can also test a patient’s range of motion.

24. The greatest risk for potential health problems occurs in which age group?
a. Newborn
b. Toddler
c. School-age NURSINGTB.COM
d. Adolescence
ANS: A
Newborns have a greater risk for potential health problems than other age groups but also
have the potential for better health than the other age groups.

25. A common method for estimating gestational age of a newborn is to assess:

a. middle finger length.
b. creases on the sole of the foot.
c. umbilical placement.
d. visual acuity.
ANS: B
To determine gestational age, look at the soles of the feet. Before 36 weeks’ gestation, only
one or two transverse creases are present; by 40 weeks’ gestation, many creases are present on
the soles of the feet. Other clues to gestational age include a breast nodule less than 3 cm,
cartilage in the helix of the ear, descending of the scrotum and amount of rugae, and
extremities in flexed positions.

NURSINGTB.COM
26. To promote a child’s cooperation during your examination, your approach to the examination
should be to:
a. ask the parent to give the child a bottle during the examination.
b. sing songs with the child during the examination.
c. conduct the physical examination on the child while the parent is holding the child.
d. let the child play with examination room equipment to feel more comfortable.
ANS: C
For children, the examination sequence depends on their cooperation for as long as possible.
To promote this, examine the child while the parent is holding the child, which maximizes
inspection and opportunities for physical examination.

27. Which cannot be assessed in the crying infant?

a. Tactile fremitus
b. Respiratory rate
c. Lung excursion
d. Facial symmetry
ANS: B
Respirations cannot be counted in the crying infant. Tactile fremitus can be felt when the
infant is crying.

M Integrity: Basic Care and Comfort
U S N T O
28. The Ballard Gestational Age Test is completed within 36 hours of birth to:
a. determine if the menstrual estimated age is correct.
b. determine if the newborn is premature.
c. determine an actual quantitative measure.
d. determine combined objective and subjective observations.
ANS: B
Because menstrual histories are inaccurate, the Ballard Gestational Age assessment tool
contains newborn characteristics that can determine prematurity.

29. Mrs. Kia has brought her newborn infant in for a 2-week examination. The examination of the
newborn should begin with:
a. inspection.
b. palpation.
c. vital signs.
d. auscultation.
ANS: A
NURSINGTB.COM
The examination of a newborn should begin with inspection; skin color, flaccidity, tension,
gross deformities, or distortions of faces should be noted. All the other examination
techniques follow inspection.

30. The best way to ease the apprehension of a 3-year-old child before a physical examination is
to:
a. explain that you will be gentle.
b. hand the child a picture book.
c. let the child hold the stethoscope while you listen.
d. tell the child that he or she will get a lollipop for good behavior.
ANS: C
The best way to ease the apprehension of a 3-year-old child before a physical examination is
to encourage the child to participate by helping you. Ask the child to hold the endpiece of the
stethoscope or to “blow out” your flashlight.

31. In crying infants, it is often difficult to:

a. perform tactile fremitus assessments.
b. determine lung expansion.
c. auscultate heart sounds.
d. visualize the pharynx.
NURSINGTB.COM
ANS: C
For the crying infant, lungs can be auscultated between consolable moments. While the infant
is crying, the examiner can assess the lustiness of cry, tactile fremitus, lung excursion, facial
symmetry, and appearance of the mouth and pharynx. Each time a breath is taken, heart tone
can be auscultated.

32. When you attempt to move a 10-month-old child from his mother’s lap to the examination
table, he screams loudly. Your best action is to:
a. move the child to the examination table and proceed matter of factly with the
examination.
b. ask the mother to try to get the child to stop crying.
c. perform the examination while the child is in the mother’s lap.
d. defer the examination until another day.
ANS: C
The parent’s lap is a great examination table because it helps the child feel more at ease and is
also a good way to observe the nature of the parent-child relationship. All the other actions
would not comfort the patient or make the situation better.

NURSINGTB.COM
33. When conducting a geriatric assessment, keep in mind that basic activities of daily living
(ADL) include:
a. bathing.
b. housekeeping.
c. medication compliance.
d. communication skills.
ANS: A
Basic ADL include bathing, dressing, toileting, ambulating, and feeding. All the other options
represent instrumental ADL.

