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Bates Nursing Guide to Physical Examination and
History Taking 2nd Edition Testbank
Nursing Research (Miami Dade College)
)
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Chapter 1 Introduction to Health Assessment
Multiple Choice
1. For which of the following patients would a comprehensive health history be appropriate?
A) A new patient with the chief complaint of ―I sprained my ankle‖
B) An established patient with the chief complaint of ―I have an upper respiratory infection‖
C) A new patient with the chief complaint of ―I am here to establish care‖
D) A new patient with the chief complaint of ―I cut my hand‖
Ans:C
Chapter: 01
Page and Header: 4, Patient Assessment: Comprehensive or Focused
Feedback: This patient is here to establish care, and because she is new to you, a comprehensive health
history is appropriate.
2. The components of the health history include all of the following except which one?
A) Review of systems
B) Thorax and lungs
C) Present illness
D) Personal and social items
Ans:B
Chapter: 01
Feedback: The thorax and lungs are part of the physical examination, not part of the health history.
The others answers are all part of a complete health history.
3. Is the following information subjective or objective?
Mr. M. has shortness of breath that has persisted for the past 10 days; it is worse with activity and
relieved by rest.
A) Subjective
B) Objective
Ans:A
Chapter: 01
Feedback: This is information given by the patient about the circumstances of his chief complaint. It
does not represent an objective observation by the examiner.
4. Is the following information subjective or objective? Mr. M.
has a respiratory rate of 32 and a pulse rate of 120.
A) Subjective
B) Objective
Ans: B Chapter: 01
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Feedback: This is a measurement obtained by the examiner, so it is considered objective data. The
patient is unlikely to be able to give this information to the examiner.
5. The following information is recorded in the health history: ―The patient has had abdominal pain
for 1 week. The pain lasts for 30 minutes at a time; it comes and goes. The severity is 7 to 9 on a scale
of 1 to 10. It is accompanied by nausea and vomiting. It is located in the mid- epigastric area.‖
Which of these categories does it belong to?
A) Chief complaint
B) Present illness
C) Personal and social history
D) Review of systems
Ans: B Chapter: 01
Feedback: This information describes the problem of abdominal pain, which is the present illness.
The interviewer has obtained the location, timing, severity, and associated manifestations of the pain.
The interviewer will still need to obtain information concerning the quality of the pain, the setting in
which it occurred, and the factors that aggravate and alleviate the pain. You will notice that it does
include portions of the pertinent review of systems, but because it relates directly to the complaint, it
is included in the history of present illness.
6. The following information is recorded in the health history: ―The patient completed 8th grade. He
currently lives with his wife and two children. He works on old cars on the weekend. He works in a
glass factory during the week.‖
Which category does it belong to?
A) Chief complaint
B) Present illness
C) Personal and social history
D) Review of systems
Ans: C Chapter: 01
Feedback: Personal and social history information includes educational level, family of origin,
current household status, personal interests, employment, religious beliefs, military history, and
lifestyle (including diet and exercise habits; use of alcohol, tobacco, and/or drugs; and sexual
preferences and history). All of this information is documented in this example.
7. The following information is recorded in the health history: ―I feel really tired.‖
Which category does it belong to?
A) Chief complaint
B) Present illness
C) Personal and social history
D) Review of systems
Ans: A Chapter: 01
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Feedback: The chief complaint is an attempt to quote the patient's own words, as long as they are
suitable to print. It is brief, like a headline, and further details should be sought in the present illness
section. The above information is a chief complaint.
8. The following information is recorded in the health history: ―Patient denies chest pain,
palpitations, orthopnea, and paroxysmal nocturnal dyspnea.‖
Which category does it belong to?
A) Chief complaint
B) Present illness
C) Personal and social history
D) Review of systems
Ans: D
Feedback: Review of systems documents the presence or absence of common symptoms related to
each major body system. The absence of cardiac symptoms is listed in the above example.
9. The following information is best placed in which category? ―The
patient has had three cesarean sections.‖
A) Adult illnesses
B) Surgeries
C) Obstetrics/gynecology
D) Psychiatric
Ans: B Chapter: 01
Feedback: A cesarean section is a surgical procedure. Approximate dates or the age of the patient at the
time of the surgery should also be recorded.
10. The following information is best placed in which category?
―The patient had a stent placed in the left anterior descending artery (LAD) in 1999.‖
A) Adult illnesses
B) Surgeries
C) Obstetrics/gynecology
D) Psychiatric
Ans: A Chapter: 01
Feedback: The adult illnesses category is reserved for chronic illnesses, significant hospitalizations,
significant injuries, and significant procedures. A stent is a major procedure but does not involve a
surgeon.
11. The following information is best placed in which category?
―The patient was treated for an asthma exacerbation in the hospital last year; the patient has never
been intubated.‖
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A) Adult illnesses
B) Surgeries
C) Obstetrics/gynecology
D) Psychiatric
Ans: A Chapter: 01
Feedback: This is information about a significant hospitalization and should be placed in the adult
illnesses section. If the patient is being seen for an asthma exacerbation, you may consider placing
this information in the present illness section, because it relates to the chief complaint at that visit.
Chapter 2 Critical Thinking in Health Assessment
MULTIPLE CHOICE
1. When performing a physical assessment, the first technique the nurse will always use is:
a.
b.
c.
d.
Palpation.
Inspection.
Percussion.
Auscultation.
ANS: B
The skills requisite for the physical examination are inspection, palpation, percussion, and
auscultation. The skills are performed one at a time and in this order (with the exception of the
abdominal assessment, during which auscultation takes place before palpation and percussion). The
assessment of each body system begins with inspection. A focused inspection takes time and yields a
surprising amount of information.
2. The nurse is preparing to perform a physical assessment. Which statement is true about the
physical assessment? The inspection phase:
a.
b.
c.
d.
Usually yields little information.
Takes time and reveals a surprising amount of information.
May be somewhat uncomfortable for the expert practitioner.
Requires a quick glance at the patients body systems before proceeding with
palpation.
ANS: B
A focused inspection takes time and yields a surprising amount of information. Initially, the examiner
may feel uncomfortable, staring at the person without also doing something. A focused assessment is
significantly more than a quick glance.
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3. The nurse is assessing a patients skin during an office visit. What part of the hand and
technique should be used to best assess the patients skin temperature?
a. Fingertips; they are more sensitive to small changes in temperature.
b. Dorsal surface of the hand; the skin is thinner on this surface than on the palms.
c. Ulnar portion of the hand; increased blood supply in this area enhances
temperature sensitivity.
d. Palmar surface of the hand; this surface is the most sensitive to temperature
variations because of its increased nerve supply in this area.
ANS: B
The dorsa (backs) of the hands and fingers are best for determining temperature because the skin is
thinner on the dorsal surfaces than on the palms. Fingertips are best for fine, tactile discrimination.
The other responses are not useful for palpation.
4. Which of these techniques uses the sense of touch to assess texture, temperature, moisture, and
swelling when the nurse is assessing a patient?
a. Palpation
b. Inspection
c. Percussion
d. Auscultation
ANS: A
Palpation uses the sense of touch to assess the patient for these factors. Inspection involves vision;
percussion assesses through the use of palpable vibrations and audible sounds; and auscultation uses
the sense of hearing.
5. The nurse is preparing to assess a patients abdomen by palpation. How should the nurse
proceed?
a. Palpation of reportedly tender areas are avoided because palpation in these areas may
cause pain.
b. Palpating a tender area is quickly performed to avoid any discomfort that the
patient may experience.
c. The assessment begins with deep palpation, while encouraging the patient to relax and
to take deep breaths.
d. The assessment begins with light palpation to detect surface characteristics and to
accustom the patient to being touched.
ANS: D
Light palpation is initially performed to detect any surface characteristics and to accustom the person to
being touched. Tender areas should be palpated last, not first.
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6. The nurse would use bimanual palpation technique in which situation?
a.
b.
c.
d.
Palpating the thorax of an infant
Palpating the kidneys and uterus
Assessing pulsations and vibrations
Assessing the presence of tenderness and pain
ANS: B
Bimanual palpation requires the use of both hands to envelop or capture certain body parts or organs
such as the kidneys, uterus, or adnexa. The other situations are not appropriate for bimanual
palpation.
7. The nurse is preparing to percuss the abdomen of a patient. The purpose of the percussion is to
assess the
of the underlying tissue.
a. Turgor
b. Texture
c. Density
d. Consistency
ANS: C
Percussion yields a sound that depicts the location, size, and density of the underlying organ. Turgor
and texture are assessed with palpation.
8. The nurse is reviewing percussion techniques with a newly graduated nurse. Which technique, if
used by the new nurse, indicates that more review is needed?
a.
b.
c.
d.
Percussing once over each area
Quickly lifting the striking finger after each stroke
Striking with the fingertip, not the finger pad
Using the wrist to make the strikes, not the arm
ANS: A
For percussion, the nurse should percuss two times over each location. The striking finger should be
quickly lifted because a resting finger damps off vibrations. The tip of the striking finger should make
contact, not the pad of the finger. The wrist must be relaxed and is used to make the strikes, not the
arm.
9. When percussing over the liver of a patient, the nurse notices a dull sound. The nurse should:
a.
b.
c.
d.
Consider this a normal finding.
Palpate this area for an underlying mass.
Reposition the hands, and attempt to percuss in this area again.
Consider this finding as abnormal, and refer the patient for additional treatment.
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ANS: A
Percussion over relatively dense organs, such as the liver or spleen, will produce a dull sound. The
other responses are not correct.
10. The nurse is unable to identify any changes in sound when percussing over the abdomen of an
obese patient. What should the nurse do next?
a. Ask the patient to take deep breaths to relax the abdominal musculature.
b. Consider this finding as normal, and proceed with the abdominal assessment.
c. Increase the amount of strength used when attempting to percuss over the
abdomen.
d. Decrease the amount of strength used when attempting to percuss over the
abdomen.
ANS: C
The thickness of the persons body wall will be a factor. The nurse needs a stronger percussion stroke
for persons with obese or very muscular body walls. The force of the blow determines the loudness of
the note. The other actions are not correct.
11. The nurse hears bilateral loud, long, and low tones when percussing over the lungs of a 4- yearold child. The nurse should:
a.
b.
c.
d.
Palpate over the area for increased pain and tenderness.
Ask the child to take shallow breaths, and percuss over the area again.
Immediately refer the child because of an increased amount of air in the lungs.
Consider this finding as normal for a child this age, and proceed with the
examination.
ANS: D
Percussion notes that are loud in amplitude, low in pitch, of a booming quality, and long in duration are
normal over a childs lung.
12. A patient has suddenly developed shortness of breath and appears to be in significant respiratory
distress. After calling the physician and placing the patient on oxygen, which of these actions is the
best for the nurse to take when further assessing the patient?
a. Count the patients respirations.
b. Bilaterally percuss the thorax, noting any differences in percussion tones.
c. Call for a chest x-ray study, and wait for the results before beginning an
assessment.
d. Inspect the thorax for any new masses and bleeding associated with respirations.
ANS: B
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Percussion is always available, portable, and offers instant feedback regarding changes in underlying
tissue density, which may yield clues of the patients physical status.
