Health assessment

1. The consumption of alcohol, tobacco, caffeine, or herbal products is important

in health history and which are part of what?
a. illegal activity
b. habit & life style pattern
c. fun & pleasure
d. rest & recreation

2. We know that the nurse knows the right time to do a physical assessment when she
says:
a. I will do it as soon as possible
b. I think the next shift will do it
c. after I gave the medication
d. may be latter when I done with others

3. The difference between a "head to toe" assessment and a "focused assessment"

a. head to toe is systemic while focus concentrated on regional part
b. head to toe is completed when the patient is admitted; focused
concentrated on particular part of body
c. head to toe is done on every shift; while focused is done when person is admitted
d. both Rn & LPN’s should do head to toe assessment as well as focused assessment

4. In the interview portion of the physical assessment, since we are not actually
touching the patient, there is no need to wash our hands.
a. it is true
b. it is false
c. it is not related to health assessment
d. it is purely related to physical assessment

5. Before the beginning of a physical examination, to make the patient more

comfortable, what should be done first
a. give patient warm blanket
b. ask if patient want a glass of water
c. offer patient to empty his/her bladder
d. provide a small cup of tea
6. When performing a head-to-toe assessment, we normally begin with a
neurologic assessment. What is the next?
a. skin hair head & neck including eye ear nose throat
b. chest
c. back
d. arm

7. In the mnemonic used for assessments, what does PS stand for in ABC in and out,
PS?
a. painful sensation
b. problem & solution
c. pain & safety
d. pernicious stimulation

8. PERRLA refers to
a. motor function
b. order of assessment
c. level of consciousness
d. papillary response

9. Vital signs are reliable even when there is a central nervous system deficit
a. it is true
b.
c. it is false
d. it’s not related
it is relevant

10. A patient has just been admitted. During physical assessment, it was observed that
patient had decreased skin turgor and dried outer lips. What would be the most
appropriate thing to offer this patient while the physical assessment is going on?
a. a chair to sit on
b. empty bladder
c. supine position
d. prone position
11. Mr. Teban is a 73-year old patient diagnosed with pneumonia. Which data
would be of greatest concern to the nurse when completing the nursing
assessment of the patient?
a. Alert and oriented to date, time, and place
b. Buccal cyanosis and capillary refill greater than 3 seconds
c. Clear breath sounds and nonproductive cough
d. Hemoglobin concentration of 13 g/dl and leukocyte count 5,300/mm3

12. 2. During the nursing assessment, which data represent information

concerning health beliefs?
a. Family role and relationship patterns
b. Educational level and financial status
c. Promotive, preventive, and restorative health practices
d. Use of prescribed and over-the-counter medications

13. Nurse Patrick is acquiring information from a client in the emergency department.
Which is an example of biographic information that may be obtained during a
health history?
a. The chief complaint
b. Past health status
c. History immunizations
d. Location of an advance directive

14. John Joseph was scheduled for a physical assessment. When percussing the
client’s chest, the nurse would expect to find which assessment data as a
normal sign over his lungs?
a. Dullness
b. Resonance
c. Hyperresonance
d. Tympany
15. Matteo is diagnosed with dehydration and underwent series of tests. Which
laboratory result would warrant immediate intervention by the nurse?
a. Serum sodium level of 138 mEq/L
b. Serum potassium level of 3.1 mEq/L
c. Serum glucose level of 120 mg/dl
d. Serum creatinine level of 0.6 mg/100 ml

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

the client from discomfort and injury?
a. Tipping the client’s head away from the examiner and pulling the ear up and back
b. Inserting the otoscope inferiorly into the distal portion of the external canal
c. Inserting the otoscope superiorly into the proximal two-thirds of the external
canal
d. Bracing the examiner’s hand against the client’s head

17. When assessing the lower extremities for arterial function, which intervention
should the nurse perform?
a. Assessing the medial malleoli for pitting edema
b. Performing Allen’s test
c. Assessing the Homans’ sign
d. Palpating the pedal pulses

18. Newly hired nurse Liza is excited to perform her very first physical assessment
with a 19-year-old client. Which assessment examination requires Liza to wear
gloves?
a. Breast
b. Integumentary
c. Ophthalmic
d. Oral
19. Nurse Renor is about to perform Romberg’s test to Pierro. To ensure the
latter’s safety, which intervention should nurse Renor implement?
a. Allowing the client to keep his eyes open
b. Having the client hold on to furniture
c. Letting the client spread his feet apart
d. Standing close to provide support

20. Physical assessment is being performed to Geoff by Nurse Tine. During the
abdominal examination, Tine should perform the four physical examination
techniques in which sequence?
a. Auscultation immediately after inspection and then percussion and palpation
b. Percussion, followed by inspection, auscultation, and palpatio
c. Palpation of tender areas first and then inspection, percussion, and auscultation
d. Inspection and then palpation, percussion, and auscultation

21. Which assessment data should the nurse include when obtaining a review of body
systems
a. Brief statement about what brought the client to the health care provider
b. Client complaints of chest pain, dyspnea, or abdominal pain
c. Information about the client’s sexual performance and preference
d. The client’s name, address, age, and phone number

22. Tywin has come to the nursing clinic for a comprehensive health assessment.
Which statement would be the best way to end the history interview?
a. “What brought you to the clinic today?”
b. “Would you describe your overall health as good?”
c. “Do you understand what is happening?”
d. “Is there anything else you would like to tell me?”
23. For which time period would the nurse notify the health care provider that the
client had no bowel sounds?
a. 2 minutes
b. 3 minutes
c. 4 minutes
d. 5 minutes

24. Evaluating the apical pulse is the most reliable noninvasive way to assess cardiac
function. Which is the best area for auscultating the apical pulse?
a. Aortic arch
b. Pulmonic area
c. Tricuspid area
d. Mitral area

25. Beginning in their 20s, women should be told about the benefits and limitations of
breast self-exam (BSE). Which scientific rationale should the nurse remember when
performing a breast examination on a female client?
a. One half of all breast cancer deaths occur in women ages 35 to 45
b. The tail of Spence area must be included in self-examination
c. The position of choice for the breast examination is supine
d. A pad should be placed under the opposite scapula of the breast being palpated

26. Mr. Lim, who has chronic pain, loss of self-esteem, no job, and bodily disfigurement
from severe burns over the trunk and arms, is admitted to a pain center. Which
evaluation criteria would indicate the client’s successful rehabilitation?
a. The client remains free of the aftermath phase of the pain experience
b. The client experiences decreased frequency of acute pain episodes
c. The client continues normal growth and development with intact support
systems.
d. The client develops increased tolerance for severe pain in the future.
27. Christine Ann is about to take her NCLEX examination next week and is currently
reviewing the concept of pain. Which scientific rationale would indicate that she
understands the topic?
a. Pain is an objective sign of a more serious problem
b. Pain sensation is affected by a client’s anticipation of pain
c. Intractable pain may be relieved by treatment
d. Psychological factors rarely contribute to a client’s pain perception

28. Miggy, a 6-year-old boy, received a small paper cut on his finger, his mother let him
wash it and apply small amount of antibacterial ointment and bandage. Then she
let him watch TV and eat an apple. This is an example of which type of pain
intervention?
a. Pharmacologic therapy
b. Environmental alteration
c. Control and distraction
d. Cutaneous stimulation

29. Which statement represents the best rationale for using noninvasive
and non-pharmacologic pain-control measures in conjunction with
other measures?
a. These measures are more effective than analgesics.
b. These measures decrease input to large fibers.
c. These measures potentiate the effects of analgesics.
d. These measures block transmission of type C fiber impulses.