34. When examining a “difficult” patient, it is best to allow which person in the examination
room?
a. The clinician
b. Patient’s small children
c. An interpreter
d. A chaperone
ANS: D
A chaperone for “difficult” patients ensures the examination goes smoothly. The chaperone
may also assist with patient positioning.

M Integrity: Basic Care and Comfort
U S N T O
35. Functional assessment is most important during the examination of a(n):
a. adolescent.
b. infant.
c. older adult.
d. young adult.
ANS: C
Functional assessment is most important when examining the older adult. Initial observation
and interaction can provide a great deal of information about the individual’s independent
functional capacity. Attention should be given to self-care activities and instrumental
activities.

36. Observation of the child playing in the playroom provides information about which two
systems?
a. Dermatologic and cardiovascular
b. Neurologic and musculoskeletal
c. Respiratory and ear, nose, and throat
d. Gastrointestinal and genitourinary
ANS: B
NURSINGTB.COM
The child playing on the floor offers an opportunity to evaluate the musculoskeletal and
neurologic systems by noting the child’s coordination of activities, such as when throwing a
ball, drawing, coloring, walking, and jumping.

37. Throughout the history and physical examination, the clinician should:
a. concentrate on emotional issues.
b. follow an inflexible sequence.
c. evaluate the whole patient.
d. deal only with previously identified problems.
ANS: C
The clinician should evaluate the whole patient, including physical, emotional, and social
needs. Learning how to follow a disciplined course and be flexible will help the clinician
during the history and physical examination. The information obtained should be kept
organized to provide essential patient care.

38. For a routine physical examination, which equipment is not necessary?

a. A penlight
b. A measuring tape
c. Examination gloves
d. A monofilament
NURSINGTB.COM
ANS: D
A penlight, measuring tape, and examination gloves are needed for every routine examination;
a monofilament is not.

39. The cranial nerves are usually assessed while the patient is in which position?
a. Standing
b. Supine
c. Sitting
d. Prone
ANS: C
While the patient is in the sitting position, you can assess all cranial nerve functions.

40. Which action should the nurse take before auscultating bowel sounds in an 18-month-old
child?
a. Stand to the left of the child
b. Palpate the abdomen
c. Loosen the diaper
NURSINGTB.COM
d. Position the child prone

ANS: C
The diaper must be loosened so the nurse is able to place the stethoscope on the child’s skin
and not the diaper. Placing the stethoscope on the child’s diaper will interfere with the nurse’s
ability to hear the bowel sounds.

41. Which position is most likely the most comfortable for a patient who is 6 months pregnant?
a. Side-lying
b. Lithotomy
c. Prone
d. Flexed-knee
ANS: A
Late in pregnancy, the patient may find it difficult to assume the lithotomy or supine position.
The nurse should position pillows so that the patient is in the side-lying position as much as
possible during the examination.

42. What is the “brown-bag approach” in regard to examining an older adult?

a. The patient’s stool sample is brought to the examination in a brown bag.
b. The patient’s medications are brought to the examination in a brown bag.
c. The patient’s change of clothes
NURSisIbrought to theMexamination in a brown bag.
d. The patient’s assistive device NGTB.C
is brought to theOexamination in a brown bag.
ANS: B
Older adults are often asked to bring in all of their medications, prescription and
non-prescription, from all healthcare providers to their physical examination appointment.
This is referred to as the “brown-bag approach.”

COMPLETION
1. Mrs. Jones is a 44-year-old patient who presents for a routine physical examination. The
patient is unable to shrug her shoulders against the examiner’s hands during the examination.
The cranial nerve involved with successful shoulder shrugging is CN ____.
ANS:
XI
Cranial nerve XI enables the patient to shrug her shoulders.

NURSINGTB.COM
2. Ms. Stein visits the nurse practitioner for an annual examination. The nurse practitioner tests
Ms. Stein’s tongue for movement and strength. The nurse practitioner is assessing CN
_______.
ANS:
XII
Cranial nerve XII enables the patient to demonstrate tongue movement and strength.

