Cardiac
A nurse is unable to palpate the PMI on a client during a cardiac assessment. What is the most appropriate nursing action?
A. Notify the healthcare provider immediately
B. Document it as a normal finding in all adults
C. Reposition the client to a supine position with legs elevated
D. Ask the client to lean forward or lie on their left side
D. Ask the client to lean forward or lie on their left side
The PMI can be difficult to palpate in some clients, especially those with a thick chest wall or obesity. Having the client lean forward or lie in the left lateral decubitus position brings the heart closer to the chest wall, making the impulse more detectable.
A nurse is assessing a client with suspected arterial insufficiency. Which of the following findings should the nurse expect?
A. Warm, reddened skin on the lower legs
B. Brown pigmentation around the ankles
C. Diminished or absent peripheral pulses
D. Edema that worsens at the end of the day
C. Diminished or absent peripheral pulses
Arterial insufficiency results in reduced or absent blood flow, leading to diminished or absent pulses.
Venous insufficiency is more likely to present with warm skin, edema, and brown discoloration.
A nurse is performing an initial musculoskeletal assessment. Which of the following questions should the nurse ask first?
A. "Do you have any history of fractures or bone disease?"
B. "Do you have any joint stiffness at the end of the day?"
C. "Do you have difficulty performing daily activities such as dressing or walking?"
D. "Have you noticed any swelling or redness in your joints?
C. "Do you have difficulty performing daily activities such as dressing or walking?"
This answer allows the client to provide a general overview of their musculoskeletal system. It starts the conversation by asking about functionality and challenges associated with mobility.
A nurse observes a client swaying and nearly falling when performing a Romberg’s test. What does this finding indicate?
A. Cerebrovascular accident (CVA)
B. Positive Babinski sign
C. Positive Romberg’s sign
D. Negative Romberg’s sign
C. Positive Romberg's Sign
Swaying or loss of balance with eyes closed indicates a positive Romberg’s test, suggesting sensory ataxia due to impaired proprioception (e.g., from dorsal column disease or vitamin B12 deficiency).
A negative sign means the client maintains balance.
The nurse asks the client to perform the finger-to-nose test during a neurological exam. Which cranial nerve function is primarily being assessed?
A. Cranial Nerve V (Trigeminal)
B. Cranial Nerve VIII (Vestibulocochlear)
C. Cranial Nerve VII (Facial)
D. Cranial Nerve XII (Hypoglossal)
B. Cranial Nerve VIII (Vestibulocochlear)
The finger-to-nose test assesses coordination and proprioception, functions linked to the cerebellum and vestibular system, which is innervated by Cranial Nerve VIII. While it’s not a direct test of the nerve, abnormalities can suggest dysfunction involving this nerve.
A nurse palpates a client’s left carotid artery and notes a weak, thready pulse. Which condition is most likely associated with this finding?
A. Hypertension
B. Dehydration or hypovolemia
C. Aortic regurgitation
D. Hyperthyroidism
B. Dehydration or Hypovolemia
A weak, thready carotid pulse often indicates low blood volume or decreased cardiac output, both of which are common in hypovolemia or dehydration.
Aortic regurgitation causes bounding pulses
Hyperthyroidism can cause increased pulse strength and rate
A nurse is assessing a client with bilateral lower extremity edema. How should the nurse document the following finding: deep indentation remains for 30 seconds after pressure is applied?
A. 2+ pitting edema
B. 3+ pitting edema
C. 1+ pitting edema
D. 4+ pitting edema
D. 4+ pitting edema
Pitting edema is graded on a scale from 1+ to 4+.
4+: Very deep pit (8 mm or more), indentation lasts longer than 20–30 seconds, and swelling is obvious.
1+ to 3+ indicates progressively less depth and duration.
A nurse is assessing a client with rheumatoid arthritis. Which of the following findings is most characteristic of this condition?