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

appropriate adaptation?
a. The client distracts himself during pain episodes.
b. The client denies the existence of any pain.
c. The client reports no need for family support.
d. The client reports pain reduction with decreased activity.
31. In planning pain reduction interventions, which pain theory provides
information most useful to nurses?
a. Specificity theory
b. Pattern theory
c. Gate-control theory
d. Central-control theory

32. Ryan underwent an open reduction and internal fixation of the left hip. One day
after the operation, the client is complaining of pain. Which data would cause the
nurse to refrain from administering the pain medication and to notify the health
care provider instead?
a. Left hip dressing dry and intact
b. Blood pressure of 114/78 mm Hg; pulse rate of 82 beats per minute
c. Left leg in functional anatomic position
d. Left foot cold to touch; no palpable pedal pulse

33. Which term would the nurse use to document pain at one site that is perceived
in other site?
a. Referred pain
b. Phantom pain
c. Intractable pain
d. Aftermath of pain

34. Chuck, who is in the hospital, complains of abdominal pain that ranks 9 on a scale
of 1 (no pain) to 10 (worst pain). Which interventions should the nurse
implement? (Select all that apply.)
a. Assessing the client’s bowel sounds
b. Taking the client’s blood pressure and apical pulse
c. Obtaining a pulse oximeter reading
d. Notifying the health care provider
e. Determining the last time the client received pain medication
f. Encouraging the client to turn, cough, and deep breathe
35. Albert who suffered severe burns 6 months ago is expressing concern about the
possible loss of job-performance abilities and physical disfigurement. Which
intervention is the most
appropriate for him?
a. Referring the client for counseling and occupational therapy
b. Staying with the client as much as possible and building trust
c. Providing cutaneous stimulation and pharmacologic therapy
d. Providing distraction and guided imagery techniques

36. Mrs. Bagapayo who had abdominal surgery 3 days earlier complains of sharp,
throbbing abdominal pain that ranks 8 on a scale of 1 (no pain) to 10 (worst pain).
Which intervention should the nurse implement first?
a. Assessing the client to rule out possible complications secondary to surgery
b. Checking the client’s chart to determine when pain medication was last administered
c. Explaining to the client that the pain should not be this severe 3 days postoperatively
d. Obtaining an order for a stronger pain medication because the client’s pain has increased

37. Which term refers to the pain that has a slower onset, is diffuse, radiates, and is
marked by somatic pain from organs in any body activity?
a. Acute pain
b. Chronic pain
c. Superficial pain
d. Deep pain

38. A 50-year-old widower has arthritis and remains in bed too long because it
hurts to get started. Which intervention should the nurse plan?
a. Telling the client to strictly limit the amount of movement of his inflamed joints
b. Teaching the client’s family how to transfer the client into a wheelchair
c. Teaching the client the proper method for massaging inflamed, sore joints
d. Encouraging gentle range-of-motion exercises after administering aspirin and
before rising
39. Which intervention should the nurse include as a no pharmacologic pain-relief
intervention for chronic pain?
a. Referring the client for hypnosis
b. Administering pain medication as prescribed
c. Removing all glaring lights and excessive noise
d. Using transcutaneous electric nerve stimulation

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

41. The nurse is looking at the information collected during the health interview in an
effort to cluster or group the data together. The nurse is demonstrating which phase
of the nursing process?
a. planning
b. assessment
c. diagnose
d. evaluation

42. During the interview process and physical assessment of Ms. Wong, which of the
following would alert the nurse of a possible fluid volume deficit?
a. lips & mucus dry
b. nausea
c. skin warm
d. abdominal tenderness

43. During the health interview, the client mentions that she is "very stressed about
her home situation." The nurse sees this information as impacting the client's level
of pain control. Which approach is the nurse using during the health interview?
a. communication
b. holistic
c. cultural
d. developmental
44. After conducting the health interview, the nurse begins to measure the client's
vital signs. The nurse is collecting:
a. subjective data
b. secondary data
c. objective data
d. constant data

45. The nurse is documenting the findings from a health assessment. Which of the
following demonstrates the documentation of subjective information?
a. blood pressure 110/60
b. it hurt when I put weight on my leg
c. abdomen soft & nontender to palpation
d. pulses present in lower extremities

46. skin temperature assessment is best done by nurse’s

a. palm
b. finger tip
c. elbow
d. dorsum of the finger

47. color, size, shape, position & symmetry can be assess using the
a. inspection
b. palpation
c. percussion
d. auscultation

48. light palpation is used to assess

a. tenderness
b. body organ & mass
c. skin temperature
d. bowl sound

49. one of the following assessment is not consider the assessment of skin
a. temperature
b. moisture
c. odor
d. texture

50. normal angle at a nail base is

a. 10 degree
b. 160 degree
c. 130degree
d. 180 degree
51. normal color of nail is
a. bluish
b. pinkish
c. yellowish
d. black

52. normal capillary refill duration is

a. less than two second
b. less than three second
c. less than five second
d. less than eight second

53. all of the following normal skin finding except one

a. elastic
b. smooth
c. moist
d. rough

54. the interviewer start collecting data at which stage of interview

a. the opening
b. the body
c. closing
d. before interview

55. The superior part of the tympanic membrane is known as the pars flaccida.
a. true
b. false
c. it is not a superior part of forehead
d. it is inferior part of brain

56. The bridge of the nose is made out of cartilage.

a. no it is bony structure
b. yes it is cartilageous in nature
c. it is made by septum
d. there is no vomar bone in nose

57. Inspection of the nasal mucosa of an individual with rhinitis would demonstrate
mucosa that is
a. bright red & swollen
b. dark purplish
c. light yellow
d. dark brown
58. What question would you ask to determine whether an individual has epistaxis?
a. Do you know what is it?
b. Do you experience nose bleed?
c. Do you manage it during bleeding?
d. Do you bleed before it?

59. In addition to initiating digestion of food, Cleans and protects mucosa

a. Blood
b. Water
c. Saliva
d. Lymph

60. Purpose of the ___sinuses is Airfield pockets within the cranium to lighten the
weight of the skull, serve as resonators for sound production, and provide mucus,
which drains into.

a. Frontal
b. Temporal
c. Paranasal
d. Ethmoid

61. Monique is diagnosed with Ménière’s disease, which diet would be most
appropriate to discuss with her?
a. Low-fiber
b. Low-potassium
c. Low-sodium
d. Low-protein
62. For a client diagnosed with epistaxis, which intervention would be included in the
care plan?
a. Performing several abdominal thrust (Heimlich) maneuvers

b. Compressing the nares to the septum for 5 to 10 minutes

c. Applying an ice collar to the neck area
d. Encouraging warm saline throat gargles
63. An 8-year-old boy is returned to his room following a tonsillectomy. He remains
sleepy from the anesthesia but is easily awakened. The nurse should place the child
in which of the following positions?
a. Sims’
b. Side-lying
c. Supine
d. Prone
64. Which assessment data would the nurse expect as the chief complaint from a
client who is experiencing an acute exacerbation of Ménière’s disease?
a. Vertigo
b. Dizziness
c. Severe ear pain
d. Sudden deafness

65. While inserting a nasogastric tube, the nurse should use which of the following
protective measures?
a. Gloves, gown, goggles, and surgical cap
b. Sterile gloves, mask, plastic bags, and gown
c. Gloves, gown, mask, and goggles
d. Double gloves, goggles, mask, and surgical cap

66. Which of the following is a small boil located in the skin or mucous membrane of
the nose that appears red and swollen and is quite painful?
a. polyp
b. lesion
c. furuncle
d. lymph

67. Which of the following grades would be given to tonsils that are halfway
between the tonsillar pillars and uvula?
a. 1+
b. 2+
c. 3+
d. 4+

68. Which of the following is a bony or membranous septum between the nasal cavity
and the pharynx of the newborn?
a. foreign body
b. choanal atresia
c. acute rhinitis
d. chronic rhinitis
69. Which of the following terms describes cracking at the corners of the mouth?
a. chelitis
b. polyps
c. xerostomia
d. soreness

70. Medication with the potential to cause gastrointestinal bleeding (e.g.

anticoagulants, aspirin, etc) may cause the stool to appear:
a. black
b. red
c. pink
d. all of the above

71. What is the term used to describe the technique of "bearing down" when passing
a bowel movement?
a. hemorrhoid
b. defecation
c. valsalva maneuver
d. bowl elimination

72. At what age are the internal and external anal sphincters fully developed,
leading to the voluntary control of defecation?

a. 12 to 36 month
b. 30 month
c. 18 to 24 month
d. 1 year

73. When preserving a specimen en-route to the laboratory, the most efficient method
is:
a. heat
b. refrigeration
c. freezing
d. boiling
74. Which of the following is the definition of intestinal gas?
a. flatulence
b. fart
c. flatus
d. fleetus

75. What refers to the emptying of te large intestine?

a. defecation
b. stool
c. bowl movement
d. both a & c

76. Using the principles of standard precautions, the nurse would wear gloves in
what nursing interventions?

a. Providing a back massage

b. Feeding a client
c. Providing hair care
d. Providing oral hygiene

77. A nurse obtained a client’s pulse and found the rate to be above normal. The
nurse document these findings as:
a. Tachypnea
b. Hyperpyrexia
c. Arrhythmia
d. Tachycardia

78. Which of the following is the meaning of PRN?

a. When advice
b. Immediately
c. When necessary
d. Now
79. Which of the following is the abbreviation of drops?
a. Gtt.
b. Gtts.
c. Dp.
d. Dr.