13. The nurse is teaching a class on basic assessment skills. Which of these statements is true
regarding the stethoscope and its use?
a. Slope of the earpieces should point posteriorly (toward the occiput).
b. Although the stethoscope does not magnify sound, it does block out extraneous
room noise.
c. Fit and quality of the stethoscope are not as important as its ability to magnify
sound.
d. Ideal tubing length should be 22 inches to dampen the distortion of sound.
ANS: B
The stethoscope does not magnify sound, but it does block out extraneous room sounds. The slope of
the earpieces should point forward toward the examiners nose. Long tubing will distort sound. The fit
and quality of the stethoscope are both important.
14. The nurse is preparing to use a stethoscope for auscultation. Which statement is true
regarding the diaphragm of the stethoscope? The diaphragm:
a.
b.
c.
d.
Is used to listen for high-pitched sounds.
Is used to listen for low-pitched sounds.
Should be lightly held against the persons skin to block out low-pitched sounds.
Should be lightly held against the persons skin to listen for extra heart sounds and
murmurs.
ANS: A
The diaphragm of the stethoscope is best for listening to high-pitched sounds such as breath, bowel,
and normal heart sounds. It should be firmly held against the persons skin, firmly enough to leave a
ring. The bell of the stethoscope is best for soft, low-pitched sounds such as extra heart sounds or
murmurs.
15. Before auscultating the abdomen for the presence of bowel sounds on a patient, the nurse
should:
a. Warm the endpiece of the stethoscope by placing it in warm water.
b. Leave the gown on the patient to ensure that he or she does not get chilled during the
examination.
c. Ensure that the bell side of the stethoscope is turned to the on position.
d. Check the temperature of the room, and offer blankets to the patient if he or she feels
cold.
ANS: D
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The examination room should be warm. If the patient shivers, then the involuntary muscle
contractions can make it difficult to hear the underlying sounds. The end of the stethoscope should
be warmed between the examiners hands, not with water. The nurse should never listen through a
gown. The diaphragm of the stethoscope should be used to auscultate for bowel sounds.
16. The nurse will use which technique of assessment to determine the presence of crepitus,
swelling, and pulsations?
a.
b.
c.
d.
Palpation
Inspection
Percussion
Auscultation
ANS: A
Palpation applies the sense of touch to assess texture, temperature, moisture, organ location and size, as
well as any swelling, vibration or pulsation, rigidity or spasticity,
17. The nurse is preparing to use an otoscope for an examination. Which statement is true
regarding the otoscope? The otoscope:
a.
b.
c.
d.
Is often used to direct light onto the sinuses.
Uses a short, broad speculum to help visualize the ear.
Is used to examine the structures of the internal ear.
Directs light into the ear canal and onto the tympanic membrane.
ANS: D
The otoscope directs light into the ear canal and onto the tympanic membrane that divides the external
and middle ear. A short, broad speculum is used to visualize the nares.
18. An examiner is using an ophthalmoscope to examine a patients eyes. The patient has
astigmatism and is nearsighted. The use of which of these techniques would indicate that the
examination is being correctly performed?
a. Using the large full circle of light when assessing pupils that are not dilated
b. Rotating the lens selector dial to the black numbers to compensate for
astigmatism
c. Using the grid on the lens aperture dial to visualize the external structures of the eye
d. Rotating the lens selector dial to bring the object into focus
ANS: D
The ophthalmoscope is used to examine the internal eye structures. It can compensate for
nearsightedness or farsightedness, but it will not correct for astigmatism. The grid is used to assess
size and location of lesions on the fundus. The large full spot of light is used to assess dilated pupils.
Rotating the lens selector dial brings the object into focus.
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19. The nurse is unable to palpate the right radial pulse on a patient. The best action would be to:
a.
b.
c.
d.
Auscultate over the area with a fetoscope.
Use a goniometer to measure the pulsations.
Use a Doppler device to check for pulsations over the area.
Check for the presence of pulsations with a stethoscope.
ANS: C
Doppler devices are used to augment pulse or blood pressure measurements. Goniometers measure
joint range of motion. A fetoscope is used to auscultate fetal heart tones. Stethoscopes are used to
auscultate breath, bowel, and heart sounds.
20. The nurse is preparing to perform a physical assessment. The correct action by the nurse is
reflected by which statement? The nurse:
a. Performs the examination from the left side of the bed.
b. Examines tender or painful areas first to help relieve the patients anxiety.
c. Follows the same examination sequence, regardless of the patients age or
condition.
d. Organizes the assessment to ensure that the patient does not change positions too
often.
ANS: D
The steps of the assessment should be organized to ensure that the patient does not change positions
too often. The sequence of the steps of the assessment may differ, depending on the age of the person
and the examiners preference. Tender or painful areas should be assessed last.
Chapter 3 Interviewing and Communication
Multiple Choice
1. You are running late after your quarterly quality improvement meeting at the hospital and have
just gotten paged from the nurses' station because a family member of one of your patients wants to
talk with you about that patient's care. You have clinic this afternoon and are double- booked for the
first appointment time; three other patients also have arrived and are sitting in the waiting room.
Which of the following demeanors is a behavior consistent with skilled interviewing when you walk
into the examination room to speak with your first clinic patient?
A) Irritability
B) Impatience
C) Boredom
D) Calm
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Ans: D Chapter: 03
Feedback: The appearance of calmness and patience, even when time is limited, is the hallmark of a
skilled interviewer.
2. Suzanne, a 25 year old, comes to your clinic to establish care. You are the student preparing to go
into the examination room to interview her. Which of the following is the most logical sequence for
the patient–provider interview?
A) Establish the agenda, negotiate a plan, establish rapport, and invite the patient's story.
B) Invite the patient's story, negotiate a plan, establish the agenda, and establish rapport.
C) Greet the patient, establish rapport, invite the patient's story, establish the agenda, expand and
clarify the patient's story, and negotiate a plan.
D) Negotiate a plan, establish an agenda, invite the patient's story, and establish rapport.
Ans: C Chapter: 03
Feedback: This is the most productive sequence for the interview. Greeting patients and establishing
rapport allows them to feel more comfortable before ―inviting‖ them to relate their story. After hearing
the patient's story, together you establish the agenda regarding the most important items to expand
upon. At the end, together you negotiate the plan of diagnosis and treatment.
3. Alexandra is a 28-year-old editor who presents to the clinic with abdominal pain. The pain is
a dull ache, located in the right upper quadrant, that she rates as a 3 at the least and an 8 at the worst.
The pain started a few weeks ago, it lasts for 2 to 3 hours at a time, it comes and goes, and it seems to
be worse a couple of hours after eating. She has noticed that it starts after eating greasy foods, so she
has cut down on these as much as she can. Initially it occurred once a week, but now it is occurring
every other day. Nothing makes it better. From this description, which of the seven attributes of a
symptom has been omitted?
A) Setting in which the symptom occurs
B) Associated manifestations
C) Quality
D) Timing
Ans: B Chapter: 03
Feedback: The interviewer has not recorded whether or not the pain has been accompanied by
nausea, vomiting, fever, chills, weight loss, and so on. Associated manifestations are additional
symptoms that may accompany the initial chief complaint and that help the examiner to start refining
his or her differential diagnosis.
4. Jason is a 41-year-old electrician who presents to the clinic for evaluation of shortness of breath.
The shortness of breath occurs with exertion and improves with rest. It has been going on for several
months and initially occurred only a couple of times a day with strenuous exertion; however, it has
started to occur with minimal exertion and is happening more than a dozen times per day. The
shortness of breath lasts for less than 5 minutes at a time. He has no cough, chest pressure, chest pain,
swelling in his feet, palpitations, orthopnea, or paroxysmal nocturnal dyspnea.
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Which of the following symptom attributes was not addressed in this description?
A) Severity
B) Setting in which the symptom occurs
C) Timing
D) Associated manifestations
Ans: A Chapter: 03
Feedback: The severity of the symptom was not recorded by the interviewer, so we have no
understanding as to how bad the symptom is for this patient. The patient could have been asked to
rate his pain on a 0 to 10 scale or used one of the other standardized pain scales available.
This allows the comparison of pain intensity before and after an intervention.
5. You are interviewing an elderly woman in the ambulatory setting and trying to get more
information about her urinary symptoms. Which of the following techniques is not a component of
adaptive questioning?
A) Directed questioning: starting with the general and proceeding to the specific in a manner that
does not make the patient give a yes/no answer
B) Reassuring the patient that the urinary symptoms are benign and that she doesn't need to
worry about it being a sign of cancer
C) Offering the patient multiple choices in order to clarify the character of the urinary symptoms that
she is experiencing
D) Asking her to tell you exactly what she means when she states that she has a urinary tract
infection
Ans: B Chapter: 03
Feedback: Reassurance is not part of clarifying the patient's story; it is part of establishing rapport
and empathizing with the patient.
6. Mr. W. is a 51-year-old auto mechanic who comes to the emergency room wanting to be
checked out for the symptom of chest pain. As you listen to him describe his symptom in more
detail, you say ―Go on,‖ and later, ―Mm-hmmm.‖ This is an example of which of the following
skilled interviewing techniques?
A) Echoing
B) Nonverbal communication
C) Facilitation
D) Empathic response
Ans: C Chapter: 03
Feedback: This is an example of facilitation. Facilitation can be posture, actions, or words that
encourage the patient to say more.
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7. Mrs. R. is a 92-year-old retired teacher who comes to your clinic accompanied by her
daughter. You ask Mrs. R. why she came to your clinic today. She looks at her daughter and
doesn't say anything in response to your question. This is an example of which type of
challenging patient?
A) Talkative patient
B) Angry patient
C) Silent patient
D) Hearing-impaired patient
Ans: C Chapter: 03
Feedback: This is one example of a silent patient. There are many possibilities for this patient's silence:
depression, dementia, the manner in which you asked the question, and so on.
8. Mrs. T. comes for her regular visit to the clinic. She is on your schedule because her regular
provider is on vacation and she wanted to be seen. You have heard about her many times from your
colleague and are aware that she is a very talkative person. Which of the following is a helpful
technique to improve the quality of the interview for both the provider and the patient?
A) Allow the patient to speak uninterrupted for the duration of the appointment.
B) Briefly summarize what you heard from the patient in the first 5 minutes and then try to have her
focus on one aspect of what she told you.
C) Set the time limit at the beginning of the interview and stick with it, no matter what occurs in the
course of the interview.
D) Allow your impatience to show so that the patient picks up on your nonverbal cue that the
appointment needs to end.
Ans: B Chapter: 03
Feedback: You can also say, ―I want to make sure I take good care of this problem because it is very
important. We may need to talk about the others at the next appointment. Is that okay with you?‖
This is a technique that can help you to change the subject but, at the same time, validate the patient's
concerns; it also can provide more structure to the interview.
9. Mrs. H. comes to your clinic, wanting antibiotics for a sinus infection. When you enter the
room, she appears to be very angry. She has a raised tone of voice and states that she has been
waiting for the past hour and has to get back to work. She states that she is unimpressed by the
reception staff, the nurse, and the clinic in general and wants to know why the office wouldn't call
in an antibiotic for her. Which of the following techniques is not useful in helping to calm this
patient?