A. Pain that worsens with movement and improves with rest
B. Symmetrical joint swelling, especially in the hands
C. Heberden’s and Bouchard’s nodes
D. Joint stiffness lasting less than 15 minutes in the morning
B. Symmetrical joint swelling, especially in the hands
RA is an autoimmune disease that causes symmetrical inflammation of small joints (e.g., hands and wrists). Morning stiffness lasting longer than 30 minutes is typical. The other options describe osteoarthritis, a degenerative joint disease.
(Both notes are common manifestations with osteoarthritis. However, Bouchard's although rare can occur with Rheumatoid arthritis.)
A nurse is assessing a client with Parkinson’s disease and notes bradykinesia. Which of the following best describes this finding?
A. Involuntary muscle jerking movements
B. Difficulty initiating and performing voluntary movements
C. Muscle paralysis on one side of the body
D. Spasticity in the upper and lower limbs
B. Difficulty initiating and performing voluntary movements
Bradykinesia is the slowness of movement and difficulty initiating motor activity, commonly seen in Parkinson’s disease. It impacts walking, facial expressions, speech, and fine motor skills.
A nurse is assessing a patient with jugular vein distention (JVD). What position should the client be in for this assessment?
A. Supine, head turned to the right
B. Sitting upright at a 90-degree angle
C. Semi-Fowler's position, 30–45 degrees
D. Lying flat with head of bed at 0 degrees
C. Semi-Fowler's position, 30–45 degrees
Jugular vein distention (JVD) is best assessed when the client is in a 30–45 degree angle. This helps visualize venous distention due to right-sided heart failure or fluid overload.
A nurse is auscultating a client’s heart and hears a whooshing sound between the S1 and S2 heart sounds. How should the nurse document this finding?
A. A systolic murmur
B. A diastolic murmur
C. A pericardial friction rub
D. A third heart sound (S3)
A. A systolic murmur
Heart murmurs are extra heart sounds caused by turbulent blood flow. If the murmur occurs between S1 and S2, it is systolic.
Diastolic murmurs occur between S2 and the next S1.
Friction rubs are scratchy, high-pitched sounds caused by inflamed pericardium.
S3 is a low-pitched sound heard after S2.
Which of the following are appropriate components of a peripheral vascular system assessment?
A. Identify vascular abnormalities
B. Assessing capillary refill time
C. Auscultating over the carotid artery
D. Palpating peripheral pulses
E. Checking for pitting edema
F. Testing deep tendon reflexe
Correct: A, B, C, D, E
A. Identify vascular abnormalities by comparing blood pressure in upper extremities to check for differences
B. Assessing capillary refill time
Indicates peripheral perfusion; delayed refill (>2 seconds) suggests decreased circulation.
C. Auscultating over the carotid artery
Checking for bruits (turbulent flow) can indicate arterial narrowing.
D. Palpating peripheral pulses
Essential for evaluating arterial blood flow in the extremities.
E. Checking for pitting edema
Suggests venous insufficiency, fluid overload, or heart failure.
Incorrect (F): Testing deep tendon reflexes
This is part of a neurologic, not vascular, assessment.
The school nurse is screening a 13-year-old for scoliosis. Which of the following findings is most indicative of scoliosis?
A. Equal shoulder height
B. Symmetrical waist creases
C. Slight lumbar lordosis when standing
D. One scapula more prominent than the other when bending forward
D. One scapula more prominent than the other when bending forward
The Adam’s forward bend test is commonly used to screen for scoliosis. Asymmetry in the rib cage or scapula (e.g., one scapula higher or more prominent) indicates a potential lateral curvature of the spine, suggestive of scoliosis.
A nurse is performing a neurological assessment on a client who suffered a head injury. Which of the following should the nurse assess first?
A. Pupil reaction
B. Level of consciousness (LOC)
C. Sensory response to pain
D. Gag reflex
B. Level of consciousness (LOC)
LOC is the most sensitive indicator of neurological status and the earliest sign of deterioration. While other assessments are important, LOC provides a quick overview of cerebral function.
Which of the following assessments evaluates short-term memory?