80. The abbreviation for micro drop is…

a. µgtt
b. gtt
c. mdr
d. mgts

81. Which of the following cluster of data belong to Maslow’s hierarchy of needs
a. Love and belonging
b. Physiologic needs
c. Self actualization
d. All of the above

82. This is characterized by severe symptoms relatively of short duration.

a. Chronic Illness
b. Acute Illness
c. Pain
d. Syndrome

83. Which of the following is the nurse’s role in the health promotion
a. Health risk appraisal
b. Teach client to be effective health consumer
c. Worksite wellness
d. None of the above
84. It is a transparent membrane that focuses the light that enters the eyes to the retina.
a. Lens
b. Sclera
c. Cornea
d. Pupils

85. Exchange of gases takes place in which of the following organ?

a. Kidney
b. Lungs
c. Liver
d. Heart

86. The chamber of the heart that receives oxygenated blood from the lungs is the:
a. Left atrium
b. Right atrium
c. Left ventricle
d. Right ventricle

87. A muscular enlarge pouch or sac that lies slightly to the left which is used for
temporary storage of food…
a. Gallbladder
b. Urinary bladder
c. Stomach
d. Lungs

88. The ability of the body to defend itself against scientific invading agent such as
baceria, toxin, viruses and foreign body
a. Hormones
b. Secretion
c. Immunity
d. Glands
89. A client who is unconscious needs frequent mouth care. When performing a
mouth care, the best position of a client is:
a. Fowler’s position
b. Side lying
c. Supine
d. Trendelenburg

90. A client is hospitalized for the first time, which of the following actions ensure the
safety of the client?
a. Keep unnecessary furniture out of the way
b. Keep the lights on at all time
c. Keep side rails up at all time
d. Keep all equipment out of view

91. A walk-in client enters into the clinic with a chief complaint of abdominal pain and
diarrhea.
The nurse takes the client’s vital sign hereafter. What phrase of nursing
process is being implemented here by the nurse?
a. Assessment
b. Diagnosis
c. Planning
d. Implementation

92. A nurse must measure the intake and output (I&O) for a patient who
has a urinary retention catheter. Which equipment is most appropriate
to use to accurately measure urine output from a urinary retention
catheter?
a. Urinal
b. Graduate
c. Large syringe
d. Urine collection bag
93. A patient’s urine is cloudy, is amber, and has an unpleasant odor. What
problem may this information indicate that requires the nurse to make a
focused assessment?
a. Urinary retention
b. Urinary tract infection
c. Ketone bodies in the urine
d. High urinary calcium level

94. John Joseph was scheduled for a physical assessment. When percussing the
client’s chest, the nurse would expect to find which assessment data as a normal
sign over his lungs?
a. Dullness
b. Resonance
c. Hyper resonance
d. Tympany

95. Matteo is diagnosed with dehydration and underwent series of tests. Which
laboratory result would warrant immediate intervention by the nurse?
a. Serum sodium level of 138 mEq/L
b. Serum potassium level of 3.1 mEq/L
c. Serum glucose level of 120 mg/dl
d. Serum creatinine level of 0.6 mg/100 ml

96. Which term would the nurse use to document pain at one site that is perceived in
other site?
a. Referred pain
b. Phantom pain
c. Intractable pain
d. Aftermath of pain
97. For which time period would the nurse notify the health care provider that the client
had no bowel sounds?

a. 2 minute
b. 3 minutes
c. 4 minute
d. 5 minutes

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

a. Aortic arch
b. Pulmonic area
c. Tricuspid area
d. Mitral area

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

department. Which is an example of biographic information that may be obtained
during a health history?
a. The chief complaint
b. Past health status
c. History immunizations
d. Location of an advance directive
100. Newly hired nurse Liza is excited to perform her very first physical
assessment with a 19-year-old client. Which assessment examination requires Liza
to wear gloves?
a. Breast
b. Integumentary
c. Ophthalmic
d. Oral
101. The fleshy outer part of the female reproductive system where the opening
to the vagina is located.
a. uterus
b. ovary
c. vulva
d. vagina

102. The shedding of the lining of the uterus along with some blood once a
month. Also called a monthly period.
a. gestation
b. conception
c. menstruation
d. ovulation

103. the opening of uterus

a. vagina
b. ovary
c. cervix
d. vulva

104. The tiny female sex cell that unites with a male sperm to form a zygote or
fertilized egg.
a. ovary
b.
c. ovum
d. gonad
egg

105. Which of the following is the location where fertilization occurs?

a. Ovaries
b. Vagina
c. Uterus
d. Fallopian Tubes

106. Which of the following terms correspond with the phrase: a woman that is
pregnant?

a. Gravida
b. Parity
c. Spermatogonia
d. Zona pellucid
107. Which of the following sign's may indicate pregnancy?

a. Chadwick's sign
b. Turner's sign
c. Virchow's sign
d. Kock's sign

108. Which of the following is not an associated change during the antepartum period?

a. Increased urination frequency

b. Increased respiratory requirements
c. Decreased basal metabolic rate
d. Goodell's sign

109. Which of the following matches the definition: abnormal placenta development
covering the cervix?

a. Placenta Previa
b. Abruptio Placenta
c. Multigravida
d. Proliferative phase

110. Which of the following is not scored with the APGAR?

a. 0
b. Heart Rate
c. Color
d. Tone

111. Which of these is not considered a T.O.R.C.H. infection?

a. Rubella
b. Herpes
c. Cytomegalovirus
d. Croup

112. Which of the following develops into the ejaculatory duct and ductus deferens?

a. Paramesonephric duct
b. Mesonephric duct
c. Sympathetic duct
d. Parasympathetic duct
113. Which of the following is the result of poor fusion between the paramesonephric
ducts in females?

a. Placenta Previa
b. Bicornuate uterus
c. Multigravida
d. Proliferative phase

114. Where does spermatogenesis occur?

a. Seminiferous tubules
b. Corpus spongiosoma
c. Prostate gland

115. The tip of the sperm is called the ____.

a. Head
b. Acrosome
c. Tail
d. Nucleus

116. Which of the following develops into: bone, connective tissue, blood, and the
spleen?

a. Notochord
b. Endoderm
c. Mesoderm
d. Ectoderm

117. Which of the following is not a germ layer during the 3rdweek of development?

a. Mesoderm
b. Ectoderm
c. Endoderm
d. Exoderm

118. The umbilical vein carries _____ blood.

a. Deoxygenated
b. Oxygenated

119. Ovulation occurs during which of the following phases?

a. Menstrual
b. Secretory
c. Proliferative
d. Follicle
120. Following fertilization the blastocyst secrets a hormone called?