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NURSINGTB.COM
Chapter 26: Emergency or Life-Threatening Situations

MULTIPLE CHOICE
1. During initial ABCDE assessments of life-threatening conditions, D (disability) in neurologic

status is assessed by the patient’s:
a. pupil size.
b. degree of responsiveness.
c. nuchal rigidity.
d. mood and affect.
ANS: B
The D (disability) in neurologic status of the primary assessment is assessed by determination
of the patient’s degree of responsiveness to stimuli.

2. You have gone by ambulance to a construction site where an adult male is lying on the street.
The only information you have is that he fell three stories. His neck is immobilized with sacks
of concrete mix on either side. Your first action should be to determine:
a. airway patency.
b. bleeding sites.
c. cranial nerve function.
d. limb position.
NURSINGTB.COM
ANS: A
On arriving at the site, the patency of the upper airway is the priority and should be managed
before proceeding with further assessments.

3. The ABCs of a primary survey would be interrupted to:

a. complete the assessment record.
b. manage life-threatening conditions.
c. reassess the patient’s temperature.
d. transport the patient via airlift.
ANS: B
The primary assessment is interrupted to manage a life-threatening condition as soon as it is
detected. Once the condition is stabilized, the primary assessment is continued. Recording of
events as they occur should be completed in a manner that does not interrupt continued care or
transport. Reassessment of the patient’s temperature is inappropriate because it would
interrupt the continued assessment process. Transporting the patient may begin after the
primary assessment has been completed to determine the needs of the patient adequately.

NURSINGTB.COM
4. The term status epilepticus is defined as:

a. convulsive activity uncontrolled by medication.
b. nonconvulsive brain wave disturbance, with psychomotor dysfunction.
c. prolonged seizures that occur without recovery of consciousness.
d. seizures that result in hypotension, pallor, and prolonged diaphoresis.
ANS: C
Status epilepticus is a prolonged seizure or series of seizures that occur without recovery of
consciousness.

5. Pulsus paradoxus greater than 20 mm Hg, tachycardia greater than 130 beats/min, and
increasing dyspnea are signs of:
a. intracranial pressure.
b. pulmonary hypertension.
c. status asthmaticus.
d. tetanic contractions.
ANS: C
Status asthmaticus is a severe and prolonged asthma attack that resists the usual therapeutic
approaches. The patient experiences dyspnea, can only get out a few words between breaths,
and has tachycardia often greater than 130 beats/min and pulsus paradoxus greater than 20
mm Hg. Pulsus paradoxus is more likely in pericardial effusion, constrictive pericarditis, and
severe asthma.
NUR(Analysis)
SINGTB.COM OBJ: Nursing process—diagnosis
6. The Cushing triad includes:

a. tachycardia.
b. irregular respirations.
c. tachypnea.
d. constricted pupils.
ANS: B
The Cushing triad is associated with increased intracranial pressure. It includes bradycardia,
hypertension, and irregular respirations, even Cheyne-Stokes respirations.

7. Blood, vomitus, and foreign bodies are removed from the oropharynx of the unconscious
patient by:
a. stimulating the cough reflex.
b. using a sweeping motion with the finger.
c. performing a back thrust.
d. using suction.
ANS: D
NURSINGTB.COM
Suction is used to remove blood, vomitus, or foreign bodies from the airway of an
unconscious patient. The other choices put the patient at risk for aspiration or further injury if
a neck injury is involved.

8. While performing the primary survey on a trauma victim, the patient is answering your
questions. You may assume that during the time of the questioning:
a. his airway is open.
b. he is alert and oriented.
c. no head injury has occurred.
d. there is no respiratory compromise.
ANS: A
The patency of the upper airway is assessed at the start by asking the patient a question. If the
patient answers, this is a sign that the airway is open at this time.

9. If trauma above the clavicle is suspected, it is important to:

a. test range of motion of the neck.
b. remove any headgear.
c. arrange for neck extension x-ray studies.
d. stabilize the neck in a neutral position.
ANS: D N R I G B.C M
If trauma above the clavicle is U S N T
suspected, O
it is necessary to control the cervical spine by
stabilizing the neck in a neutral position. Excessive movement can convert a fracture or
dislocation without neurologic damage to one with neurologic damage.