A. Having the client remember and repeat three unrelated words at different time intervals
B. Asking the client to recall their childhood address
C. Asking the client’s name and date of birth
D. Observing the client’s ability to follow a three-step command
A. Having the client remember and repeat three unrelated words at different time intervals
Short-term memory is tested by asking the client to recall information after a short delay, such as repeating three words after a few minutes.
Which of the following best describes the clinical significance of a pulse deficit?
A. It indicates decreased lung expansion
B. It suggests weak or thready peripheral pulses due to hypothermia
C. It reflects the difference between systolic and diastolic pressure
D. It may indicate that some heartbeats are not perfusing to the periphery
D. It may indicate that some heartbeats are not perfusing to the periphery
A pulse deficit occurs when the apical rate is higher than the peripheral (radial) pulse, suggesting ineffective cardiac contractions—the heart beats, but some beats are too weak to create a palpable peripheral pulse.
Which of the following are functions of the lymphatic system?
A. Maintains fluid balance in the body
B. Absorbs dietary fats from the gastrointestinal tract
C. Produces red blood cells in adults
D. Filters and removes pathogens from lymph
E. Transports oxygen to tissues
F. Facilitates immune responses through lymphocyte activity
Correct: A, B, D, F
A. Maintains fluid balance in the body
The lymphatic system collects excess interstitial fluid and returns it to the bloodstream, maintaining fluid homeostasis.
B. Absorbs dietary fats from the gastrointestinal tract
Specialized lymphatic vessels called lacteals in the small intestine absorb fats and fat-soluble vitamins (A, D, E, K).
D. Filters and removes pathogens from lymph
Lymph nodes filter lymph and trap bacteria, viruses, and other foreign substances for destruction by immune cells.
F. Facilitates immune responses through lymphocyte activity
Lymphatic organs such as lymph nodes, tonsils, spleen, and thymus house and support lymphocytes (T and B cells) that identify and destroy pathogens.
Incorrect (C): Produces red blood cells in adults
RBCs are produced in the bone marrow, not by the lymphatic system. This is true in fetal development but not in adults.
Incorrect (E): Transports oxygen to tissues
This is a function of the circulatory system, specifically red blood cells, not the lymphatic system.
Which of the following findings are commonly associated with nerve compression? Select all that apply
A. Burning or tingling sensations
B. Muscle atrophy in the affected area
C. Decreased peripheral pulses
D. Radiating pain from the spine
E. Loss of deep tendon reflexes
F. Swelling and redness around the joint
Correct: A, B, D, E
A: Paresthesia (burning/tingling) is a hallmark of nerve compression.
B: Chronic nerve compression can lead to muscle atrophy.
D: Radicular pain occurs when spinal nerves are compressed.
E: Loss of reflexes can indicate motor nerve involvement.
Incorrect (C and F): relate more to vascular or inflammatory processes than nerve compression.
A nurse is assessing a client with a suspected brain injury. Which of the following is the most concerning neurological finding?
A. Pupils equal and reactive to light
B. Glasgow Coma Scale score of 13
C. Sudden decerebrate posturing
D. Mild slurring of speech
C. Sudden decerebrate posturing
Decerebrate posturing (rigid extension of arms and legs) indicates severe brainstem injury and is a medical emergency.
GCS 13 is mild impairment; slurred speech may be early, but posturing signals serious deterioration.
Which of the following are correct nursing practices when assessing the carotid arteries? Select all that apply.
A. Palpate gently, one side at a time
B. Auscultate before palpation if a bruit is suspected
C. Use firm pressure to assess for pulse strength
D. Ask the client to hold their breath while auscultating
E. Use the bell of the stethoscope to auscultate for bruits
F. Palpate both arteries simultaneously to compare strength
Correct: A, D, E
A: Proper technique—gentle palpation, one at a time
D: Asking the client to hold their breath briefly helps eliminate respiratory sounds when listening for a bruit
E: The bell is best for detecting low-pitched vascular sounds like bruits
Incorrect (B): Palpate before auscultation, as pressing on a vessel with a known bruit could dislodge plaque
Incorrect (C and F): Firm pressure and bilateral palpation are unsafe practices
Which of the following statements about blood flow through the heart are accurate? Select all that apply.