a. Human Chorionic Gonadotropin

b. Oxytocin
c. FSH
d. LH

121. Progesterone is secreted from a female's _____ to help the implanted embryo and
continue the pregnancy.

a. Corpus luteum
b. Mesoderm
c. Endoderm
d. Thyroid

122. Which of the following is not appropriately matched with the term:
Braxton Hicks contractions?

a. Painless
b. Intermittent contractions
c. Edema
d. Irregular

123. If a newborn exhibits a heart rate of 80 bpm the APGAR score should be?

a. 0
b. 1
c. 2
d. 3

124. If a newborn exhibits blue extremities and the body is pink the APGAR score
should be?

a. 0
b. 1
c. 2
d. 3

125. Which of the following is the best method for performing a physical examination
on a
toddler
a. From head to toe
b. Distally to proximally
c. From abdomen to toes
d. From least to most intrusive
 126. Which of the following situations increase risk of lead poisoning in children?
a. playing in the park with heavy traffic and with many vehicles passing by
b. playing sand in the park
c. playing plastic balls with other children
d. playing with stuffed toys at home

127. An inborn error of metabolism that causes premature destruction of RBC?

a. G6PD
b. Hemocystinuria
c. Phenylketonuria
d. Celiac Disease

128. A baby is born precipitously in the ER. The nurses initial action should be to:

a. Establish an airway for the baby

b. Ascertain the condition of the fundus
c. Quickly tie and cut the umbilical cord
d. Move mother and baby to the birthing unit

129. The primary critical observation for Apgar scoring is the:

a. Heart rate
b. Respiratory rate
c. Presence of meconium
d. Evaluation of the Moro reflex

130. When performing a newborn assessment, the nurse should measure the vital
signs in the following sequence:

a. Pulse, respirations, temperature

b. Temperature, pulse, respirations
c. Respirations, temperature, pulse
d. Respirations, pulse, temperature
131.Within three (3) minutes after birth the normal heart rate of the infant may
range between: a. 100 and 180
b. 130 and
170 c. 120
and 160 d.
100 and 130

132.The expected respiratory rate of a neonate within three (3) minutes of birth may be as
high as:

a. 50
b. 60
c. 80
d. 100

133. The nurse is aware that a healthy newborn’s respirations are:

a. Regular, abdominal, 40-50 per minute, deep

b. Irregular, abdominal, 30-60 per minute, shallow
c. Irregular, initiated by chest wall, 30-60 per minute, deep
d. regular, initiated by the chest wall, 40-60 per minute, shallow

134.A nurse in the newborn nursery is monitoring a preterm newborninfant for

respiratory distress syndrome. Which assessment signs if noted in the newborn infant
would alert the nurse to the possibility of this syndrome?

a. Hypotension and Bradycardia

b. Tachypnea and retractions
c. Acrocyanosis and grunting
d. The presence of a barrel chest with grunting
135.Soon after delivery a neonate is admitted to the central nursery. The nursery nurse
begins the initial assessment by

a. auscultate bowel sounds.

b. determining chest circumference.
c. inspecting the posture, color, and respiratory effort.
d. checking for identifying birthmarks.

136. The home health nurse visits the Cox family 2 weeks after hospital discharge. She
observes that the umbilical cord has dried and fallen off. The area appears healed with
no drainage or erythema present. The mother can be instructed to

a. cover the umbilicus with a band-aid.

b. continue to clean the stump with alcohol for one week.
c. apply an antibiotic ointment to the stump.
d. give him a bath in an infant tub now

137. When performing an assessment on a neonate, which assessment finding is most

suggestive of hypothermia?

a. Bradycardia
b. Hyperglycemia
c. Metabolic alkalosis
d. Shivering
138.The nurse is aware that the most common assessment finding in a child with ulcerative
colitis
is:

a. Intense abdominal cramps

b. Profuse diarrhea
c. Anal fissures
d. Abdominal distention

139. When administering an I.M. injection to an infant, the nurse in charge should use
which site?

a. Deltoid
b. Dorsogluteal
c. Ventrogluteal
d. Vastus lateralis

140. When assessing an older adult. The nurse may expect an increase in:

a. nail growth
b. skin turgor
c. urine residual
d. nerve conduction

141. Support the baby's head for the first

a. 6weeks
b. 4 month
c. 3 month
d. 1 year
142. When do u burp a breast fed baby
a. when the baby done eating
b. before you feed
c. after each breast
d. before & after

143. How do u test a bottle temp

a. thermometer
b. inside wrist
c. you do not taste it
d. on your hand
144. What do you use to wash baby eyes
a. face cloth
b. cotton ball
c. towel
d. toilet paper
145. when do congenital disability happen
a. before birth
b. after birth
c. during labour
d. unknown
146. Which of these theorists believed that people develop through a series of
stages related to age?
a. jean piaget
b. ekick erekson
c. lawren Kohlberg
d. all of the above

147. The four main concepts common to nursing that appear in each of
the current conceptual models are:
a. Person, nursing, environment, medicine
b. Person, health, nursing, support systems
c. Person, health, psychology, nursing
d. Person, environment, health, nursing
148. In Maslow’s hierarchy of physiologic needs, the human need of greatest
priority is:
a. Love
b. Elimination
c. Nutrition
d. Oxygen
149. Which of the following parameters should be checked when
assessing respirations?
a. Rate
b. Rhythm
c. Symmetry
d. All of the above
150. High-pitched gurgles head over the right lower quadrant are:
a. A sign of increased bowel motility
b. A sign of decreased bowel motility
c. Normal bowel sounds
d. A sign of abdominal cramping
151. A patient about to undergo abdominal inspection is best placed in
which of the following positions?
a. Prone
b. Trendelenburg
c. Supine
d. Side-lying
152. For a rectal examination, the patient can be directed to assume which
of the following positions?
a. Genupectoral
b. Sims
c. Horizontal recumbent
d. All of the above
153. During a Romberg test, the nurse asks the patient to assume which
position?
a. Sitting
b. Standing
c. Genupectoral
d. Trendelenburg
154. If a patient’s blood pressure is 150/96, his pulse pressure is:
a. 54
b. 96
c. 150
d. 246
155. Effective hand washing requires the use of:
a. Soap or detergent to promote emulsification
b. Hot water to destroy bacteria
c. A disinfectant to increase surface tension
d. All of the above
156. After routine patient contact, hand washing should last at least:
a. 30 seconds
b. 1 minute
c. 2 minutes
d. 3 minutes
157. The most appropriate time for the nurse to obtain a sputum specimen for
culture is:
a. Early in the morning
b. After the patient eats a light breakfast
c. After aerosol therapy
d. After chest physiotherapy
158. All of the following measures are recommended to prevent pressure ulcers
except:
a. Massaging the reddened area with lotion
b. Using a water or air mattress
c. Adhering to a schedule for positioning and turning
d. Providing meticulous skin care
 159. Which of the following blood tests should be performed
before a blood transfusion?
a. Prothrombin and coagulation time
b. Blood typing and cross-matching
c. Bleeding and clotting time
d. Complete blood count (CBC) and electrolyte levels.
160. The primary purpose of a platelet count is to evaluate the:
a. Potential for clot formation
b. Potential for bleeding
c. Presence of an antigen-antibody response
d. Presence of cardiac enzymes
161. plan of care that identifies the specific needs of the client and that needs
will be addressed by the healthcare system or skilled nursing facility is
a. Health identification
b. Health assessment
c. Health examination
d. Disease identification
e. Patients assessment
162. The process in which diseases detect early in people that may look and feel
well is called
a. Medical assessment
b. Disease assessment
c. Investigation of disease
d. Health assessment
e. Health care
163. Nurses use physical assessment skills to
a. To identify and manage a variety of patient problems
b. To discharge the patient from hospital
c. To collect the health history
d. To realize the patient importance to relatives
e. To enhance the quality of care
164. When a client have a complain of severe headache a nurse assess that it is
a. Objective data
b. Subjective data
c. Client history
d. Chief complain
e. Present complain
 165. A patient admit in general ward and have a complain of vertigo a
nurse check blood pressure and inform to doctor it is called
a. Subjective data
b. Take vital sign of client
c. Health history
d. Objective data
e. duty of nurse