10. Paradoxical chest movement suggests a:

a. spontaneous pneumothorax.
b. flail chest.
c. clavicle fracture.
d. pulmonary contusion.
ANS: B
Paradoxical chest movement is associated with fractured ribs or a flail chest. This fracture
should be stabilized immediately.

11. Respiratory distress may be evidenced by:

a. retractions of accessory muscles.
b. bradycardia.
c. flushed skin.
NURSINGTB.COM
d. decreased capillary refill time.

ANS: A
Respiratory distress results in an increased intrathoracic negative pressure as the body
attempts to suck in more atmospheric air. This increased negative pressure causes the chest
wall skin to retract around the ribs during inspiration. The other choices are related to
cardiovascular distress.

12. On palpating the chest wall of a trauma patient, you feel subcutaneous crepitus (emphysema),
which is a sign that:
a. air has leaked into soft tissue.
b. a fracture underlies the injury.
c. a foreign body is present.
d. there is vascular obstruction.
ANS: A
Crepitus is a sign of air leakage into soft tissue. Crepitus in soft tissues is caused by air that
has penetrated the area as a result of injury; it is also referred to as subcutaneous emphysema.
Bony crepitus is a grating or grinding sensation caused by fractured bone ends or joints
rubbing together. A foreign body could obstruct the patient’s airway, producing stridor, or a
bark may be heard with an obstructed airway.

N R I G B.C M
U nose
S Nor T
13. Clear or amber drainage from the ears of O
a blunt trauma patient may indicate:
a. epiglottitis.
b. a retropharyngeal abscess.
c. a basilar skull fracture.
d. a perforated tympanic membrane.
ANS: C
Clear or amber drainage from the nose or ears may indicate a basilar skull fracture. Bloody
drainage is associated with a perforated tympanic membrane.

14. Delayed capillary refill may alert you to:

a. hypovolemic shock.
b. moderate hypoxemia.
c. subnormal intracranial pressure.
d. upper respiratory infection.
ANS: A
Delayed capillary refill means that the vessels are taking an extended time to fill, which is a
sign of decreased cardiac output. To assess peripheral perfusion further and detect
hypovolemic shock, note the skin color, presence and quality of pulses, and temperature of the
extremities.
NURSINGTB.COM

15. Capillary refill can be assessed by applying pressure over a nail bed or a(n):
a. bony prominence.
b. eyelid.
c. mucous membrane.
d. femoral vein.
ANS: A
Capillary refill can be assessed by pressing firmly over a nail bed or bony prominence such as
the chin, forehead, or sternum until the skin blanches. Count the seconds it takes for color to
return. Less than 2 seconds is a normal finding, and longer than 2 seconds indicates poor
perfusion.

16. The secondary survey of a patient with hypotension would begin with the assessment of:
a. blood type.
b. level of consciousness.
c. number of fractures.
d. swallowing ability.
ANS: B
Secondary assessments are done after life-threatening problems are determined. For the
hypotensive patient, it wouldNbe R
most important
GTB.CtoObegin
M secondary assessment of cerebral
U SINlevel
perfusion by determining the patient’s of consciousness.

17. You would complete a Glasgow Coma Scale rating during the:
a. health history.
b. physical examination.
c. primary survey.
d. secondary survey.
ANS: D
During the secondary survey, the full range of injuries is determined. The level of
consciousness is determined, and the Glasgow Coma Scale is scored as indicated.

18. Mr. Stinson is a 34-year-old patient who presents to the emergency department after an auto
accident. On examination, you note raccoon eyes and a positive Battle sign. Raccoon eyes and
the Battle sign are associated with:
a. multisystem trauma.
b. orbital fractures.
c. basilar skull fractures.
NURSINGTB.COM
d. subdural hematoma.
ANS: C
Raccoon eyes (bruising around the eyes) and the Battle sign (bruising behind the ears) both
indicate a basilar skull fracture. Symptoms of orbital fractures are swelling of the eyelid,
bruising of the eye, pain in the eye, double vision, and decreased movement of the affected
eye. Signs and symptoms of a subdural hematoma are loss of consciousness after the original
injury, steady or fluctuating headache, weakness, numbness or inability to speak, slurred
speech, nausea, vomiting, lethargy, and seizures.