A) Avoiding admission that you had a part in provoking her anger because you were late
B) Accepting angry feelings from the patient and trying not to get angry in return
C) Staying calm
D) Keeping your posture relaxed
Ans: A
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Feedback: In this scenario, the provider was 1 hour late in seeing the patient. The provider should
acknowledge that he was late and apologize for this, no matter the reason for being late. It often
helps to acknowledge that a patient's anger with you is understandable and that you might be angry
in a similar situation.
10. A 23-year-old graduate student comes to your clinic for evaluation of a urethral discharge. As
the provider, you need to get a sexual history. Which one of the following questions is
inappropriate for eliciting the information?
A) Are you sexually active?
B) When was the last time you had intimate physical contact with someone, and did that contact
include sexual intercourse?
C) Do you have sex with men, women, or both?
D) How many sexual partners have you had in the last 6 months?
Ans: A Chapter: 03
Feedback: This is inappropriate because it is too vague. Given the complaint, you should probably
assume that he is sexually active. Sometimes patients may respond to this question with the phrase
―No, I just lie there.‖ A specific sexual history will help you to assess this patient's risk for other
sexually transmitted infections.
11. Mr. Q. is a 45-year-old salesman who comes to your office for evaluation of fatigue. He has
come to the office many times in the past with a variety of injuries, and you suspect that he has a
problem with alcohol. Which one of the following questions will be most helpful in diagnosing this
problem?
A) You are an alcoholic, aren't you?
B) When was your last drink?
C) Do you drink 2 to 3 beers every weekend?
D) Do you drink alcohol when you are supposed to be working?
Ans: B Chapter: 03
Feedback: This is a good opening question that is general and neutral in tone; depending on the timing,
you will be able to ask for more specific information related to the patient's last drink.
The others will tend to stifle the conversation because they are closed-ended questions. Answer D
implies negative behavior and may also keep the person from sharing freely with you.
12. On a very busy day in the office, Mrs. Donelan, who is 81 years old, comes for her usual visit for
her blood pressure. She is on a low-dose diuretic chronically and denies any side effects. Her blood
pressure is 118/78 today, which is well-controlled. As you are writing her script, she mentions that it
is hard not having her husband Bill around anymore. What would you do next?
A) Hand her the script and make sure she has a 3-month follow-up appointment.
B) Make sure she understands the script.
C) Ask why Bill is not there.
D) Explain that you will have more time at the next visit to discuss this.
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Ans: C Chapter: 03
Feedback: Sometimes, the patient's greatest need is for support and empathy. It would be
inappropriate to ignore this comment today. She may have relied heavily upon Bill for care and may
be in danger. She may be depressed and even suicidal, but you will not know unless you discuss this
with her. Most importantly, you should empathize with her by saying something like ―It must be very
difficult not to have him at home‖ and allow a pause for her to answer. You may also ask ―What did
you rely on him to do for you?‖ Only a life-threatening crisis with another patient should take you
out of her room at this point, and you may need to adjust your office schedule to allow adequate time
for her today.
13. A patient is describing a very personal part of her history very quickly and in great detail. How
should you react to this?
A) Write down as much as you can, as quickly as possible.
B) Ask her to repeat key phrases or to pause at regular intervals, so you can get almost every
word.
C) Tell her that she can go over the notes later to make sure they are accurate.
D) Push away from the keyboard or put down your pen and listen.
Ans: D Chapter: 03
Feedback: This is a common event in clinical practice. It is much more important to listen actively
with good eye contact at this time than to document the story verbatim. You want to minimize
interruption (e.g., answer B). It is usually not appropriate to ask a patient to go over the written notes,
but it would be a good idea to repeat the main ideas back to her. You should be certain she has
completed her story before doing this. By putting down your pen or pushing away from the
keyboard, you let the patient know that her story is the most important thing to
you at this moment.
14. You arrive at the bedside of an elderly woman who has had a stroke, affecting her entire right
side. She cannot speak (aphasia). You are supposed to examine her. You notice that the last
examiner left her socks at the bottom of the bed, and although sensitive areas are covered by a sheet,
the blanket is heaped by her feet at the bottom of the bed. What would you do next?
A) Carry out your examination, focusing on the neurologic portion, and then cover her properly.
B) Carry out your examination and let the nurse assigned to her ―put her back together.‖
C) Put her socks back on and cover her completely before beginning the evaluation.
D) Apologize for the last examiner but let the next examiner dress and cover her.
Ans: C Chapter: 03
Feedback: It is crucial to make an effort to make a patient comfortable. In this scenario, the patient
can neither speak nor move well. Take a moment to imagine yourself in her situation. As a matter of
respect as well as comfort, you should cover the patient appropriately and consider returning a little
later to do your examination if you feel she is cold. While it is her nurse's job to keep her
comfortable, it is also your responsibility, and you should do what you can. It is unacceptable to
leave the patient in the same state in which you found her.
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15. When you enter your patient's examination room, his wife is waiting there with him. Which of
the following is most appropriate?
A) Ask if it's okay to carry out the visit with both people in the room.
B) Carry on as you would ordinarily. The permission is implied because his wife is in the room with
him.
C) Ask his wife to leave the room for reasons of confidentiality.
D) First ask his wife what she thinks is going on.
Ans: A Chapter: 03
Feedback: Even in situations involving people very familiar with each other, it is important to respect
individual privacy. There is no implicit consent merely because he has allowed his wife to be in the
room with him. On the other hand, it is inappropriate to assume that his wife should leave the room.
Remember, the patient is the focus of the visit, so it would be appropriate to allow him to control who
is in the room with him and inappropriate to address his wife first.
Although your duty is to the patient, you may get optimal information by offering to speak to both
people confidentially. This situation is analogous to an adolescent's visit.
16. A patient complains of knee pain on your arrival in the room. What should your first
sentence be after greeting the patient?
A) How much pain are you having?
B) Have you injured this knee in the past?
C) When did this first occur?
D) Could you please describe what happened?
Ans: D Chapter: 03
Feedback: When looking into a complaint, it is best to start with an invitation for the patient to tell
you in his or her own words. More specific questions should be used later in the interview to fill in
any gaps.
17. You have just asked a patient how he feels about his emphysema. He becomes silent, folds his
arms across his chest and leans back in his chair, and then replies, ―It is what it is.‖ How should you
respond?
A) ―You seem bothered by this question.‖
B) ―Next, I would like to talk with you about your smoking habit.‖
C) ―Okay, let's move on to your other problems.‖
D) ―You have adopted a practical attitude toward your problem.‖
Ans: A Chapter: 03
Feedback: You have astutely noted that the patient's body language changed at the time you asked
this question, and despite the patient's response, you suspect there is more beneath the surface.
Maybe he is afraid of being browbeaten about his smoking, maybe a relative has recently died from
this disorder, or maybe a friend told him 20 years ago that he would eventually get emphysema.
Regardless, by sharing your observation and leaving a pause, he may begin to talk about some issues
which are very important to him.
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18. A patient tells you about her experience with prolonged therapy for her breast cancer. You
comment, ―That must have been a very trying time for you.‖ What is this an example of?
A) Reassurance
B) Empathy
C) Summarization
D) Validation
Ans: D Chapter: 03
Feedback: This is an example of validation to legitimize her emotional experience. ―Now that you
have had your treatment, you should not have any further troubles‖ is an example of reassurance. ―I
understand what you went through because I am a cancer survivor myself‖ is an example of
empathy. ―So, you have had a lumpectomy and multiple radiation treatments‖ is an example of
summarization as applied to this vignette.
19. You are performing a young woman's first pelvic examination. You make sure to tell her
verbally what is coming next and what to expect. Then you carry out each maneuver of the
examination. You let her know at the outset that if she needs a break or wants to stop, this is
possible. You ask several times during the examination, ―How are you doing, Brittney?‖ What are
you accomplishing with these techniques?
A) Increasing the patient's sense of control
B) Increasing the patient's trust in you as a caregiver
C) Decreasing her sense of vulnerability
D) All of the above
Ans: D Chapter: 03
Feedback: These techniques minimize the effects of transitions during an examination and
empower the patient. Especially during a sensitive examination, it is important to give the
patient as much control as possible.
20. When using an interpreter to facilitate an interview, where should the interpreter be
positioned?
A) Behind you, the examiner, so that the lips of the patient and the patient's nonverbal cues can be
seen
B) Next to the patient, so the examiner can maintain eye contact and observe the nonverbal cues of
the patient
C) Between you and the patient so all parties can make the necessary observations
D) In a corner of the room so as to provide minimal distraction to the interview Ans:
B
Feedback: Interpreters are invaluable in encounters where the examiner and patient do not speak the
same language, including encounters with the deaf. It should be noted that deaf people from different
regions of the world use different sign languages. The priority is for you to have a good view of the
patient. Remember to use short, simple phrases while speaking directly to the patient and ask the
patient to repeat back what he or she understands.
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Chapter 4 The Health History
Multiple Choice
1. A 15-year-old high school sophomore and her mother come to your clinic because the mother is
concerned about her daughter's weight. You measure her daughter's height and weight and obtain a
BMI of 19.5 kg/m2. Based on this information, which of the following is appropriate?
A) Refer the patient to a nutritionist and a psychologist because the patient is anorexic.
B) Reassure the mother that this is a normal body weight.
C) Give the patient information about exercise because the patient is obese.
D) Give the patient information concerning reduction of fat and cholesterol in her diet because she
is obese.
Ans: B Chapter: 04
Feedback: The patient has a normal BMI; the range for a normal BMI is 18.5 to 24.9 kg/m 2. You
may be able to give the patient and her mother the lower limit of normal in pounds for her daughter's
height, or instruct her in how to use a BMI table.
2. A 25-year-old radio announcer comes to the clinic for an annual examination. His BMI is
26.0 kg/m2. He is concerned about his weight. Based on this information, what is appropriate counsel
for the patient during the visit?
A) Refer the patient to a nutritionist because he is anorexic.
B) Reassure the patient that he has a normal body weight.
C) Give the patient information about reduction of fat, cholesterol, and calories because he is
overweight.
D) Give the patient information about reduction of fat and cholesterol because he is obese.
Ans: C Chapter: 04
Feedback: The patient has a BMI in the overweight range, which is 25.0 to 29.9 kg/m 2. It is prudent to
give him information about reducing calories, fat, and cholesterol in his diet to help prevent further
weight gain.
3. A 30-year-old sales clerk comes to your office wanting to lose weight; her BMI is 30.0 kg/m2.
What is the most appropriate amount for a weekly weight reduction goal?
A) .5 to 1 pound per week
B) 1 to 2.5 pounds per week
C) 2.5 to 3.5 pounds per week
D) 3.5 to 4.5 pounds per week
Ans: A Chapter: 04
Feedback: Based on the NIH Obesity Guidelines, this is the weekly weight loss goal to strive for to
maintain long-term control of weight. More rapid weight loss than this does not result in a better
outcome at one year.