166. A seated position back unsupported and legs hanging freely is

a. Dorsal recumbent
b. Supine
c. Sims
d. Lithotomy
e. Sitting
167. Lies on abdomen with head torn to the side, with or without a small pillow
this is
a. Supine position
b. Lithotomy position
c. Horizontal recumbent position
d. Prone position
e. Sims position
168. A assessment technique in which critical observation of client done
without touching by nurse or health care provider is
a. Inspection
b. Palpation
c. Percussion
d. Auscultation
e. Objective data
169. During assessment a sounds produced by striking body surface of
individual this step of technique is called
a. Subjective data
b. Objective data
c. Inspection
d. Percussion
e. Diagnostic procedure
170. A Stethoscope is used to listening the sounds produced by the body of
patient or individual this technique is called
a. Inspection
b. Palpation
c. Percussion
d. Auscultation
e. Physical examination
171. During the physical examination a lubricant like xylocain jell or liquid
paraffin is used to
a. Ease the insertion of instrument
b. Visualize the body part
c. Heal the injury
d. Enhance the client’s complain
e. Document the main complain of patient
172. A physical examination in which tongue blades ( depressor) is used
a. To depress the tongue during assessment of nose and throat
b. To depress the tongue during assessment of mouth and larynx
c. To depress the tongue during assessment of mouth and pharynx
d. To depress the tongue during assessment of mouth and esophagus
e. To elevate the tongue during assessment of mouth and pharynx
173. Vaginal speculum is used to assess the
a. ovary
b. fallopian tube
c. Uterus
d. Cervix & vagina
e. Urethra
174. During assessment a lighted instrument is used to visualize the anterior of
eye is called
a. Otoscope
b. Stethoscope
c. Laryngoscope
d. Nasal speculum
e. Ophthalmoscope
175. When client have a complain of congested chest and sounds are audible
without stethoscope it is
a. Direct auscultation
b. Indirect auscultation
c. Inspection
d. Percussion
e. Palpation

176. Acknowledging the patient’s verbal and nonverbal communication

conveys true interest and encourages further communication by
a. History taking
b. Interview
c. Data collection
d. Subjective data
e. Objective data
177. Otitis media is an
a. Inflammation of external ear
b. Inflammation of middle ear
c. Inflammation of inner ear
d. Inflammation of nasal cavity
e. Inflammation of oral cavity
178. The interviews require less time and are very effective for obtaining
factual data with specific questions and are controlled by the nurse
a. Interview
b. Directive interview
c. Nondirective interview
d. History taking step
e. Open-ended question
179. In interview elicit a “yes” or “no” response, to client this type of question
are
a. Open question
b. Closed question
c. Direct question
d. Indirect question
e. Simple question
180. The time during which a female is menstruating
a. Menopause
b. Menstrual period
 c. Last menstrual period
d. Expected date of menstruation
e. Irregular cycle
181. X-ray of breast
a. Mammogram
b. Digital x-ray
c. Ct-scan
d. MRI
e. Barium scan
182. The process of identification of the condition, needs, abilities and
preferences of a patient is
a. Nursing assessment
b. Patient assessment
c. Medical assessment
d. Professional assessment
e. Physical assessment
183. The process gathering of information about a patient's physiological,
psychological, sociological, and spiritual status in
a. Nursing assessment
b. Patient assessment
c. Medical assessment
d. Professional assessment
e. Physical assessment
184. When Blanch Test is performed and nails pressed between the fingers the
nails return to usual color in less than
a. 4 seconds
b. 6 seconds
c. 8 second
d. 2 second
e. 3 second

185. The thyroid gland is not visible during the

a. Inspection
b. Palpation
c. Percussion
d. Auscultation
e. Surgery
186. Patient was able to read the newsprint at a distance of
a. 8 inche
b.
s 10
c.
d. inches
e. 12
inches
20
inches
25
inches

187. Able to hear ticking on right ear at a distance of one inch and was able to
hear the ticking on the left ear at the same distance this assessment test is
called
a. Hearing Acuity Test
b.
Watch Tick Test
c.
d. Blanch Test
e. Weber test
Assessment test
188. An instrument used to measure the B.P of client is called
a. Stethoscope
b. Otoscope
c. Ophthalmoscope
d. Sphygmomanometer
e. Laryngoscope
189. The sweat to reduce the body temperature is eliminated by
a. Sweats gland
b. Apocrine gland
c. Eccrine gland
d. Thyroid gland
e. Hypothalamus gland

190. For the detection of hearing loss an instrument in physical examination is

called
a. Otoscope
b. Ophthalmoscope
c. Hammer
d. Tuning fork
e. Speculum
191. Cleft palate is a congenital defect where the maxillary process fails to
fuse. This causes a gap in the
a. hard palate and possibly the lower lip
b. soft palate and possibly the upper lip
c. hard palate and possibly the upper lip
d. hard palate and possibly the corner of lip
e. hard palate and possibly the mucous part of lip
192. A 70-year-old woman complains of dry mouth. The most frequent cause
of this problem is:
a. The aging process
b. Related to medications she may be taking
c. The use of dentures
d. Related to a diminished sense of smell
e. Atrophy of esophagus
193. 72-year-old client is considered a normal process or aging the most
common complain
a. My tongue feels swollen.”
b. “My tonsils are large and sore.”
c. “I have white and black spots under my tongue.”
d. “Food does not taste the same as it used to.”
e. insomnia
194. A technique in which the hands and fingers are used to gather
information by touch or it may be either superficial or deep
a. Inspection
b. Palpation
 c. Percussion
d. Auscultation
e. Physical examination
195. During physical examination when using the stethoscope its exact
position between
a. index and little fingers
b. thumb and all four fingers
c. index and ring fingers
d. thumb and index fingers
e. index and middle fingers
196. Occipital lobe of brain is said to be
a. memory storage center
b. Emotions control center
c. Visual center
d. Interpretation of sensory center
e. Auditory center

197. Name, Date of Birth, Age, Parents & siblings information of client are
gather in
a. Present history
b. Past medical history
c. Bio-graphic data
d. Health history
e. Interview
198. When a nurse performed the physical examination of abdomen the
sequence of examination should be
a. Inspection, auscultation, Percussion, palpation
b. Inspection, palpation ,Percussion, , auscultation,
c. auscultation , Inspection, , Percussion, palpation
d. Percussion, Inspection, auscultation, palpation
e. Palpation, Inspection, auscultation, Percussion,
199. The appropriate time to collect a urine specimen from a patient Is
a. before the physical examination
b. any time the patient feels he can provide a specimen
c. during the examination
d. after the examination
e. after follow up
200. The best examination position for the physician to evaluate the patient's
ability to fully expand the lungs is the
a. Sitting position
b. Prone position
c. Lithotomy position
d. knee-chest position
e. Fowler's position
201. A patient who has low blood pressure or is in shock would be placed in a
a. Sitting position
b. Prone position
c. Lithotomy position
d. knee-chest position

e. Trendelenburg position

203. The normal range for body temperature is

a. 96°F to 98°F
b. 97°F to 99°F
c. 98°F to 99°F
d. 97°F to 100.4°F
e. 96°F to 97 °F
204. A temperature of 103°F is classified as
a. Normal
b. Hypo pyrexia
c. Hyper pyrexia
d. Low-grade fever
e. Pyrexia
205. One respiration consists of
a. One inhalation
b. One exhalation
c. One inhalation and one exhalation
d. The opening and closing of the valves of the heart
e. The opening and closing of the pulmonary valves of the lungs
206. The normal respiratory rate of an adult ranges from:
a. 8 to 16 respirations per minute
b. 10 to 18 respirations per minute
c. 12 to 20 respirations per minute
d. 16 to 22 respirations per minute
e. 14 to 20 respirations per minute
207. The abbreviation used to record oxygen saturation as measured by a
pulse oximeter is:
a. SaO2
b. PCO2
c. PO2
d. SpO2
e. SpO4
208. Blood pressure is measured in:
a. Units
b. Degrees
c. Beats/min
d. Millimeters of mercury
 e. Nanometer
209. Over which artery is the stethoscope placed when taking blood pressure:
a. Radial
b. Brachial
c. Apical
d. Carotid
e. Femoral
210. When measuring blood pressure, the patient’s arm should be positioned
a. Above heart level
b.
At heart level
c.
d. Across the chest
e. With the palm facing downward
With the palm facing upward
211. The term used to describe the point of lesser pressure on the arterial
walls when assessing blood pressure:
a. Systolic pressure
b.
Diastolic pressure
c.
d. Diastole
e. Hypotension
Pulse pressure
212. Which Of The Following Statements Is True Regarding The Internal
Structures Of The Breast? The Breast Is:

a. Mainly Muscle, With Very Little Fibrous Tissue.

