1. When planning an assessment of the patient’s musculoskeletal,
neurologic, and peripheral vascular systems, what timing will result in
the most accurate assessment data?
A. Assessment of these systems should always be completed in a specific
order.
B. The assessment should be performed after other system assessments.
C. The assessment should be integrated into bathing, positioning, or play.
D. The assessment should be performed only when the patient is well
rested.
Rationale: Because the most accurate assessment of a patient occurs
when the patient is calm and free from anxiety, the best time to perform
a physical assessment is when the patient is doing activities of daily
living or playing. Although a systematic approach helps the nurse
remember all the steps of an assessment, assessing a patient means that
flexibility may be more important than following the exact same order
each time or assessing one system before or after others. Although
having the patient well rested is helpful, there may be times when
performing the examination is necessary even if the patient is not well
rested.
2. A finding of an increased lumbar curvature would indicate what
conditions?
A. Kyphosis
B. Lordosis
C. Scoliosis
D. Osteoporosis
Rationale: Lordosis is an increased lumbar curvature. Kyphosis is an
exaggerated posterior curvature of the thoracic spine. Scoliosis is a
lateral spinal curvature. Osteoporosis is not an abnormal curve of
posture but a leaching of calcium from the bones.
3. An infant with asymmetric facial features while crying has an
abnormality in which CN?
A. CN VII
B. CN V
C. CN VI
D. CN X
Rationale: CN VII is the facial nerve and is assessed by observing for
facial symmetry. Asymmetric facial features indicate an abnormality in
CN VII, such as Bell’s palsy or a CVA. CN V is the trigeminal nerve and
deals with sensation. CN VI is the abducens and is one of the nerves that
assists with EOM functioning. CN X is the vagus nerve and involves the
gag reflex.
4. What should the nurse do when performing a Romberg test?
A. Stand close to the patient.
B. Use a penlight.
C. Whisper in the patient’s ear.
D. Have the patient bend over.
Rationale: The nurse should stand close to the patient. The Romberg
test is used to assess the patient’s balance by having the patient stand
with feet together and arms at the sides, first with the eyes open and
then with the eyes closed. It is normal for the patient to have slight
swaying. If there is an abnormality, the patient may lose balance and fall
with the eyes closed; therefore, standing near the patient during the test
to prevent a fall is important for the patient’s safety. A penlight should be
used to examine pupillary reflexes. Whispering in a patient’s ear is used
to assess hearing. Having a patient bend over is a common procedure to
assess spinal curvature.
5. The nurse needs to assess for what common complication in a patient
on prolonged bed rest?
A. Guillain-Barré syndrome
B. DVT
C. Osteoporosis
D. Pain
Rationale: The nurse must assess for DVT in a patient who has been on
prolonged bed rest, because the patient is at risk for altered tissue
perfusion. Circulatory stasis combines with hypercoagulability, which
leads to thrombus or embolus formation. Guillain-Barré syndrome is a
lower motor neuron disorder. Osteoporosis is a deficiency of calcium in
the bones. Pain is not a common complication of prolonged bed rest; in
most cases, it is associated with the injury that necessitated bed rest.
6. A family member brings an 18-month-old to be examined because the
patient is not using the right arm. How should the nurse assess the
patient’s arm movement?
A. Give the patient a crayon and paper.
B. Perform passive ROM.
C. Ask the patient to shake hands.
D. Offer the patient a toy or treat.
Rationale: The easiest way to get a toddler to move the arms is to offer a
treat. A normal 18-month-old patient readily reaches for and grasps a
toy or treat with the dominant hand. If the toy or treat is placed in front
of the injured arm and the patient reaches with the unaffected arm, in
most cases this indicates an alteration in mobility in the other arm.
Asking a toddler to shake hands or giving a toddler a crayon and paper
may not be developmentally appropriate. Performing passive ROM
would not give information on how the patient moves the arms.
7. The GCS score would be inaccurate for a patient with what condition?
A. Meningitis
B. Quadriplegia
C. Trauma
D. Cerebral edema
Rationale: A patient with alterations in muscular functioning, such as
quadriplegia, cannot respond to commands physically and may score
very low on the GCS yet still be cerebrally intact. The GCS in this situation
would give an inaccurate score. Trauma, meningitis, and cerebral edema
are all appropriate conditions to be assessed using the GCS.
8. Which technique would the nurse use first to assess a toddler’s motor
coordination and strength?
A. Have the patient resist pressure.
B. Watch the patient play.
C. Rate muscle strength.
D. Palpate bilateral muscle groups.
Rationale: The nurse would first watch the patient play because
reaching and grasping toys and ambulating provide information about
motor coordination and strength. Palpation, pressure resistance, and
rating muscle strength are all more invasive and therefore should follow
observation.
9. Which strategy would the nurse use to assess the orientation of a
preverbal patient?
A. Observe the patient’s gait.
B. Assess the functioning of CN II.
C. Observe for recognition of family members.
D. Assess the color and condition of the skin.
Rationale: The nurse can observe for recognition of family members and
familiar objects to assess the orientation of a preverbal patient. The
patient’s gait is indicative of motor and cerebellar function, not
orientation. CN II, the optic nerve, is assessed by testing visual acuity,
which is neither reflective of orientation nor feasible in nonverbal
patients. Assessment of the color and condition of the skin is part of the
peripheral vascular assessment.
10. Which assessment finding should the nurse report to the
practitioner?
A. Symmetric facial expressions
B. Capillary refill of less than 2 seconds
C. Peripheral pulses of 2+
D. Resistance to palpation
Rationale: Resistance to palpation is an abnormal finding suggestive of
pain that should be reported to the practitioner, as it could indicate
injury, infection, trauma, or another abnormality. Symmetric facial
expressions, capillary refill of less than 2 seconds, and 2+ peripheral
pulses are all normal and expected findings.