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4. A 67-year-old retired janitor comes to the clinic with his wife. She brought him in because she is
concerned about his weight loss. He has a history of smoking 3 packs of cigarettes a day for 30 years,
for a total of 90 pack-years. He has noticed a daily cough for the past several years, which he states is
productive of sputum. He came into the clinic approximately 1 year ago, and at that time his weight
was 140 pounds. Today, his weight is 110 pounds.
Which one of the following questions would be the most important to ask if you suspect that he has
lung cancer?
A) Have you tried to force yourself to vomit after eating a meal?
B) Do you have heartburn/indigestion and diarrhea?
C) Do you have enough food to eat?
D) Have you tried to lose weight?
Ans: D Chapter: 04
Feedback: This is important: If the patient hasn't tried to lose weight, then this weight loss is
inadvertent and poses concern for a neoplastic process, especially given his smoking history.
5. Common or concerning symptoms to inquire about in the General Survey and vital signs
include all of the following except:
A) Changes in weight
B) Fatigue and weakness
C) Cough
D) Fever and chills
Ans: C Chapter: 04
Feedback: This symptom is more appropriate to the respiratory review of systems.
6. You are beginning the examination of a patient. All of the following areas are important to
observe as part of the General Survey except:
A) Level of consciousness
B) Signs of distress
C) Dress, grooming, and personal hygiene
D) Blood pressure
Ans: D Chapter: 04
Feedback: Blood pressure is a vital sign, not part of the General Survey.
7. A 55-year-old bookkeeper comes to your office for a routine visit. You note that on a previous
visit for treatment of contact dermatitis, her blood pressure was elevated. She does not have prior
elevated readings and her family history is negative for hypertension. You measure her blood
pressure in your office today. Which of the following factors can result in a false high reading?
A) Blood pressure cuff is tightly fitted.
B) Patient is seated quietly for 10 minutes prior to measurement.
C) Blood pressure is measured on a bare arm.
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D) Patient's arm is resting, supported by your arm at her mid-chest level as you stand to measure the
blood pressure.
Ans: A Chapter: 04
Feedback: A blood pressure cuff that is too tightly fitted can result in a false high reading. The other
answers are important to observe to obtain an accurate blood pressure reading. JNC-7 also mentions
the importance of having the back supported when obtaining blood pressure in the sitting position.
8. A 49-year-old truck driver comes to the emergency room for shortness of breath and swelling in
his ankles. He is diagnosed with congestive heart failure and admitted to the hospital. You are the
student assigned to do the patient's complete history and physical examination. When you palpate the
pulse, what do you expect to feel?
A) Large amplitude, forceful
B) Small amplitude, weak
C) Normal
D) Bigeminal
Ans: B Chapter: 04
Feedback: Congestive heart failure is characterized by decreased stroke volume or increased peripheral
vascular resistance, which would result in a small-amplitude, weak pulse. Subtle differences in
amplitude are usually best detected in large arteries close to the heart, like the carotid pulse. You may
not be able to notice these in other locations.
9. An 18-year-old college freshman presents to the clinic for evaluation of gastroenteritis. You
measure the patient's temperature and it is 104 degrees Fahrenheit. What type of pulse would you
expect to feel during his initial examination?
A) Large amplitude, forceful
B) Small amplitude, weak
C) Normal
D) Bigeminal
Ans: A Chapter: 04
Feedback: Fever results in an increased stroke volume, which results in a large-amplitude, forceful
pulse. Later in the course of the illness, if dehydration and shock result, you may expect small
amplitude and weak pulses.
10. A 25-year-old type 1 diabetic clerk presents to the emergency room with shortness of breath and
states that his blood sugar was 605 at home. You diagnose the patient with diabetic ketoacidosis.
What is the expected pattern of breathing?
A) Normal
B) Rapid and shallow
C) Rapid and deep
D) Slow
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Ans: C Chapter: 04
Feedback: This is the expected rate and depth in diabetic ketoacidosis. The body is trying to rid itself
of carbon dioxide to compensate for the acidosis. This is known as Kussmaul's breathing and is seen
in other causes of acidosis as well.
11. Mrs. Lenzo weighs herself every day with a very accurate balance-type scale. She has
noticed that over the past 2 days she has gained 4 pounds. How would you best explain this?
A) Attribute this to some overeating at the holidays.
B) Attribute this to wearing different clothing.
C) Attribute this to body fluid.
D) Attribute this to instrument inaccuracy.
Ans: C Chapter: 04
Feedback: This amount of weight over a short period should make one think of body fluid changes.
You may consider a kidney problem or heart failure in your differential. The other reasons should be
considered as well, but this amount of weight gain over a short period usually indicates causes other
than excessive caloric intake. A rule of thumb for dieters is that an energy excess of 3500 calories will
cause a 1-pound weight gain, if the increase is to be attributed to food intake.
12. Mr. Curtiss has a history of obesity, diabetes, osteoarthritis of the knees, HTN, and obstructive
sleep apnea. His BMI is 43 and he has been discouraged by his difficulty in losing weight. He is
also discouraged that his goal weight is 158 pounds away. What would you tell him?
A) ―When you get down to your goal weight, you will feel so much better.‖
B) ―Some people seem to be able to lose weight and others just can't, no matter how hard they try.‖
C) ―We are coming up with new medicines and methods to treat your conditions every day.‖
D) ―Even a weight loss of 10% can make a noticeable improvement in the problems you
mention.‖
Ans: D Chapter: 04
Feedback: Many patients trying to change a habit are overwhelmed by how far they are from their
goal. As the proverb says: ―A journey of a thousand miles begins with one step.‖ Many patients find
it empowering to know that they can achieve a small goal, such as a loss of 1 pound per week. They
must be reminded that this process will take time and that slow weight loss is more successful longterm. Research has shown that significant benefits often come with even a 10% weight loss.
13. Jenny is one of your favorite patients who usually shares a joke with you and is nattily dressed.
Today she is dressed in old jeans, lacks makeup, and avoids eye contact. To what do you attribute
these changes?
A) She is lacking sleep.
B) She is fatigued from work.
C) She is running into financial difficulty.
D) She is depressed.
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Ans: D Chapter: 04
Feedback: It is important to use all of your skills and memory of an individual patient to guide your
thought process. She is not described as sleepy. Work fatigue would most likely not cause avoidance
of eye contact. Financial difficulties would not necessarily deplete a nice wardrobe. It is most likely
that she is depressed or in another type of difficulty.
14. You are seeing an older patient who has not had medical care for many years. Her vital signs
taken by your office staff are: T 37.2, HR 78, BP 118/92, and RR 14, and she denies pain. You notice
that she has some hypertensive changes in her retinas and you find mild proteinuria on a urine test in
your office. You expected the BP to be higher. She is not on any medications. What do you think is
causing this BP reading, which doesn't correlate with the other findings?
A) It is caused by an ―auscultatory gap.‖
B) It is caused by a cuff size error.
C) It is caused by the patient's emotional state.
D) It is caused by resolution of the process which caused her retinopathy and kidney problems.
Ans: A Chapter: 04
Feedback: The blood pressure is unusual in this case in that the systolic pressure is normal while the
diastolic pressure is elevated. Especially with the retinal and urinary findings, you should consider that
the BP may be much higher and that an auscultatory gap was missed. This can be avoided by checking
for obliteration of the radial pulse while the cuff is inflated. Although a large cuff can cause a slightly
lower BP on a patient with a small arm, this does not account for the elevated DBP. Emotional upset
usually causes elevation of the BP. Although a process which caused the retinopathy and kidney
problems may have resolved, leaving these findings, it is a dangerous assumption that this is the sole
cause of the problems seen in this patient.
15. Despite having high BP readings in the office, Mr. Kelly tells you that his readings at home are
much lower. He checks them twice a day at the same time of day and has kept a log. How do you
respond?
A) You diagnose ―white coat hypertension.‖
B) You assume he is quite nervous when he comes to your office.
C) You question the accuracy of his measurements.
D) You question the accuracy of your measurements.
Ans: C Chapter: 04
Feedback: It is not uncommon to see differences in a patient's home measurements and your own in
the office. Presuming that this is ―white coat hypertension‖ can be dangerous because this condition
is not usually treated. This allows for the effects of a missed diagnosis of hypertension to go
unchecked. It is also very difficult to judge if a patient is outwardly nervous. You should always
consider that your measurements are not accurate as well, but the fact that you and your staff are welltrained and perform this procedure on hundreds of patients a week makes this less likely. Ideally, you
would ask the patient to bring in his BP equipment and take a simultaneous reading with you to make
sure that he is getting an accurate reading.
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16. You are observing a patient with heart failure and notice that there are pauses in his breathing.
On closer examination, you notice that after the pauses the patient takes progressively deeper breaths
and then progressively shallower breaths, which are followed by another apneic spell. The patient is
not in any distress. You make the diagnosis of:
A) Ataxic (Biot's) breathing
B) Cheyne-Stokes respiration
C) Kussmaul's respiration
D) COPD with prolonged expiration
Ans: B Chapter: 04
Feedback: Cheyne-Stokes respiration can be seen in patients with heart failure and is usually not a
sign of an immediate problem. Ataxic breathing is very irregular in rhythm and depth and is seen with
brain injury. Kussmaul's respiration is seen in patients with a metabolic acidosis, as they are trying to
rid their bodies of carbon dioxide to compensate. Respirations in COPD are usually regular and are
not usually associated with apneic episodes.
17. Mr. Garcia comes to your office for a rash on his chest associated with a burning pain. Even a
light touch causes this burning sensation to worsen. On examination, you note a rash with small
blisters (vesicles) on a background of reddened skin. The rash overlies an entire rib on his right side.
What type of pain is this?
A) Idiopathic pain
B) Neuropathic pain
C) Nociceptive or somatic pain
D) Psychogenic pain
Ans: B Chapter: 04
Feedback: This vignette is consistent with a diagnosis of herpes zoster, or shingles. This is caused by
reemergence of dormant varicella (chickenpox) viruses from Mr. Garcia's nerve root. The
characteristic burning quality without a history of an actual burn makes one think of neuropathic
pain. It will most likely remain for months after the rash has resolved. There is no evidence of
physical injury and this is a peculiar distribution, making nociceptive pain less likely. There is no
evidence of a psychogenic etiology for this, and the presence of a rash makes this possibility less
likely as well. Because of your astute diagnostic abilities, the pain is not idiopathic.
18. A 50-year-old body builder is upset by a letter of denial from his life insurance company. He is
very lean but has gained 2 pounds over the past 6 months. You personally performed his health
assessment and found no problems whatsoever. He says he is classified as ―high risk‖ because of
obesity. What should you do next?
A) Explain that even small amounts of weight gain can classify you as obese.
B) Place him on a high-protein, low-fat diet.
C) Advise him to increase his aerobic exercise for calorie burning.
D) Measure his waist.
Ans: D Chapter: 04
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Feedback: The patient most likely had a high BMI because of increased muscle mass. In this
situation, it is important to measure his waist. It is most likely under 40 inches, which makes obesity
unlikely (even to an insurance company). It is important that you personally contact the company
and explain your reasoning. Be prepared to back your argument with data. A special diet is unlikely
to be of much use, and more aerobic exercise, while probably a good idea for most, is redundant for
this individual.