b. Composed Of Fibrous, Glandular, And Adipose Tissue.
c. Composed Mostly Of Milk Ducts, Known As Lactiferous Ducts.
d. Composed Of Glandular Tissue, Which Supports The Breast By Attaching To The Chest
Wall.
e. Epithelial tissue that play a role of support

213. In performing a breast examination, the nurse knows that it is especially

important to examine the upper outer quadrant of the breast. The reason
for this is that the upper outer quadrant is:

a. the largest quadrant of the breast

b. the location of most breast tumors
c. where most of the suspensory ligaments attach
d. more prone to injury and calcifications than other locations in the breast
e. Non grandular tissue
 214. In performing an assessment of a woman's axillary lymph system, the
nurse should assess which of these nodes?
a. Central, axillary, lateral, and sternal nodes
b. Pectoral, lateral, anterior, and sternal nodes
c. Central, lateral, pectoral, and subscapular node
d. Lateral, pectoral, axillary, and suprascapular nodes
e. Medial , pectoral axillary node

215. If a patient reports a recent breast infection, then the nurse should expect
to find
_____ node enlargement.

a. nonspecific
b. ipsilateral axillar
c. contralateral axillary
d. inguinal and cervical
e. Contra lateral specific

216. A 9-year-old girl is in the clinic for sports physical. After some initial
shyness she finally asks, "Am I normal? I don't seem to need a bra yet, but
I have some friends who do. What if I never get breasts?" The nurse's best
response would be:

a. “Don't worry, you still have plenty of time to develop."

b. "I know just how you feel; I was a late bloomer myself. Just be patient and they will
grow."
c. "You will probably get your periods before you notice any significant growth in your
breasts."
d. "I understand that it is hard to feel different from your friends. Breasts
usually develop between 8 and 10 years of age."
e. You will probably get your periods after you notice any significant growth in your breasts

217. A patient contacts the office and tells the nurse that she is worried about
her 10-year-old daughter having breast cancer. She describes a unilateral
enlargement of the right breast with associated tenderness. She is worried
because the left breast is not enlarged. What would be the nurse's best
response?

a. Tell the mother that breast development is usually fairly symmetric and she should be
examined right away.
b. Tell the mother that she should bring her daughter in right away because breast
cancer is fairly common in preadolescent girls
c. Tell the mother that, although an examination of her daughter would rule out a
problem, it is most likely normal breast development.
d. Tell the mother that it is unusual for breasts that are first developing to feel tender
because they haven't developed much fibrous tissue.
e. Tell the doctor that it is unusual for breasts that are first developing to feel tender
because they haven't developed much connective issue
 218. In examining a 70-year-old male patient, the nurse notices that he has
bilateral gynecomastia. Which of the following describes the nurse's best
course of action?

a. Recommend that he make an appointment with his physician for a mammogram.

b. Ignore it; it is not unusual for men to have benign breast enlargement.
c. Explain that this condition may be the result of hormonal changes and
recommend that he see his physician.
d. Tell him that gynecomastia in men is usually associated with prostate
enlargement and recommend that he be screened thoroughly.
e. Do not Ignore it; it is not unusual for men to have benign breast enlargement

219. During an examination of a 7-year-old girl, the nurse notices that

the girl is showing breast budding. What should the nurse do next?

a. Ask her if her periods have started.

b. Assess the girl's weight and body mass index (BMI).
c. Ask the girl's mother at what age she started to develop breasts.
d. Nothing; this is a normal finding
e.Ask the girl's mother at what age she started menstrual cycle

220. The nurse is preparing for a class in early detection of breast cancer.
Which statement is true with regard to breast cancer in African-
American women in the United States?

a. Breast cancer is not a threat to African-American women.

b. African-American women have a lower incidence of regional or distant breast cancer
than white women.
c. American women are more likely to die of breast cancer at any age.
d. Breast cancer incidence in African-American women is higher than that of white women
after age
e. Breast cancer incidence in African-American women is lower than that of white women
after age

221. During a breast health interview, a patient states that she has noticed
pain in her left breast. The nurse's most appropriate response to this
would be:

a. "Don't worry about the pain; breast cancer is not painful."

b. “I would like some more information about the pain in your left breast."
c. “Oh, I had pain like that after my son was born; it turned out to be a blocked milk duct."
d. “Breast pain is almost always the result of benign breast disease."
e. “Breast pain is almost always the result of malignancy breast disease."
 141. During a history interview, a female patient states that she has noticed a
few drops of clear discharge from her right nipple. The nurse should do
next?

a. Contact the physician immediately to report the discharge.

b. Ask her if she is possibly pregnant.
c. Ask her some additional questions about the medications she is taking.
d. Immediately obtain a sample for culture and sensitivity testing.
f. .Ask her if she is missed abort fetus

141. A forecast of the probable course and outcome of the disorder and the
prospects for recovery is the

a. Clinical diagnosis.
b. physical examination
c. prognosis
d. Differential diagnosis.
e. Gross examination

142. The appropriate time to collect a urine specimen from a patient is

a. Before the physical examination.

b. any time the patient feels he can provide a specimen.
c. During the examination.
d. after the examination
e. after the duty of staff nurse

143. Physicians perform general physical examinations for what purposes?

a. to obtain information about the patient's educational and social history

b. to examine a healthy patient to confirm an overall state of health and to provide
baseline values for vital signs and mensuration
c. to order laboratory and x-ray tests in order to make a differential diagnosis
d. to obtain information about the patient's financial status
e. to obtain the information about the patient personal information

144. The best examination position for the physician to evaluate the patient's
ability to fully expand the lungs is the ____ position.

a. Sitting
b. Prone
c. Lithotomy
d. knee-chest
e. dorsal recumbent
 145. Another name for the supine position is the ____ position

a. Lithotomy
b. Sims'
c. knee-chest
d. recumbent
e. prone

146. A patient is supine on a tilted table with the head lower than the legs in a
____
position

a. Prone
b. Fowler's
c. Trendelenburg
d. Lithotomy
e. Supine

147. In which position does the patient lie flat on the examination table,
facedown, with the head turned to one side and the arms placed at the
sides or bent at the elbows?

a. Supine
b. Fowler's
c. Prone
d. Trendelenburg
e. Proximal

148. In which examination position does the patient lie on his back with his
knees drawn up and his feet flat on the table?
a. Prone
b. dorsal recumbent
c. Fowler's
d. Sims'
e. Lithotomy

149. A patient who has low blood pressure or is in shock would be placed in a
____
position.

a. Trendelenburg
b. prone
c. supine
d. Fowler's
e. Sami Fowler's
 150. Approximately how long does it take for a spermatocyte to
complete its differentiation into a spermatozoa in the testis?

a. 7 hour
b. 70days
c. 7 day
d. 72hours
e. 24 hour

151. Cervical mucus becomes thin and stretchy under the influence of
__________

a. Hotness
b. Estrogen
c. Progesterone
d. FSH
e. LH

152. The gonadotrophins FSH and LH are secreted by the _______ lobe of the
pituitary gland

a. Anterior
b. Posterior
c. Medulaoblingata
d. Pons
e. Thyroid

153. The first line of treatment in a chemical injury is

a. Admission if sever
b. Topical antibiotic
c. Topical cycloplegia
d. Neutralization of PH by irrigation
e. Oral analgesia

