A nursing student is outlining her plan for completing an abdominal assessment. Which statement indicates a need for further teaching?
A. “I will inspect the abdomen first for contour and symmetry.”
B. “I will auscultate bowel sounds before palpating the abdomen.”
C. “I will percuss the abdomen and then palpate for tenderness.”
D. “I will percuss, palpate, and then auscultate the abdomen.”
D. “I will percuss, palpate, and then auscultate the abdomen.”
Rationale: The correct order for abdominal assessment is inspect → auscultate → percuss → palpate. Auscultation must be performed before percussion and palpation because these actions can stimulate bowel sounds, leading to inaccurate findings.
A nurse elicits tenderness at both costovertebral angles during an abdominal assessment. This finding is most indicative of which condition?
A. Liver inflammation
B. Bladder distention
C. Kidney inflammation or infection
D. Intestinal obstruction
C. Kidney inflammation or infection
Rationale: Costovertebral angle (CVA) tenderness is associated with kidney pathology, most commonly inflammation or infection such as pyelonephritis. It is assessed by percussion over the area where the kidneys are located in the back.
A nursing student is performing a neurological assessment on a patient. Which statement indicates the student is performing the assessments correctly?
A. “I will let the client look at the object before identifying it to make it easier.”
B. “I will ask the client to close their eyes while identifying the object and tracing the number.”
C. “It doesn’t matter if the client sees the number traced on the palm.”
B. “I will ask the client to close their eyes while identifying the object and tracing the number.”
Rationale: Stereognosis and graphesthesia test cortical sensory function, which requires tactile perception without visual input. Allowing the client to see the object or number would invalidate the assessment.
During a pediatric musculoskeletal assessment, a nurse observes that a child’s knees remain wide apart when the ankles are together. Which term describes this finding?
A. Genu valgum
B. Genu varum
C. Pes planus
D. Clubfoot
B. Genu varum
Rationale: Genu varum (“bowlegs”) is when knees angle outward while ankles stay together. Genu valgum (“knock-knees”) occurs when knees angle inward and touch while ankles are apart. Pes planus is the terms for flat feet. Clubfoot is a congenital foot deformity with inward rotation.
These are dry, flaky patches of skin caused by shedding of dead keratinized cells, often seen in conditions like eczema or psoriasis.
What are scales?
Rationale: Scales=flaky keratin
A nurse assesses four patients’ abdominal contours. Which finding requires priority follow-up?
A. A toddler with a protuberant abdomen
B. A postpartum client with a slightly protuberant abdomen and active bowel sounds
C. A client with a distended, firm abdomen and hypoactive bowel sounds
D. A client with a rounded abdomen that is soft and non-tender
C. A client with a distended, firm abdomen and hypoactive bowel sounds
Rationale: A distended, firm abdomen with hypoactive bowel sounds may indicate a serious condition such as bowel obstruction, ileus, or fluid accumulation, requiring prompt evaluation.
A nursing student is reviewing management strategies for a patient with stress incontinence. Which statement by the student indicates a need for further teaching?
A. “Kegel exercises can help strengthen pelvic floor muscles to reduce leakage.”
B. “I will encourage the client to empty the bladder regularly and avoid constipation.”
C. “Limiting fluid intake to very small amounts will resolve your stress incontinence.”
D. “I will educate the client about bladder training and timed voiding.”
C. “Limiting fluid intake to very small amounts will resolve your stress incontinence.”
Rationale: Stress incontinence is caused by weak pelvic floor muscles or urethral sphincter incompetence, not excessive fluid. Fluid restriction can lead to urinary tract infections and dehydration, and will not resolve stress incontinence. Correct interventions include pelvic floor exercises, bladder training, timed voiding, and managing constipation.
A nurse is assessing a client who had a left-sided stroke. The client understands questions but struggles to form words, often speaking in short, fragmented sentences. Which type of aphasia is most consistent with these findings?
A. Receptive aphasia
B. Expressive aphasia
C. Dysarthria
D. Dyshagia
B. Expressive aphasia
Rationale: Expressive aphasia (Broca’s aphasia) is caused by lesions in the left frontal lobe. Patients understand language but have difficulty producing speech.