19. Ms. Wright comes to your office, complaining of palpitations. While checking her pulse you
notice an irregular rhythm. When you listen to her heart, every fourth beat sounds different. It sounds
like a triplet rather than the usual ―lub dup.‖ How would you document your examination?
A) Regular rate and rhythm
B) Irregularly irregular rhythm
C) Regularly irregular rhythm
D) Bradycardia
Ans: C Chapter: 04
Feedback: Because this unusual beat occurs every fourth set of heart sounds, it is regularly irregular.
This is most consistent with ventricular premature contractions (or VPCs). This is generally a common
and benign rhythm. An irregularly irregular rhythm is a classic finding in atrial fibrillation. The
rhythm is very random in character. Bradycardia refers to the rate, not the rhythm.
Chapter 5 Cultural and Spiritual Assessment
MULTIPLE CHOICE
1. The nurse is reviewing the development of culture. Which statement is correct regarding the
development of ones culture? Culture is:
a.
b.
c.
d.
Genetically determined on the basis of racial background.
Learned through language acquisition and socialization.
A nonspecific phenomenon and is adaptive but unnecessary.
Biologically determined on the basis of physical characteristics.
ANS: B
Culture is learned from birth through language acquisition and socialization. It is not biologically or
genetically determined and is learned by the individual.
2. During a class on the aspects of culture, the nurse shares that culture has four basic
characteristics. Which statement correctly reflects one of these characteristics?
a. Cultures are static and unchanging, despite changes around them.
b. Cultures are never specific, which makes them hard to identify.
c. Culture is most clearly reflected in a persons language and behavior.
d. Culture adapts to specific environmental factors and available natural resources.
ANS: D
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Culture has four basic characteristics. Culture adapts to specific conditions related to environmental
and technical factors and to the availability of natural resources, and it is dynamic and ever changing.
Culture is learned from birth through the process of language acquisition and socialization, but it is not
most clearly reflected in ones language and behavior.
3. During a seminar on cultural aspects of nursing, the nurse recognizes that the definition stating the
specific and distinct knowledge, beliefs, skills, and customs acquired by members of a society reflects
which term?
a.
b.
c.
d.
Mores
Norms
Culture
Social learning
ANS: C
The culture that develops in any given society is always specific and distinctive, encompassing all of
the knowledge, beliefs, customs, and skills acquired by members of the society. The other terms do
not fit the given definition.
4. When discussing the use of the term subculture, the nurse recognizes that it is best described as:
a. Fitting as many people into the majority culture as possible.
b. Defining small groups of people who do not want to be identified with the larger
culture.
c. Singling out groups of people who suffer differential and unequal treatment as a
result of cultural variations.
d. Identifying fairly large groups of people with shared characteristics that are not
common to all members of a culture.
ANS: D
Within cultures, groups of people share different beliefs, values, and attitudes. Differences occur
because of ethnicity, religion, education, occupation, age, and gender. When such groups function
within a large culture, they are referred to as subcultural groups.
5. When reviewing the demographics of ethnic groups in the United States, the nurse recalls that the
largest and fastest growing population is:
a.
b.
c.
d.
Hispanic.
Black.
Asian.
American Indian.
ANS: A
Hispanics are the largest and fastest growing population in the United States, followed by Asians,
Blacks, American Indians and Alaska natives, and other groups.
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6. During an assessment, the nurse notices that a patient is handling a small charm that is tied to a
leather strip around his neck. Which action by the nurse is appropriate?
a.
b.
c.
d.
Ask the patient about the item and its significance.
Ask the patient to lock the item with other valuables in the hospitals safe.
Tell the patient that a family member should take valuables home.
No action is necessary.
ANS: A
The nurse should inquire about the amulets meaning. Amulets, such as charms, are often considered an
important means of protection from evil spirits by some cultures.
7. The nurse manager is explaining culturally competent care during a staff meeting. Which
statement accurately describes the concept of culturally competent care? The caregiver:
a. Is able to speak the patients native language.
b. Possesses some basic knowledge of the patients cultural background.
c. Applies the proper background knowledge of a patients cultural background to
provide the best possible health care.
d. Understands and attends to the total context of the patients situation.
ANS: D
Culturally competent implies that the caregiver understands and attends to the total context of the
individuals situation. This competency includes awareness of immigration status, stress factors, other
social factors, and cultural similarities and differences. It does not require the caregiver to speak the
patients native language.
8. The nurse recognizes that an example of a person who is heritage consistent would be a:
a.
b.
c.
d.
Woman who has adapted her clothing to the clothing style of her new country.
Woman who follows the traditions that her mother followed regarding meals.
Man who is not sure of his ancestors country of origin.
Child who is not able to speak his parents native language.
ANS: B
Someone who is heritage consistent lives a lifestyle that reflects his or her traditional heritage, not the
norms and customs of the new country.
9. After a class on culture and ethnicity, the new graduate nurse reflects a correct understanding of
the concept of ethnicity with which statement?
a. Ethnicity is dynamic and ever changing.
b. Ethnicity is the belief in a higher power.
c. Ethnicity pertains to a social group within the social system that claims shared
values and traditions.
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d. Ethnicity is learned from birth through the processes of language acquisition and
socialization.
ANS: C
Ethnicity pertains to a social group within the social system that claims to have variable traits, such
as a common geographic origin, migratory status, religion, race, language, values, traditions,
symbols, or food preferences.Culture is dynamic, ever changing, and learned from birth through the
processes of language acquisition and socialization. Religion is the belief in a higher power.
10. The nurse is comparing the concepts of religion and spirituality. Which of the following is an
appropriate component of ones spirituality?
a.
b.
c.
d.
Belief in and the worship of God or gods
Attendance at a specific church or place of worship
Personal effort made to find purpose and meaning in life
Being closely tied to ones ethnic background
ANS: C
Spirituality refers to each persons unique life experiences and his or her personal effort to find purpose
and meaning in life. The other responses apply to religion.
11. A woman who has lived in the United States for a year after moving from Europe has learned to
speak English and is almost finished with her college studies. She now dresses like her peers and says
that her family in Europe would hardly recognize her. This nurse recognizes that this situation
illustrates which concept?
a. Assimilation
b. Heritage consistency
c. Biculturalism
d. Acculturation
ANS: A
Assimilation is the process by which a person develops a new cultural identity and becomes like
members of the dominant culture. This concept does not reflect heritage consistency.
Biculturalism is a dual pattern of identification; acculturation is the process of adapting to and
acquiring another culture.
12. The nurse is conducting a heritage assessment. Which question is most appropriate for this
assessment?
a.
b.
c.
d.
What is your religion?
Do you mostly participate in the religious traditions of your family?
Do you smoke?
Do you have a history of heart disease?
ANS: B
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Asking questions about participation in the religious traditions of family enables the nurse to assess a
persons heritage. Simply asking about ones religion, smoking history, or health history does not reflect
heritage.
13. In the majority culture of America, coughing, sweating, and diarrhea are symptoms of an
illness. For some individuals of Mexican-American origin, however, these symptoms are a
normal part of living. The nurse recognizes that this difference is true, probably because
Mexican-Americans:
a.
b.
c.
d.
Have less efficient immune systems and are often ill.
Consider these symptoms part of normal living, not symptoms of ill health.
Come from Mexico, and coughing is normal and healthy there.
Are usually in a lower socioeconomic group and are more likely to be sick.
ANS: B
The nurse needs to identify the meaning of health to the patient, remembering that concepts are derived,
in part, from the way in which members of the cultural group define health.
14. The nurse is reviewing theories of illness. The germ theory, which states that microscopic
organisms such as bacteria and viruses are responsible for specific disease conditions, is a basic
belief of which theory of illness?
a.
b.
c.
d.
Holistic
Biomedical
Naturalistic
Magicoreligious
ANS: B
Among the biomedical explanations for disease is the germ theory, which states that microscopic
organisms such as bacteria and viruses are responsible for specific disease conditions. The
naturalistic, or holistic, perspective holds that the forces of nature must be kept in natural balance.
The magicoreligious perspective holds that supernatural forces dominate and cause illness or health.
15. An Asian-American woman is experiencing diarrhea, which is believed to be cold or yin. The
nurse expects that the woman is likely to try to treat it with:
a.
b.
c.
d.
Foods that are hot or yang.
Readings and Eastern medicine meditations.
High doses of medicines believed to be cold.
No treatment is tried because diarrhea is an expected part of life.
ANS: A
Yin foods are cold and yang foods are hot. Cold foods are eaten with a hot illness, and hot foods are
eaten with a cold illness. The other explanations do not reflect the yin/yang theory.
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16. Many Asians believe in the yin/yang theory, which is rooted in the ancient Chinese philosophy of
Tao. Which statement most accurately reflects health in an Asian with this belief?
a.
b.
c.
d.
A person is able to work and produce.
A person is happy, stable, and feels good.
All aspects of the person are in perfect balance.
A person is able to care for others and function socially.
ANS: C
Many Asians believe in the yin/yang theory, in which health is believed to exist when all aspects of
the person are in perfect balance. The other statements do not describe this theory.
17. Illness is considered part of lifes rhythmic course and is an outward sign of disharmony
within. This statement most accurately reflects the views about illness from which theory?
a.
b.
c.
d.
Naturalistic
Biomedical
Reductionist
Magicoreligious
ANS: A
The naturalistic perspective states that the laws of nature create imbalances, chaos, and disease. From
the perspective of the Chinese, for example, illness is not considered an introducing agent; rather,
illness is considered a part of lifes rhythmic course and an outward sign of disharmony within. The
other options are not correct.
18. An individual who takes the magicoreligious perspective of illness and disease is likely to
believe that his or her illness was caused by:
a.
b.
c.
d.
Germs and viruses.
Supernatural forces.
Eating imbalanced foods.
An imbalance within his or her spiritual nature.
ANS: B
The basic premise of the magicoreligious perspective is that the world is seen as an arena in which
supernatural forces dominate. The fate of the world and those in it depends on the actions of
supernatural forces for good or evil. The other answers do not reflect the magicoreligious
perspective.
19. If an American Indian woman has come to the clinic to seek help with regulating her
diabetes, then the nurse can expect that she:
a. Will comply with the treatment prescribed.
b. Has obviously given up her belief in naturalistic causes of disease.
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c. May also be seeking the assistance of a shaman or medicine man.
d. Will need extra help in dealing with her illness and may be experiencing a crisis of
faith.
ANS: C
When self-treatment is unsuccessful, the individual may turn to the lay or folk healing systems, to
spiritual or religious healing, or to scientific biomedicine. In addition to seeking help from a
biomedical or scientific health care provider, patients may also seek help from folk or religious
healers.
20. An older Mexican-American woman with traditional beliefs has been admitted to an inpatient care
unit. A culturally sensitive nurse would:
a. Contact the hospital administrator about the best course of action.
b. Automatically get a curandero for her, because requesting one herself is not
culturally appropriate.
c. Further assess the patients cultural beliefs and offer the patient assistance in
contacting a curandero or priest if she desires.
d. Ask the family what they would like to do because Mexican-Americans
traditionally give control of decision making to their families.
ANS: C
In addition to seeking help from the biomedical or scientific health care provider, patients may also
seek help from folk or religious healers. Some people, such as those of Mexican-American or
American-Indian origins, may believe that the cure is incomplete unless the body, mind, and spirit
are also healed (although the division of the person into parts is a Western concept).