154. The commonest cause of cataract is

a. Truma
b. Diabetic
c. TORCH infection
d. Old age
e. Childhood disease
 155. Condition in which image is formed behind retina is called

a. Farsightedness
b. Nearsightedness
c. image defect
d. blind spottinge
e. myopia

237. Condition in which image is formed in front of retina is called

a. Farsightedness
b. Defect of vision
c. nearsightedness
d. blind spotting
e. emmetropia

238. Inability of eye to see objects clearly is called

a. clarity of image
b. Defect of vision
c. blur image
d. small image
e. myopia
239. Short sightedness can be corrected if
a. converging glasses are used
b. converging mirror is used
c. diverging mirror is used
d. diverging glasses is used
e. eye drops
240. during physical examination when using the stethoscope its exact
position between
a. index and little fingers
b. thumb and all four fingers
c. index and ring fingers
d. thumb and index fingers
e. index and middle fingers

241. . A plan of care that identifies the specific needs of the client and that
needs will be addressed by the healthcare system or skilled nursing facility
is
a. Health identification
b. Health assessment
c. Health examination
d. Disease identification
e. Patients assessmen

242. The process in which diseases detect early in people that may look
and feel well is called
a. Medical assessment
b. Disease assessment
c. Investigation of disease
d. Health assessment
e. Health care
243. Nurses use physical assessment skills to

a. To identify and manage a variety of patient problems

b. To discharge the patient from hospital
c. To collect the health history
d. To realize the patient importance to relatives
e. To enhance the quality of care
244. When a client have a complain of severe headache a nurse assess that
it is

a. Objective data
b. Subjective data
c. Client history
d. Chief complain
e. Present complain
245. A patient admit in general ward and have a complain of vertigo
a nurse check blood pressure and inform to doctor it is called

a. Subjective data
b. Take vital sign of client
c. Health history
d. Objective data
e. duty of nurse

246. A seated position back unsupported and legs hanging freely is

a. Dorsal recumbent
b. Supine
c. Sims
d. Lithotomy
e. Sitting

247. Lies on abdomen with head torn to the side, with or without a small
pillow
this is

a. Supine position
b. Lithotomy position
c. Horizontal recumbent position
d. Prone position
e. Sims position

248. A assessment technique in which critical observation of client done

without touching by nurse or health care provider is

a. Inspection
b. Palpation
c. Percussion
d. Auscultation
249. Objective data
250. During assessment a sounds produced by striking body
surface of individual this step of technique is called

a. Subjective data
b. Objective data
c. Inspection
d. Percussion
e. Diagnostic procedure

251. A Stethoscope is used to listening the sounds produced by the

body of patient or individual this technique is called

a. Inspection
b. Palpation
c. Percussion
d. Auscultation
e. Physical examination

252. During the physical examination a lubricant like xylocain jell

or liquid paraffin is used to

a. Ease the insertion of instrument

b. Visualize the body part
c. Heal the injury
d. Enhance the client’s complain
e. Document the main complain of patient
253. A physical examination in which tongue blades ( depressor) is used

a. To depress the tongue during assessment of nose and throat

b. To depress the tongue during assessment of mouth and larynx
c. To depress the tongue during assessment of mouth and pharynx
d. To depress the tongue during assessment of mouth and esophagus
e. To elevate the tongue during assessment of mouth and pharynx
254. Vaginal speculum is used to assess the

a. ovary
b. fallopian tube
c. Uterus
d. Cervix & vagina
e. Urethra
255. During assessment a lighted instrument is used to visualize the
anterior of eye is called

a. Otoscope
b. Stethoscope
c. Laryngoscope
d. Nasal speculum
e. Ophthalmoscope

256. When client have a complain of congested chest and sounds are
audible without stethoscope it is

a. Direct auscultation
b. Indirect auscultation
c. Inspection
d. Percussion
e. Palpation

257. Acknowledging the patient’s verbal and nonverbal communication

conveys true interest and encourages further communication by

a. History taking
b. Interview
c. Data collection
d. Subjective data
e. Objective data
258. Otitis media is an

a. Inflammation of external ear

b. Inflammation of middle ear
c. Inflammation of inner ear
d. Inflammation of nasal cavity
e. Inflammation of oral cavity
259. The interviews require less time and are very effective for obtaining
factual data with specific questions and are controlled by the nurse

a. Interview
b. Directive interview
c. Nondirective interview
d. History taking step
e. Open-ended question
260. In interview elicit a “yes” or “no” response, to client this type of
question are

a. Open question
b. Closed question
c. Direct question
d. Indirect question
e. Simple question

261. The time during which a female is menstruating

a. Menopause
b. Menstrual period
c. Last menstrual period
d. Expected date of menstruation
e. Irregular cycle

262. X-ray of breast

a. Mammogram
b. Digital x-ray
c. Ct-scan
d. MRI
e. Barium scan

263. The process of identification of the condition, needs,

abilities and preferences of a patient is

a. Nursing assessment
b. Patient assessment
c. Medical assessment
d. Professional assessment
e. Physical assessment

264. The process gathering of information about a patient's

physiological, psychological, sociological, and spiritual status in

a. Nursing assessment
b. Patient assessment
c. Medical assessment
d. Professional assessment
e. Physical assessment
265. When Blanch Test is performed and nails pressed between the
fingers the nails return to usual color in less than
a. 4 seconds
b. 6 seconds
c. 8 second
d. 2 second
e. 3 second

266. The thyroid gland is not visible during the

a. Inspection
b. Palpation
c. Percussion
d. Auscultation
e. Surgery

267. Patient was able to read the newsprint at a distance of

a. 8 inches
b. 10 inches
c. 12 inches
d. 20 inches
e. 25 inches

268. Able to hear ticking on right ear at a distance of one inch and was
able to hear the ticking on the left ear at the same distance this assessment
test is called

a. Hearing Acuity Test

b. Watch Tick Test
c. Blanch Test
d. Weber test
e. Assessment test

269. An instrument used to measure the B.P of client is called

a. Stethoscope
b. Otoscope
c. Ophthalmoscope
d. Sphygmomanometer
e. Laryngoscope
270. The sweat to reduce the body temperature is eliminated by

a. Sweats gland
b. Apocrine gland
c. Eccrine gland
d. Thyroid gland
e. Hypothalamus gland

271. For the detection of hearing loss an instrument in physical

examination is
called

a. Otoscope
b. Ophthalmoscope
c. Hammer
d. Tuning fork
e. Speculum

272. When do coronary arteries primarily receive blood flow?

a. During inspiration
b. During diastole
c. During expiration
d. During systole
273. Which of the following illnesses is the leading cause of death in the
US?
a. Cancer
b. Coronary artery disease
c. Liver failure
d. Renal failure
274. What is the term used to describe an enlargement of the heart
muscle?
a. Cardiomegaly
b. Cardiomyopathy
c. Myocarditis
d. Pericarditis
 275. Dyspnea, cough, expectoration, weakness, and edema are classic
signs and symptoms of which of the following conditions?
a. Pericarditis
b. Hypertension
c. Obliterative
d. Restrictive
276. Which of the following types of cardiomyopathy does not affect
cardiac
output?
a. Dilated
b. Hypertrophic
c. Restrictive
277.Obliterative

278. What is the definitive test used to diagnose an abdominal aortic aneurysm?

a. Abdominal X-ray
b. Arteriogram
c. CT scan
d. Ultrasound
279. When bathing a patient’s extremities, the nurse should use long, firm
strokes from the distal to the proximal areas. This technique:
a. Provides an opportunity for skin assessment
b. Avoids undue strain on the nurse
c. Increases venous blood return
d. Causes vasoconstriction and increases circulation
280. Vivid dreaming occurs in which stage of sleep?
a. Stage I non-REM
b. Rapid eye movement (REM) stage
c. Stage II non-REM
d. Delta stage
281. The natural sedative in meat and milk products (especially warm
milk) that can help induce sleep is:
a. Flurazepam
b. Temazepam
c. Tryptophan
d. Methotrimeprazine
282. Which of the following is the nurse’s legal responsibility when
applying restraints?
a. Document the patient’s behavior
b. Document the type of restraint used
c. Obtain a written order from the physician except in an emergency,
when the patient must be protected from injury to himself or others
d. All of the above