19. A life-threatening condition is recognized with the assessment of:

a. pain with downward pressure on both anterior superior iliac spines.
b. guarding and intense pain with deep palpation of the abdomen.
c. distant and muffled heart sounds, with distended neck veins.
d. severe throbbing pain in one eye, with photophobia.
ANS: C
Distant, muffled heart sounds and distended neck veins may indicate cardiac tamponade, a
life-threatening condition. Iliac spine pain indicates a pelvic fracture that may become
life-threatening depending on the extent of occult bleeding. Intense pain with deep palpation
is not certain to be deadly. Eye pain with photophobia signals acute glaucoma, which can lead
to blindness if treatment is delayed.

MSC: Physiologic Integrity: Basic
N RCareIandGComfort
B.C
U S N T OM
20. The application of blunt sternal pressure is used to detect:
a. a fracture of attached ribs.
b. the motor function of the T7 dermatome.
c. pneumothorax.
d. cardiac contusion.
ANS: A
Blunt sternal pressure will be painful if any attached ribs are fractured. Sternal pressure is
applied to the chest to assess the stability of the chest wall.

21. Until they are stabilized, trauma patients require reevaluation:

a. every 2 minutes.
b. every 5 minutes.
c. every 10 minutes.
d. every hour.
ANS: B
An unstable patient must be reevaluated frequently so that any new signs and symptoms are
not overlooked. A primary survey should be performed every 5 minutes and the results
compared with those obtained in previous surveys.
NURSINGTB.COM

22. During injury assessment, one of the most crucial historical components is:
a. number of siblings.
b. history of prior fractures.
c. mechanism of injury.
d. past and current occupational exposure.
ANS: C
In cases of trauma, the secondary assessment is intended to identify the full range of injuries,
with particular focus on body systems affected by the mechanism of injury. All the other
choices are not crucial for the emergency.

23. Which condition manifests as unexplained shortness of breath (SOB) and cough with
hemoptysis?
a. Bleeding ulcer
b. Myocardial infarction
c. Pulmonary embolism
d. Transient ischemia
ANS: C
Symptoms of pulmonary embolism include sudden onset of unexplained SOB, pleuritic chest
pain, and coughing, with pinkNfrothy sputum. Bleeding
M ulcer symptoms are coffee grounds
emesis with gnawing pain in the URupper
SINabdomen.
GTB.C OMyocardial infarction is signified by
crushing pain in the center of the chest radiating to the arm, neck, or jaw, diaphoresis, nausea
and vomiting, SOB, and a feeling of impending doom. Transient ischemia occurs with a
sudden feeling of weakness and loss of movement of the arms or legs, numbness and/or
tingling in any part of the body, excruciating headache, and/or difficulty speaking.

24. Which injury is the most common precipitator of blunt trauma?

a. Age-related falls
b. Motor vehicle accidents
c. Work-related injuries
d. Childhood play injuries
ANS: B
Motor vehicle accidents account for the majority of severe blunt trauma cases.
DIF: Cognitive Level: Remembering (Knowledge) OBJ: Nursing process—planning

25. When calculating the force of impact of a penetrating object, use:

a. the size of the missile and size of the patient.
b. the time of the incident and depth of the wound.
NURSINGTB.COM
c. the amount of blood loss and level of consciousness.

d. the velocity of the missile and distance from the source.
ANS: D
When calculating the force of impact of a penetrating object, the amount of force is measured
by the velocity of the missile and distance from the source. The force of the penetrating object
on impact determines the transfer of energy.

26. Adults and children display different physiologic responses to injury and acute illness. An
important concept to remember when assessing infants and children is that they:
a. experience lethal dysrhythmias first, progressing to respiratory failure.
b. usually experience cardiac arrest before respiratory failure.
c. usually experience respiratory arrest before circulatory failure.
d. tolerate greater volume changes, with less severe consequences.
ANS: C
Cardiac arrest is rarely a primary event in children, as it is in adults. The child usually
experiences respiratory and ventilatory failure that progresses to respiratory arrest first.
Without rapid intervention, a cardiac arrest occurs as a secondary event.

27. The approximate expected systolic blood pressure for a child older than 1 year is:
a. 120 + child’s age in years.
N R I G B.COM
b. 80 + child’s age in years. U S N T
c. 120 ?- child’s age in years.
d. 80 + (the child’s age in years).
ANS: D
Use the equation 80 + (the child’s age in years) to calculate the expected systolic blood
pressure for a child older than 1 year.