Chapter 6 Physical Examination: Getting Started
MULTIPLE CHOICE
1. The nurse is performing a general survey. Which action is a component of the general survey?
a.
b.
c.
d.
Observing the patients body stature and nutritional status
Interpreting the subjective information the patient has reported
Measuring the patients temperature, pulse, respirations, and blood pressure
Observing specific body systems while performing the physical assessment
ANS: A
The general survey is a study of the whole person that includes observing the patients physical
appearance, body structure, mobility, and behavior.
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2. When measuring a patients weight, the nurse is aware of which of these guidelines?
a. The patient is always weighed wearing only his or her undergarments.
b. The type of scale does not matter, as long as the weights are similar from day to day.
c. The patient may leave on his or her jacket and shoes as long as these are
documented next to the weight.
d. Attempts should be made to weigh the patient at approximately the same time of day,
if a sequence of weights is necessary.
ANS: D
A standardized balance scale is used to measure weight. The patient should remove his or her
shoes and heavy outer clothing. If a sequence of repeated weights is necessary, then the nurse
should attempt to weigh the patient at approximately the same time of day and with the same
types of clothing worn each time.
3. A patients weekly blood pressure readings for 2 months have ranged between 124/84 mm Hg and
136/88 mm Hg, with an average reading of 126/86 mm Hg. The nurse knows that this blood pressure
falls within which blood pressure category?
a.
b.
c.
d.
Normal blood pressure
Prehypertension
Stage 1 hypertension
tage 2 hypertension
ANS: B
According to the Seventh Report of the Joint National Committee (JNC 7) guidelines, prehypertension
blood pressure readings are systolic readings of 120 to 139 mm Hg or diastolic readings of 50 to 89 mm
Hg.
4. During an examination of a child, the nurse considers that physical growth is the best index of a
childs:
a.
b.
c.
d.
General health.
Genetic makeup.
Nutritional status.
Activity and exercise patterns.
ANS: A
Physical growth is the best index of a childs general health; recording the childs height and weight
helps determine normal growth patterns.
5. A 1-month-old infant has a head measurement of 34 cm and has a chest circumference of 32 cm.
Based on the interpretation of these findings, the nurse would:
a. Refer the infant to a physician for further evaluation.
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b. Consider these findings normal for a 1-month-old infant.
c. Expect the chest circumference to be greater than the head circumference.
d. Ask the parent to return in 2 weeks to re-evaluate the head and chest
circumferences.
ANS: B
The newborns head measures approximately 32 to 38 cm and is approximately 2 cm larger than the
chest circumference. Between 6 months and 2 years, both measurements are approximately the
same, and after age 2 years, the chest circumference is greater than the head circumference.
6. The nurse is assessing an 80-year-old male patient. Which assessment findings would be
considered normal?
a.
b.
c.
d.
Increase in body weight from his younger years
Additional deposits of fat on the thighs and lower legs
Presence of kyphosis and flexion in the knees and hips
Change in overall body proportion, including a longer trunk and shorter
extremities
ANS: C
Changes that occur in the aging person include more prominent bony landmarks, decreased body
weight (especially in men), a decrease in subcutaneous fat from the face and periphery, and additional
fat deposited on the abdomen and hips. Postural changes of kyphosis and slight flexion in the knees
and hips also occur.
7. The nurse should measure rectal temperatures in which of these patients?
a. School-age child
b. Older adult
c. Comatose adult
d. Patient receiving oxygen by nasal cannula
ANS: C
Rectal temperatures should be taken when the other routes are impractical, such as for comatose or
confused persons, for those in shock, or for those who cannot close the mouth because of breathing
or oxygen tubes, a wired mandible, or other facial dysfunctions.
8. The nurse is preparing to measure the length, weight, chest, and head circumference of a 6month-old infant. Which measurement technique is correct?
a.
b.
c.
d.
Measuring the infants length by using a tape measure
Weighing the infant by placing him or her on an electronic standing scale
Measuring the chest circumference at the nipple line with a tape measure
Measuring the head circumference by wrapping the tape measure over the nose and
cheekbones
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ANS: C
To measure the chest circumference, the tape is encircled around the chest at the nipple line. The
length should be measured on a horizontal measuring board. Weight should be measured on a
platform-type balance scale. Head circumference is measured with the tape around the head, aligned
at the eyebrows, and at the prominent frontal and occipital bonesthe widest span is correct.
9. The nurse knows that one advantage of the tympanic membrane thermometer (TMT) is that:
a. Rapid measurement is useful for uncooperative younger children.
b. Using the TMT is the most accurate method for measuring body temperature in
newborn infants.
c. Measuring temperature using the TMT is inexpensive.
d. Studies strongly support the use of the TMT in children under the age 6 years.
ANS: A
The TMT is useful for young children who may not cooperate for oral temperatures and fear rectal
temperatures. However, the use a TMT with newborn infants and young children is conflicting.
10. When assessing an older adult, which vital sign changes occur with aging?
a.
b.
c.
d.
Increase in pulse rate
Widened pulse pressure
Increase in body temperature
Decrease in diastolic blood pressure
ANS: B
With aging, the nurse keeps in mind that the systolic blood pressure increases, leading to widened
pulse pressure. With many older people, both the systolic and diastolic pressures increase. The pulse
rate and temperature do not increase.
11. The nurse is examining a patient who is complaining of feeling cold. Which is a mechanism of
heat loss in the body?
a.
b.
c.
d.
Exercise
Radiation
Metabolism
Food digestion
ANS: B
The body maintains a steady temperature through a thermostat or feedback mechanism, which is
regulated in the hypothalamus of the brain. The hypothalamus regulates heat production from
metabolism, exercise, food digestion, and external factors with heat loss through radiation,
evaporation of sweat, convection, and conduction.
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12. When measuring a patients body temperature, the nurse keeps in mind that body temperature is
influenced by:
a.
b.
c.
d.
Constipation.
Patients emotional state.
Diurnal cycle.
Nocturnal cycle.
ANS: C
Normal temperature is influenced by the diurnal cycle, exercise, and age. The other responses do not
influence body temperature.
13. When evaluating the temperature of older adults, the nurse should remember which aspect
about an older adults body temperature?
a. The body temperature of the older adult is lower than that of a younger adult.
b. An older adults body temperature is approximately the same as that of a young
child.
c. Body temperature depends on the type of thermometer used.
d. In the older adult, the body temperature varies widely because of less effective heat
control mechanisms.
ANS: A
In older adults, the body temperature is usually lower than in other age groups, with a mean
temperature of 36.2 C.
14. A 60-year-old male patient has been treated for pneumonia for the past 6 weeks. He is seen
today in the clinic for an unexplained weight loss of 10 pounds over the last 6 weeks. The nurse
knows that:
a.
b.
c.
d.
Weight loss is probably the result of unhealthy eating habits.
Chronic diseases such as hypertension cause weight loss.
Unexplained weight loss often accompanies short-term illnesses.
Weight loss is probably the result of a mental health dysfunction.
ANS: C
An unexplained weight loss may be a sign of a short-term illness or a chronic illness such as endocrine
disease, malignancy, depression, anorexia nervosa, or bulimia.
15. When assessing a 75-year-old patient who has asthma, the nurse notes that he assumes a tripod
position, leaning forward with arms braced on the chair. On the basis of this observation, the nurse
should:
a. Assume that the patient is eager and interested in participating in the interview.
b. Evaluate the patient for abdominal pain, which may be exacerbated in the sitting
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position.
c. Assume that the patient is having difficulty breathing and assist him to a supine
position.
d. Recognize that a tripod position is often used when a patient is having respiratory
difficulties.
ANS: D
Assuming a tripod positionleaning forward with arms braced on chair armsoccurs with chronic
pulmonary disease. The other actions or assumptions are not correct.
16. Which of these actions illustrates the correct technique the nurse should use when assessing oral
temperature with a mercury thermometer?
a. Wait 30 minutes if the patient has ingested hot or iced liquids.
b. Leave the thermometer in place 3 to 4 minutes if the patient is afebrile.
c. Place the thermometer in front of the tongue, and ask the patient to close his or her
lips.
d. Shake the mercury-in-glass thermometer down to below 36.6 C before taking the
temperature.
ANS: B
The thermometer should be left in place 3 to 4 minutes if the person is afebrile and up to 8 minutes if
the person is febrile. The nurse should wait 15 minutes if the person has just ingested hot or iced
liquids and 2 minutes if he or she has just smoked.
17. The nurse is taking temperatures in a clinic with a TMT. Which statement is true regarding use
of the TMT?
a.
b.
c.
d.
A tympanic temperature is more time consuming than a rectal temperature.
The tympanic method is more invasive and uncomfortable than the oral method.
The risk of cross-contamination is reduced, compared with the rectal route.
The tympanic membrane most accurately reflects the temperature in the
ophthalmic artery.
ANS: C
he TMT is a noninvasive, nontraumatic device that is extremely quick and efficient. The chance of
cross-contamination with the TMT is minimal because the ear canal is lined with skin, not mucous
membranes.
18. To assess a rectal temperature accurately in an adult, the nurse would:
a.
b.
c.
d.
Use a lubricated blunt tip thermometer.
Insert the thermometer 2 to 3 inches into the rectum.
Leave the thermometer in place up to 8 minutes if the patient is febrile.
Wait 2 to 3 minutes if the patient has recently smoked a cigarette.
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ANS: A
A lubricated rectal thermometer (with a short, blunt tip) is inserted only 2 to 3 cm (1 inch) into the
adult rectum and left in place for 2 minutes. Cigarette smoking does not alter rectal temperatures.
19. Which technique is correct when the nurse is assessing the radial pulse of a patient?
The pulse is counted for:
a. 1 minute, if the rhythm is irregular.
b. 15 seconds and then multiplied by 4, if the rhythm is regular.
c. 2 full minutes to detect any variation in amplitude.
d. 10 seconds and then multiplied by 6, if the patient has no history of cardiac
abnormalities.
ANS: A
Recent research suggests that the 30-second interval multiplied by 2 is the most accurate and
efficient technique when heart rates are normal or rapid and when rhythms are regular. If the
rhythm is irregular, then the pulse is counted for 1 full minute.
20. When assessing a patients pulse, the nurse should also notice which of these characteristics?
a.
b.
c.
d.
Force
Pallor
Capillary refill time
Timing in the cardiac cycle
ANS: A
The pulse is assessed for rate, rhythm, and force.
Chapter 7 Beginning the Physical Examination: General Survey, Vital
Signs, and Pain
Multiple Choice
1. A 15-year-old high school sophomore and her mother come to your clinic because the mother is
concerned about her daughter's weight. You measure her daughter's height and weight and obtain a
BMI of 19.5 kg/m2. Based on this information, which of the following is appropriate?
A) Refer the patient to a nutritionist and a psychologist because the patient is anorexic.
B) Reassure the mother that this is a normal body weight.
C) Give the patient information about exercise because the patient is obese.
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D) Give the patient information concerning reduction of fat and cholesterol in her diet because she
is obese.