283. Kubler-Ross’s five successive stages of death and dying are:

a. Anger, bargaining, denial, depression, acceptance
b. Denial, anger, depression, bargaining, acceptance
c. Denial, anger, bargaining, depression acceptance
d. Bargaining, denial, anger, depression, acceptance
284. In which step of the nursing process does the nurse analyze
data and identify client problems?
a. Assessment
b. Diagnosis
c. Planning outcomes
d. Evaluation

285. In which phase of the nursing process does the nurse decide
whether her actions have successfully treated the client’s health problem?
a. Assessment
b. Diagnosis
c. Planning outcomes
d. Evaluation
286. What is the most basic reason that self-knowledge is important for
nurses? Because it helps the nurse to:
a. Identify personal biases that may affect his thinking and actions
b. Identify the most effective interventions for a patient
c. Communicate more efficiently with colleagues, patients, and families
d. Learn and remember new procedures and techniques
287. The nurse is assessing a patient admitted to the hospital with
rectal bleeding. The patient had a hip replacement 2 weeks ago. Which
position should the nurse avoid when examining this patient’s rectal
area?
a. Sims’
b. Supine
c. Dorsal recumbent
288. Semi-Fowler’s

289. How should the nurse modify the examination for a 7-year-old child?
a. Ask the parents to leave the room before the examination.
b. Demonstrate equipment before using it.
c. Allow the child to help with the examination.
d. Perform invasive procedures (e.g., otoscopic) last.
290. The nurse must examine a patient who is weak and unable to sit
unaided or to get out of bed. How should she position the patient to begin and
perform most of the physical examination?
a. Dorsal recumbent
b. Semi-Fowler’s
c. Lithotomy
d. Sims’
291. The nurse should use the diaphragm of the stethoscope to auscultate
which of the following?
a. Heart murmurs
b. Jugular venous hums
c. Bowel sounds
 d. Carotid bruits
292. The nurse calculates a body mass index (BMI) of 18 for a young
adult woman who comes to the physician’s office for a college physical.
This patient is considered:
a. Obese
b. Overweight
c. Average
d. Underweight
293. Nurse Aaron is inserting a nasogastric tube to a stroke
client. He understands that the best position for the insertion is?
a. Low Fowlers.
b. Sims position.
c. Trendelenburg.
d. High Fowlers.

294. Nurse Monica is handling a female client who had undergone a

mastectomy. Which is the best position in which she should place the client?
a. Head of bed elevated at least 30° with the affected arm elevated on a
pillow.
b. Forward side-lying position.
c. Supine position with the affected arm remain flat.
d. Head of bed elevated at least 30° with the unaffected arm elevated on a
pillow.
295. A nurse is caring for a client with severe burns of the face and
head. The nurse will place the client in which position?
a. Trendelenburg.
b. Head of bed elevated.
c. Supine position.
d. Prone position.
296. Which of the following does not match with the appropriate position?
a. Vaginal examination: lithotomy position.
b. Thyroidectomy: fowler’s position.
c. Hemorrhoidectomy: lateral position
 d. Hypophysectomy: Prone position.
297. Nurse Ian is handling a client with gastroesophageal reflux disease.
Which of the following position will best help the client in this case?
a. Right Lateral Recumbent.
b. Supine position.
c. Reverse Trendelenburg position.
d. Sims position.
298. A client with pleural effusion is scheduled to have a
thoracentesis. The nurse on duty will assists the client to which position
during the procedure?
a. Lying in bed on the unaffected side with head of bed elevated about
45°.
b. Forward side lying position with head of bed flat.
c. Lying in bed on the affected side with head of bed elevated about 45°.
d. Supine position with both arms extended.
299. Nurse Maria is administering a cleansing enema to a client with
severe constipation. She will place the client in which position?
a. Low fowlers position.
b. High fowlers position.
c. Left Sim’s position.
d. Right Sim’s position.
300. What type of client would benefit the most from an elevated head of
the bed position?
a. Patient who had a hemorrhoidectomy.
b. Patient who had a laryngectomy.
c. Patient who had a liver biopsy.
d. Patient who had a lumbar puncture.
301. Nurse Justin is taking care a client with deep vein thrombosis.
Which position should be provided to the client?
a. Bed rest with the affected extremity remain flat at all times.
b. Bed rest with the unaffected extremity on top of the affected extremity.
c. Bed rest with the affected extremity in a dependent position.
d. Bed rest with the affected extremity elevated.
302. Nurse Sandra had just received a postoperative total hip
replacement client from the recovery unit. Which is the best position in
which she should place the client?
a. Side-lying with the affected leg externally rotated.
b. Side-lying with the affected leg internally rotated.
c. On the nonoperative side with the legs abducted.
d. On the nonoperative side with the legs adducted.
303. A client has just returned to a nursing unit after a cardiac
catheterization performed using the femoral artery. The nurse places the
client in which position?
a. Bed rest with head elevation at 30°.
b. Bed rest with head elevation at 45°.
c. Bed rest with head elevation at 60°.
d. Bed rest with head elevation at 90°.
304. A nurse is preparing to care for a client who had undergone an
above-knee amputation of the right leg. The nurse plans to allow which
position for the client on the first 24 hours?
a. Supine position, with the affected limb flat on the bed
b. Supine position, with the affected limb supported with pillows.
c. Prone position, with the affected limb on a dependent position.
d. Trendelenburg’s position.
305. A client is to be on a bed rest for 24 hours and the affected
extremity is to be kept straight during this time. Which of the following
procedure would require a client to do the above?
a. Varicose vein surgery.
b. Myelogram
c. Abdominal aneurysm resection.
d. Arterial Vascular Grafting.
306. Which is the best position for a client with autonomic dysreflexia?
a. Sim’s Position.
b. Fowler’s Position.
c. Semi-Fowler’s Position.
d. High Fowler’s Position
 307. A nurse is caring for a client who has returned to the recovery unit
following a craniotomy. The nurse can safely place the client in which of the
position?
a. Trendelenburg position.
b. Fowler’s position with the head leaning on the left side.
c. Semi-fowlers position with the head in a midline position.
d. Supine position with the neck flexed.
308. Vital signs include, blood pressure, Pulse, Temp. Resp. rate &
Oxygen saturation
a. true
b. false
309. Where temperature is is regulated?
a. hypothalamus
b. skin
c. heat & cold
d. by what a person wear
310. What is the normal range of temperature?
a. 36.6 to 37.5c
b. 34 to 36c
c. 34.6 to 36c
d. 35.6 to 38

311. What is the normal pulse rate?

a. 12-20
b. 15-20
c. 60-100
d. 50-80
312. A weak pulse is rated as
a. 0
b. 1+
c. 2+
d. 3+
e. 4+
313. A person that is dehydrated will experience a low B/P
a. true
b. false
314. What factor does not influence Resp. rate?
a. age
b. gender
 c. smoking
d. medication
e. pain
315. tuning fork use for
a. to check the vision
b. to check the throat
c. to assess the chest
d. for various clinical test for hearing loss, vibration sense test

316. Myringotome use to

a. remove the eyelids
b. cut the ear drum
c. cut the bonecut the skin

317. which instrument use to assess the otitis media of patient

a. opthalmoscope
b. otoscope
c. stethoscope
d. laryngoscope

318. how longer should you wash your hand

a. 5-10sec
b. 10-15sec
c. 20 sec
d. 2-3sec
319. fundoscopic exam is exam of the
a. ear
b. nose
c. eye
d. heart
320. at the end of examination nurse should
a. document all finding
b. review finding with patient
c. call to doctor
d. call to attendant
321. there are ________ pair of cranial nerve
a. 20
b. 12
c. 13
d. 31
322. glasgow coma scale use to
a. assess the person activity
b. assess the level to consciousness
c. assess the exercise pattern
d. assess the range of motion

323. MSE means

a. mind state examination
b. mini sense examination
c. mental state examination
d. major social examination