During a postural assessment, a nurse observes the following:
Match each observation with the correct term.
A. 1 = Kyphosis, 2 = Scoliosis, 3 = Lordosis
B. 1 = Lordosis, 2 = Scoliosis, 3 = Kyphosis
C. 1 = Scoliosis, 2 = Kyphosis, 3 = Lordosis
D. 1 = Kyphosis, 2 = Lordosis, 3 = Scoliosis
B. 1 = Lordosis, 2 = Scoliosis, 3 = Kyphosis
Rationale: Lordosis is the inward curvature of the lumbar spine. Scoliosis is lateral curvature of the spine. Kyphosis is outward curvature of the thoracic spine.
These are dried residues of serum, blood, or pus on the skin surface, commonly observed in healing lesions or infections like impetigo.
What are crusts?
Rationale: Crusts=dried exudate, scabs
A nurse auscultates a patient's abdomen and does not hear any bowel sounds after 1 minute in the right lower quadrant. What is the nurse’s best next action?
A. Document absent bowel sounds
B. Reassess the same quadrant for up to 5 minutes
C. Notify the provider immediately
D. Proceed with palpation to stimulate bowel activity
B. Reassess the same quadrant for up to 5 minutes
Rationale: Bowel sounds are irregular, so the nurse must listen for at least 5 minutes before determining they are absent.
A 70-year-old patient reports waking 2–3 times per night to urinate but has no daytime incontinence or urgency. Which assessment consideration is most appropriate?
A. This is normal aging, and no further evaluation is needed
B. Assess for underlying conditions such as heart failure, diabetes, or bladder obstruction
C. Recommend limiting fluids during the day only
D. Teach the client Kegel exercises to reduce nighttime voiding
B. Assess for underlying conditions such as heart failure, diabetes, or bladder obstruction
Rationale: Nocturia (waking at night to urinate) may indicate heart failure, diabetes mellitus, or bladder obstruction.
What is the term for this?
During a cognitive assessment, a nurse asks a patient, “What does the saying 'People who live in glass houses shouldn’t throw stones’ mean?” The client responds: "It means you should avoid breaking windows.” Which conclusion is most appropriate?
A. The client demonstrates intact abstract reasoning.
B. The client demonstrates impaired abstract reasoning.
C. The client has impaired memory, not reasoning.
D. The client has expressive aphasia.
B. The client demonstrates impaired abstract reasoning.
Rationale: Abstract reasoning assesses the ability to understand concepts, analogies, and proverbs beyond literal meaning. Misinterpreting a proverb literally may indicate frontal lobe or higher cortical dysfunction.
A nursing student is assessing a patient's shoulder range of motion. Which statement indicates the student understands abduction and adduction correctly?
A. “Abduction is moving the arm toward the body; adduction is moving it away from the midline.”
B. “Abduction is moving the arm away from the midline; adduction is bringing it back toward the body.”
C. “Abduction and adduction only apply to bending joints forward and backward.”
D. “Abduction and adduction can only be assessed in the lower extremities.”
B. “Abduction is moving the arm away from the midline; adduction is bringing it back toward the body.”
Rationale: Abduction is movement away from the midline. Adduction is movement toward the midline (Adding it to your body)
These are raised, pus-filled lesions on the skin, often associated with bacterial infections like acne.
What are pustules?
During an abdominal assessment, a nurse palpates a patient's spleen below the left costal margin. How should the nurse interpret this finding?
A. This is an expected finding in most adults
B. The spleen is likely enlarged and requires further evaluation
C. This indicates normal variation related to respiration
D. The client likely has bladder distention
B. The spleen is likely enlarged and requires further evaluation
Rationale: The spleen is typically not palpable in healthy adults. If the spleen is palpable below the left costal margin, it usually indicates splenomegaly, which may be associated with conditions like infection, liver disease, or hematologic disorders. A palpable spleen is considered abnormal and should be further evaluated. Avoid palpation if known to be enlarged due to risk of rupture.
A nursing student is preparing to perform a bladder scan on a client. Which statement by the student indicates a need for further teaching?