Ans: B
Feedback: The patient has a normal BMI; the range for a normal BMI is 18.5 to 24.9 kg/m2. You
may be able to give the patient and her mother the lower limit of normal in pounds for her daughter's
height, or instruct her in how to use a BMI table.
2. A 25-year-old radio announcer comes to the clinic for an annual examination. His BMI is
26.0 kg/m2. He is concerned about his weight. Based on this information, what is appropriate counsel
for the patient during the visit?
A) Refer the patient to a nutritionist because he is anorexic.
B) Reassure the patient that he has a normal body weight.
C) Give the patient information about reduction of fat, cholesterol, and calories because he is
overweight.
D) Give the patient information about reduction of fat and cholesterol because he is obese.
Ans: C
Feedback: The patient has a BMI in the overweight range, which is 25.0 to 29.9 kg/m 2. It is prudent to
give him information about reducing calories, fat, and cholesterol in his diet to help prevent further
weight gain.
3. A 30-year-old sales clerk comes to your office wanting to lose weight; her BMI is 30.0 kg/m2.
What is the most appropriate amount for a weekly weight reduction goal?
A) .5 to 1 pound per week
B) 1 to 2.5 pounds per week
C) 2.5 to 3.5 pounds per week
D) 3.5 to 4.5 pounds per week Ans:
A
Feedback: Based on the NIH Obesity Guidelines, this is the weekly weight loss goal to strive for to
maintain long-term control of weight. More rapid weight loss than this does not result in a better
outcome at one year.
4. A 67-year-old retired janitor comes to the clinic with his wife. She brought him in because
she is concerned about his weight loss. He has a history of smoking 3 packs of cigarettes a day for 30
years, for a total of 90 pack-years. He has noticed a daily cough for the past several years, which he
states is productive of sputum. He came into the clinic approximately 1 year ago, and at that time his
weight was 140 pounds. Today, his weight is 110 pounds.
Which one of the following questions would be the most important to ask if you suspect that he has
lung cancer?
A) Have you tried to force yourself to vomit after eating a meal?
B) Do you have heartburn/indigestion and diarrhea?
C) Do you have enough food to eat?
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D) Have you tried to lose weight?
Ans: D
Feedback: This is important: If the patient hasn't tried to lose weight, then this weight loss is
inadvertent and poses concern for a neoplastic process, especially given his smoking history.
5. Common or concerning symptoms to inquire about in the General Survey and vital signs
include all of the following except:
A) Changes in weight
B) Fatigue and weakness
C) Cough
D) Fever and chills Ans:
C
Feedback: This symptom is more appropriate to the respiratory review of systems.
6. You are beginning the examination of a patient. All of the following areas are important to
observe as part of the General Survey except:
A) Level of consciousness
B) Signs of distress
C) Dress, grooming, and personal hygiene
D) Blood pressure Ans:
D
Feedback: Blood pressure is a vital sign, not part of the General Survey.
7. A 55-year-old bookkeeper comes to your office for a routine visit. You note that on a previous
visit for treatment of contact dermatitis, her blood pressure was elevated. She does not have prior
elevated readings and her family history is negative for hypertension. You measure her blood
pressure in your office today. Which of the following factors can result in a false high reading?
A) Blood pressure cuff is tightly fitted.
B) Patient is seated quietly for 10 minutes prior to measurement.
C) Blood pressure is measured on a bare arm.
D) Patient's arm is resting, supported by your arm at her mid-chest level as you stand to measure the
blood pressure.
Ans: A
Feedback: A blood pressure cuff that is too tightly fitted can result in a false high reading. The other
answers are important to observe to obtain an accurate blood pressure reading. JNC-7 also mentions
the importance of having the back supported when obtaining blood pressure in the sitting position.
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8. A 49-year-old truck driver comes to the emergency room for shortness of breath and swelling in
his ankles. He is diagnosed with congestive heart failure and admitted to the hospital. You are the
student assigned to do the patient's complete history and physical examination. When you palpate the
pulse, what do you expect to feel?
A) Large amplitude, forceful
B) Small amplitude, weak
C) Normal
D) Bigeminal
Ans: B
Feedback: Congestive heart failure is characterized by decreased stroke volume or increased peripheral
vascular resistance, which would result in a small-amplitude, weak pulse. Subtle differences in
amplitude are usually best detected in large arteries close to the heart, like the carotid pulse. You may
not be able to notice these in other locations.
9. An 18-year-old college freshman presents to the clinic for evaluation of gastroenteritis. You
measure the patient's temperature and it is 104 degrees Fahrenheit. What type of pulse would you
expect to feel during his initial examination?
A) Large amplitude, forceful
B) Small amplitude, weak
C) Normal
D) Bigeminal
Ans: A
Feedback: Fever results in an increased stroke volume, which results in a large-amplitude, forceful
pulse. Later in the course of the illness, if dehydration and shock result, you may expect small
amplitude and weak pulses.
10. A 25-year-old type 1 diabetic clerk presents to the emergency room with shortness of breath and
states that his blood sugar was 605 at home. You diagnose the patient with diabetic ketoacidosis.
What is the expected pattern of breathing?
A) Normal
B) Rapid and shallow
C) Rapid and deep
D) Slow Ans:
C
Feedback: This is the expected rate and depth in diabetic ketoacidosis. The body is trying to rid itself
of carbon dioxide to compensate for the acidosis. This is known as Kussmaul's breathing and is seen
in other causes of acidosis as well.
11. Mrs. Lenzo weighs herself every day with a very accurate balance-type scale. She has
noticed that over the past 2 days she has gained 4 pounds. How would you best explain this?
A) Attribute this to some overeating at the holidays.
B) Attribute this to wearing different clothing.
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C) Attribute this to body fluid.
D) Attribute this to instrument inaccuracy.
Ans: C
Feedback: This amount of weight over a short period should make one think of body fluid changes.
You may consider a kidney problem or heart failure in your differential. The other reasons should be
considered as well, but this amount of weight gain over a short period usually indicates causes other
than excessive caloric intake. A rule of thumb for dieters is that an energy excess of 3500 calories will
cause a 1-pound weight gain, if the increase is to be attributed to food intake.
12. Mr. Curtiss has a history of obesity, diabetes, osteoarthritis of the knees, HTN, and obstructive
sleep apnea. His BMI is 43 and he has been discouraged by his difficulty in losing weight. He is
also discouraged that his goal weight is 158 pounds away. What would you tell him?
A) ―When you get down to your goal weight, you will feel so much better.‖
B) ―Some people seem to be able to lose weight and others just can't, no matter how hard they try.‖
C) ―We are coming up with new medicines and methods to treat your conditions every day.‖
D) ―Even a weight loss of 10% can make a noticeable improvement in the problems you
mention.‖
Ans: D
Feedback: Many patients trying to change a habit are overwhelmed by how far they are from their
goal. As the proverb says: ―A journey of a thousand miles begins with one step.‖ Many patients find
it empowering to know that they can achieve a small goal, such as a loss of 1 pound per week. They
must be reminded that this process will take time and that slow weight loss is more successful longterm. Research has shown that significant benefits often come with even a 10% weight loss.
13. Jenny is one of your favorite patients who usually shares a joke with you and is nattily dressed.
Today she is dressed in old jeans, lacks makeup, and avoids eye contact. To what do you attribute
these changes?
A) She is lacking sleep.
B) She is fatigued from work.
C) She is running into financial difficulty.
D) She is depressed.
Ans: D
Feedback: It is important to use all of your skills and memory of an individual patient to guide your
thought process. She is not described as sleepy. Work fatigue would most likely not cause avoidance
of eye contact. Financial difficulties would not necessarily deplete a nice wardrobe. It is most likely
that she is depressed or in another type of difficulty.
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14. You are seeing an older patient who has not had medical care for many years. Her vital signs
taken by your office staff are: T 37.2, HR 78, BP 118/92, and RR 14, and she denies pain. You
notice that she has some hypertensive changes in her retinas and you find mild proteinuria
on a urine test in your office. You expected the BP to be higher. She is not on any medications. What
do you think is causing this BP reading, which doesn't correlate with the other findings?
A) It is caused by an ―auscultatory gap.‖
B) It is caused by a cuff size error.
C) It is caused by the patient's emotional state.
D) It is caused by resolution of the process which caused her retinopathy and kidney problems.
Ans: A
Feedback: The blood pressure is unusual in this case in that the systolic pressure is normal while the
diastolic pressure is elevated. Especially with the retinal and urinary findings, you should consider
that the BP may be much higher and that an auscultatory gap was missed. This can be avoided by
checking for obliteration of the radial pulse while the cuff is inflated. Although a large cuff can cause
a slightly lower BP on a patient with a small arm, this does not account for the elevated DBP.
Emotional upset usually causes elevation of the BP. Although a process which caused the retinopathy
and kidney problems may have resolved, leaving these findings, it is a dangerous assumption that this
is the sole cause of the problems seen in this patient.
15. Despite having high BP readings in the office, Mr. Kelly tells you that his readings at home are
much lower. He checks them twice a day at the same time of day and has kept a log. How do you
respond?
A) You diagnose ―white coat hypertension.‖
B) You assume he is quite nervous when he comes to your office.
C) You question the accuracy of his measurements.
D) You question the accuracy of your measurements.
Ans: C
Feedback: It is not uncommon to see differences in a patient's home measurements and your own in
the office. Presuming that this is ―white coat hypertension‖ can be dangerous because this condition
is not usually treated. This allows for the effects of a missed diagnosis of hypertension to go
unchecked. It is also very difficult to judge if a patient is outwardly nervous. You should always
consider that your measurements are not accurate as well, but the fact that you and your staff are welltrained and perform this procedure on hundreds of patients a week makes this less likely. Ideally, you
would ask the patient to bring in his BP equipment and take a simultaneous reading with you to make
sure that he is getting an accurate reading.
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Chapter 8 Nutrition and Hydration
MULTIPLE CHOICE
1. The nurse recognizes which of these persons is at greatest risk for undernutrition?
a. 5-month-old infant
b. 50-year-old woman
c. 20-year-old college student
d. 30-year-old hospital administrator
ANS: A
Vulnerable groups for undernutrition are infants, children, pregnant women, recent immigrants, persons
with low incomes, hospitalized people, and aging adults.
2. When assessing a patients nutritional status, the nurse recalls that the best definition of optimal
nutritional status is sufficient nutrients that:
a. Are in excess of daily body requirements.
b. Provide for the minimum body needs.
c. Provide for daily body requirements but do not support increased metabolic
demands.
d. Provide for daily body requirements and support increased metabolic demands.
ANS: D
Optimal nutritional status is achieved when sufficient nutrients are consumed to support day-to- day
body needs and any increased metabolic demands resulting from growth, pregnancy, or illness.
3. The nurse is providing nutrition information to the mother of a 1-year-old child. Which of
these statements represents accurate information for this age group?
a. Maintaining adequate fat and caloric intake is important for a child in this age
group.
b. The recommended dietary allowances for an infant are the same as for an
adolescent.
c. The babys growth is minimal at this age; therefore, caloric requirements are
decreased.
d. The baby should be placed on skim milk to decrease the risk of coronary artery
disease when he or she grows older.