28. In life-threatening emergencies, consent for treatment:

a. is obtained before treatment to protect the facility from liability.
b. is not necessary.
c. occurs after treatment is administered.
d. is not valid because the patient is not competent.
ANS: C
In life-threatening emergencies, the needed treatment should usually be given and formal
consent obtained later.

OBJ: Nursing process—implementing MSC: Physiologic Integrity: Basic Care and Comfort
NURSINGTB.COM

Chapter 01: The History and Interviewing Process Ball: Seidel's Guide To Physical Examination, 9th Edition

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Chapter 01: The History and Interviewing Process Ball: Seidel's Guide To Physical Examination, 9th Edition

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Chapter 01: The History and Interviewing Process

1. Which question would be considered a “leading question?”

DIF: Cognitive Level: Applying (Application)

2. When are open-ended questions generally most useful?

DIF: Cognitive Level: Understanding (Comprehension)

DIF: Cognitive Level: Understanding (Comprehension)

DIF: Cognitive Level: Analyzing (Analysis)

DIF: Cognitive Level: Applying (Application)

DIF: Cognitive Level: Applying (Application)

DIF: Cognitive Level: Analyzing (Analysis)

DIF: Cognitive Level: Applying (Application)

d. the woman’s remembering (knowledge) about pregnancy.

DIF: Cognitive Level: Understanding (Comprehension)

10. When interviewing older adults, the examiner should:

DIF: Cognitive Level: Understanding (Comprehension)

11. To what extent should the patient

DIF: Cognitive Level: Understanding (Comprehension)

12. When taking a history, the nurse should:

DIF: Cognitive Level: Understanding (Comprehension)

DIF: Cognitive Level: Applying (Application)

14. A guideline for history taking is for caregivers to:

DIF: Cognitive Level: Understanding (Comprehension)

c. personal and social history.

DIF: Cognitive Level: Understanding (Comprehension)

DIF: Cognitive Level: Remembering (Knowledge)

17. A tool used to screen adolescents

DIF: Cognitive Level: Remembering (Knowledge)

DIF: Cognitive Level: Understanding (Comprehension)

DIF: Cognitive Level: Remembering (Knowledge)

20. Constitutional symptoms in the ROS refer to:

DIF: Cognitive Level: Applying (Application)

DIF: Cognitive Level: Understanding (Comprehension)

Chapter 02: Cultural Competency

DIF: Cognitive Level: Understanding (Comprehension)

DIF: Cognitive Level: Remembering (Knowledge)

DIF: Cognitive Level: Analyzing (Analysis)

DIF: Cognitive Level: Understanding (Comprehension)

DIF: Cognitive Level: Analyzing (Analysis)

6. The definition of ill or sick is based on a:

DIF: Cognitive Level: Understanding (Comprehension)

DIF: Cognitive Level: Analyzing (Analysis)

9. An aspect of traditional Western medicine that may be troublesome to many Hispanics,

d. restore balance in an individual’s life.

DIF: Cognitive Level: Understanding (Comprehension)

10. The attitudes of the healthcare professional:

DIF: Cognitive Level: Understanding (Comprehension)

DIF: Cognitive Level: Remembering (Knowledge)

DIF: Cognitive Level: Applying (Application)

DIF: Cognitive Level: Understanding (Comprehension)

DIF: Cognitive Level: Understanding (Comprehension)

DIF: Cognitive Level: Understanding (Comprehension)

16. An example of a cold condition is:

DIF: Cognitive Level: Remembering (Knowledge)

DIF: Cognitive Level: Understanding (Comprehension)

2. Campinha-Bacote’s Process N RSINGCompetence

DIF: Cognitive Level: Understanding (Comprehension)

Chapter 03: Examination Techniques and Equipment

DIF: Cognitive Level: Remembering (Knowledge)

2. Which patient is at the highest risk for developing latex allergy?

DIF: Cognitive Level: Understanding (Comprehension)

DIF: Cognitive Level: Understanding (Comprehension)

DIF: Cognitive Level: Understanding (Comprehension)