A. “I should ensure the client’s bladder is as empty as possible before scanning.”
B. “The client should be lying flat in bed, and I need to apply the probe just above the pubic symphysis.”
C. “I will place the probe directly over the pubic bone without gel to avoid slipping.”
D. “I should instruct the client to relax and breathe normally during the scan.”
C. “I will place the probe directly over the pubic bone without gel to avoid slipping.”
Rationale: Bladder scans require ultrasound gel to transmit sound waves effectively. Placing the probe directly on skin without gel will give inaccurate readings. The probe is positioned just above the pubic symphysis, not directly on the bone.
A nurse is performing a neurological assessment on an adult patient. When stimulating the lateral aspect of the sole of the patient’s foot, the nurse observes dorsiflexion of the great toe and fanning of the other toes. How should the nurse interpret this finding?
A. This suggests possible upper motor neuron dysfunction
B. This indicates a normal plantar reflex
C. This is a normal finding in adults
D. This indicates peripheral nerve damage
A. This suggests possible upper motor neuron dysfunction
Rationale: This indicates a positive Babinski reflex. In adults, a positive Babinski sign is abnormal and typically indicates damage or dysfunction of the upper motor neurons. In contrast, this reflex is normal in infants, usually up to 2 years old.
A nurse is assessing a patient’s range of motion. The patient performs the following movements:
Which of the following statements is correct?
A. Both movements are examples of external rotation
B. Shoulder movement is internal rotation, hip movement is internal rotation
C. Shoulder movement is external rotation, hip movement is internal rotation
D. Shoulder movement is internal rotation, hip movement is external rotation
B. Shoulder movement is internal rotation, hip movement is internal rotation
Rationale: Internal rotation = turning a limb toward the midline.
A nurse assesses this area of the eye to detect early jaundice, which appears as yellowing due to elevated bilirubin levels
What is the sclera?
Rationale: Yellowing is most visible in the sclera before it appears in the skin. Early detection helps identify liver dysfunction or hemolysis.
A nurse is assessing a patient with abdominal distention. The nurse performs a fluid wave test, which is negative. Percussion reveals shifting dullness when the client rolls from side to side. How should the nurse interpret these findings?
A. No ascites is present; the distention is likely from gas or obesity
B. Small to moderate ascites is likely present; fluid wave may be negative with smaller fluid volumes
C. The patient has a tense, rigid abdomen indicating peritonitis
D. Ascites is ruled out; percussion is unreliable
B. Small to moderate ascites is likely present; fluid wave may be negative with smaller fluid volumes
Rationale: The fluid wave test detects large volumes of free fluid; smaller volumes may not produce a palpable wave.
A 68-year-old male patient reports urinary hesitancy, weak stream, and nocturia twice per night. The nurse suspects benign prostatic hyperplasia (BPH). Which assessment finding would support this suspicion?
A. Post-void residual urine of 250 mL on bladder scan
B. Urgency with leakage when coughing or sneezing
C. Continuous dribbling of urine throughout the day
D. Burning sensation during urination
A. Post-void residual urine of 250 mL on bladder scan
Rationale: BPH can cause bladder outlet obstruction, leading to incomplete emptying, weak urine stream, and nocturia. High post-void residual (PVR) confirms incomplete bladder emptying.
A nursing student is comparing postures in a neurological assessment:
Posture A: Arms flexed to the chest, legs extended Posture B: Arms and legs fully extended, wrists pronated
Which postures are these?
A. A = Decerebrate, B = Decorticate
B. A = Decorticate, B = Decerebrate
C. A = Flaccid, B = Normal
D. A = Normal, B = Decerebrate
B. A = Decorticate, B = Decerebrate
Rationale:
Decorticate: arms flexed, legs extended → injury above brainstem
Decerebrate: arms and legs extended → injury at brainstem
This congenital chest wall deformity is characterized by a sunken or concave sternum, may cause cardiac or respiratory compromise in severe cases, and is more common in males.
What is pectus excavatum?
This mnemonic helps nurses assess skin lesions for malignant melanoma.
ABCD's