A. The aorta carries oxygenated blood from the heart to the body.
B. The tricuspid valve prevents backflow into the right atrium.
C. The left ventricle pumps blood into the pulmonary circulation.
D. The pulmonary artery carries blood to the lungs.
E. Blood from the systemic circulation enters the heart through the left atrium.
Correct: A, B, D
A: True — the aorta delivers oxygenated blood to systemic circulation.
B: True — the tricuspid valve prevents backflow into the right atrium.
D: True — the pulmonary artery carries blood to the lungs for oxygenation.
C: False — the right ventricle pumps blood to the pulmonary artery.
E: False — systemic venous return enters the right atrium, not the left.
The nurse is teaching a client about Raynaud’s phenomenon. Which of the following should be included in the teaching?
A. Avoid sudden exposure to cold temperatures
B. Wear tight-fitting gloves to maintain warmth
C. Manage emotional stress
D. Limit caffeine intake
E. Smoking cessation is recommended
F. Apply hot compresses directly to skin for relief
Correct: A, C, D, E
A. Avoid sudden exposure to cold temperatures
Cold is a major trigger of vasospasm.
C. Manage emotional stress
Stress can precipitate attacks due to sympathetic nervous system activation.
D. Limit caffeine intake
Caffeine causes vasoconstriction, worsening symptoms.
E. Smoking cessation is recommended
Nicotine is a vasoconstrictor and strongly associated with exacerbation of Raynaud’s.
Incorrect (B): Wear tight-fitting gloves to maintain warmth. Gloves should be warm but not constrictive, as tight clothing may worsen circulation.
Incorrect (F): Apply hot compresses directly to skin for relief. This can lead to burns; warmth should be gradual and gentle, such as warming hands under lukewarm water.
Which findings are consistent with ataxic gait?
A. Jerky, uncoordinated movements
B. Narrow base of support
C. Difficulty maintaining balance
D. Positive Romberg test
E. Shuffling small steps
F. Wide-based gait pattern
Correct Answers: A, C, D, F
A: Ataxia includes jerky, uncoordinated movements.
C: Clients with ataxia often struggle with balance.
D: A positive Romberg test can indicate proprioceptive or cerebellar dysfunction.
F: Ataxic gait presents as a wide-based, staggering walk.
Incorrect: B and E are more typical of Parkinson’s disease (festinating or shuffling gait), not ataxia.
Which assessments are used to evaluate cranial nerve II (Optic nerve)? (Select all that apply)
A. Testing visual acuity using a Snellen chart
B. Assessing pupil size and reaction to light
C. Asking the client to clench teeth
D. Visual field confrontation test
E. Asking the client to follow a moving object with their eyes
Correct: A, B, D
A: Visual acuity is a primary function of CN II.
B: Pupillary reaction to light involves CN II (afferent limb) and CN III (efferent limb).
D: Visual fields test peripheral vision via CN II.
Incorrect (C): tests CN V (motor branch).
Incorrect (E): assesses CN III, IV, and VI (ocular movements).
Which of the following findings indicate decreased muscle strength? Select all that apply.
A. Muscle strength of 2/5 in one leg
B. Client unable to lift arm against resistance
C. Symmetrical 5/5 strength in all limbs
D. Muscle flaccidity and hypotonia
E. Difficulty standing from a seated position without using hands
F. Firm, well-defined muscle tone on palpation
Correct: A, B, D, E
A: 2/5 means the client can only move the limb with gravity eliminated, indicating weakness.
B: Inability to resist movement is a sign of decreased strength.
D: Flaccidity and hypotonia suggest neurological or muscular impairment.
E: Needing hands to push up signals proximal muscle weakness.
Incorrect (C and F): are indicators of normal strength and tone.