ANS: A
Because of rapid growth, especially of the brain, both infants and children younger than 2 years of
age should not drink skim or low-fat milk or be placed on low-fat diets. Fats (calories and essential
fatty acids) are required for proper growth and central nervous system development.
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4. A pregnant woman is interested in breastfeeding her baby and asks several questions about the
topic. Which information is appropriate for the nurse to share with her?
a.
b.
c.
d.
Breastfeeding is best when also supplemented with bottle feedings.
Babies who are breastfed often require supplemental vitamins.
Breastfeeding is recommended for infants for the first 2 years of life.
Breast milk provides the nutrients necessary for growth, as well as natural
immunity.
ANS: D
Breastfeeding is recommended for full-term infants for the first year of life because breast milk is
ideally formulated to promote normal infant growth and development, as well as natural immunity.
The other statements are not correct.
5. A mother and her 13-year-old daughter express their concern related to the daughters recent
weight gain and her increase in appetite. Which of these statements represents information the
nurse should discuss with them?
a.
b.
c.
d.
Dieting and exercising are necessary at this age.
Snacks should be high in protein, iron, and calcium.
Teenagers who have a weight problem should not be allowed to snack.
A low-calorie diet is important to prevent the accumulation of fat.
ANS: B
After a period of slow growth in late childhood, adolescence is characterized by rapid physical growth
and endocrine and hormonal changes. Caloric and protein requirements increase to meet this demand.
Because of bone growth and increasing muscle mass (and, in girls, the onset of menarche), calcium and
iron requirements also increase.
6. The nurse is assessing a 30-year-old unemployed immigrant from an underdeveloped country who
has been in the United States for 1 month. Which of these problems related to his nutritional status
might the nurse expect to find?
a.
b.
c.
d.
Obesity
Hypotension
Osteomalacia (softening of the bones)
Coronary artery disease
ANS: C
General undernutrition, hypertension, diarrhea, lactose intolerance, osteomalacia, scurvy, and dental
caries are among the more common nutrition-related problems of new immigrants from developing
countries.
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7. For the first time, the nurse is seeing a patient who has no history of nutrition-related
problems. The initial nutritional screening should include which activity?
a.
b.
c.
d.
Calorie count of nutrients
Anthropometric measures
Complete physical examination
Measurement of weight and weight history
ANS: D
Parameters used for nutrition screening typically include weight and weight history, conditions
associated with increased nutritional risk, diet information, and routine laboratory data. The other
responses reflect a more in-depth assessment rather than a screening.
8. A patient is asked to indicate on a form how many times he eats a specific food. This method
describes which of these tools for obtaining dietary information?
a.
b.
c.
d.
Food diary
Calorie count
24-hour recall
Food-frequency questionnaire
ANS: D
With this tool, information is collected on how many times per day, week, or month the individual
eats particular foods, which provides an estimate of usual intake.
9. The nurse is providing care for a 68-year-old woman who is complaining of constipation.
What concern exists regarding her nutritional status?
a.
b.
c.
d.
Absorption of nutrients may be impaired.
Constipation may represent a food allergy.
The patient may need emergency surgery to correct the problem.
Gastrointestinal problems will increase her caloric demand.
ANS: A
Gastrointestinal symptoms such as vomiting, diarrhea, or constipation may interfere with nutrient intake
or absorption. The other responses are not correct.
10. During a nutritional assessment, why is it important for the nurse to ask a patient what
medications he or she is taking?
a.
b.
c.
d.
Certain drugs can affect the metabolism of nutrients.
The nurse needs to assess the patient for allergic reactions.
Medications need to be documented in the record for the physicians review.
Medications can affect ones memory and ability to identify food eaten in the last 24
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hours.
ANS: A
Analgesics, antacids, anticonvulsants, antibiotics, diuretics, laxatives, antineoplastic drugs, steroids, and
oral contraceptives are drugs that can interact with nutrients, impairing their digestion, absorption,
metabolism, or use. The other responses are not correct.
11. A patient tells the nurse that his food simply does not have any taste anymore. The nurses best
response would be:
a.
b.
c.
d.
That must be really frustrating.
When did you first notice this change?
My food doesnt always have a lot of taste either.
Sometimes that happens, but your taste will come back.
ANS: B
With changes in appetite, taste, smell, or chewing or swallowing, the examiner should ask about the
type of change and when the change occurred. These problems interfere with adequate nutrient intake.
The other responses are not correct.
12. The nurse is performing a nutritional assessment on a 15-year-old girl who tells the nurse that she
is so fat. Assessment reveals that she is 5 feet 4 inches and weighs 110 pounds. The nurses appropriate
response would be:
a.
b.
c.
d.
How much do you think you should weigh?
Dont worry about it; youre not that overweight.
The best thing for you would be to go on a diet.
I used to always think I was fat when I was your age.
ANS: A
Adolescents increased body awareness and self-consciousness may cause eating disorders such as
anorexia nervosa or bulimia, conditions in which the real or perceived body image does not
favorably compare with an ideal image. The nurse should not belittle the adolescents feelings, provide
unsolicited advice, or agree with her.
13. The nurse is discussing appropriate foods with the mother of a 3-year-old child. Which of
these foods are recommended?
a.
b.
c.
d.
Foods that the child will eat, no matter what they are
Foods easy to hold such as hot dogs, nuts, and grapes
Any foods, as long as the rest of the family is also eating them
Finger foods and nutritious snacks that cannot cause choking
ANS: D
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Small portions, finger foods, simple meals, and nutritious snacks help improve the dietary intake of
young children. Foods likely to be aspirated should be avoided (e.g., hot dogs, nuts, grapes, round
candies, popcorn).
14. The nurse is reviewing the nutritional assessment of an 82-year-old patient. Which of these
factors will most likely affect the nutritional status of an older adult?
a.
b.
c.
d.
Increase in taste and smell
Living alone on a fixed income
Change in cardiovascular status
Increase in gastrointestinal motility and absorption
ANS: B
Socioeconomic conditions frequently affect the nutritional status of the aging adult; these factors
should be closely evaluated. Physical limitations, income, and social isolation are frequent problems
that interfere with the acquisition of a balanced diet. A decrease in taste and smell and decreased
gastrointestinal motility and absorption occur with aging. Cardiovascular status is not a factor that
affects an older adults nutritional status.
15. When considering a nutritional assessment, the nurse is aware that the most common
anthropometric measurements include:
a.
b.
c.
d.
Height and weight.
Leg circumference.
Skinfold thickness of the biceps.
Hip and waist measurements.
ANS: A
The most commonly used anthropometric measures are height, weight, triceps skinfold thickness,
elbow breadth, and arm and head circumferences.
16. If a 29-year-old woman weighs 156 pounds, and the nurse determines her ideal body weight to be
120 pounds, then how would the nurse classify the womans weight?
a.
b.
c.
d.
Obese
Mildly overweight
Suffering from malnutrition
Within appropriate range of ideal weight
ANS: A
Obesity, as a result of caloric excess, refers to weight more than 20% above ideal body weight. For
this patient, 20% of her ideal body weight would be 24 pounds, and greater than 20% of her body
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weight would be over 144 pounds. Therefore, having a weight of 156 pounds would be considered
obese.
17. How should the nurse perform a triceps skinfold assessment?
a. After pinching the skin and fat, the calipers are vertically applied to the fat fold.
b. The skin and fat on the front of the patients arm are gently pinched, and then the
calipers are applied.
c. After applying the calipers, the nurse waits 3 seconds before taking a reading.
After repeating the procedure three times, an average is recorded.
d. The patient is instructed to stand with his or her back to the examiner and arms
folded across the chest. The skin on the forearm is pinched.
ANS: C
While holding the skinfold, the lever of the calipers is released. The nurse waits 3 seconds and then
takes a reading. This procedure should be repeated three times, and an average of the three skinfold
measurements is then recorded.
18. In teaching a patient how to determine total body fat at home, the nurse includes instructions to
obtain measurements of:
a.
b.
c.
d.
Height and weight.
Frame size and weight.
Waist and hip circumferences.
Mid-upper arm circumference and arm span.
ANS: A
Body mass index, calculated by using height and weight measurements, is a practical marker of
optimal weight for height and an indicator of obesity. The other options are not correct.
19. The nurse is evaluating patients for obesity-related diseases by calculating the waist-to-hip
ratios. Which one of these patients would be at increased risk?
a.
b.
c.
d.
29-year-old woman whose waist measures 33 inches and hips measure 36 inches
32-year-old man whose waist measures 34 inches and hips measure 36 inches
38-year-old man whose waist measures 35 inches and hips measure 38 inches
46-year-old woman whose waist measures 30 inches and hips measure 38 inches
ANS: A
The waist-to-hip ratio assesses body fat distribution as an indicator of health risk. A waist-to-hip ratio
of 1.0 or greater in men or 0.8 or greater in women is indicative of android (upper body obesity) and
increasing risk for obesity-related disease and early death. The 29-year-old woman
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has a waist-to-hip ratio of 0.92, which is greater than 0.8. The 32-year-old man has a waist-to-hip ratio
of 0.94; the 38-year-old man has a waist-to-hip ratio of 0.92; the 46-year-old woman has a waist-tohip ratio of 0.78.
20. A 50-year-old woman with elevated total cholesterol and triglyceride levels is visiting the clinic
to find out about her laboratory results. What would be important for the nurse to include in patient
teaching in relation to these tests?
a.
b.
c.
d.
The risks of undernutrition should be included.
Offer methods to reduce the stress in her life.
Provide information regarding a diet low in saturated fat.
This condition is hereditary; she can do nothing to change the levels.
ANS: C
The patient with elevated cholesterol and triglyceride levels should be taught about eating a healthy
diet that limits the intake of foods high in saturated fats or trans fats. Reducing dietary fats is part of
the treatment for this condition. The other responses are not pertinent to her condition.
21. In performing an assessment on a 49-year-old woman who has imbalanced nutrition as a
result of dysphagia, which data would the nurse expect to find?
a.
b.
c.
d.
Increase in hair growth
Inadequate nutrient food intake
Weight 10% to 20% over ideal
Sore, inflamed buccal cavity
ANS: B
Dysphagia, or impaired swallowing, interferes with adequate nutrient intake.
Chapter 9 The Integumentary System
Multiple Choice
1. A 35-year-old archaeologist comes to your office (located in Phoenix, Arizona) for a regular skin
check-up. She has just returned from her annual dig site in Greece. She has fair skin and reddishblonde hair. She has a family history of melanoma. She has many freckles scattered across her skin.
From this description, which of the following is not a risk factor for melanoma in this patient?
A) Age
B) Hair color
C) Actinic lentigines
D) Heavy sun exposure
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Ans: A
Feedback: The risk for melanoma is increased in people over the age of 50; our patient is 35 years
old. The other answers represent known risk factors for melanoma. Especially with a family history
of melanoma, she should be instructed to keep her skin covered when in the sun and use strong
sunscreen on exposed areas.
2. You are speaking to an 8th grade class about health prevention and are preparing to discuss the
ABCDEs of melanoma. Which of the following descriptions correctly defines the ABCDEs?
A) A = actinic; B = basal cell; C = color changes, especially blue; D = diameter >6 mm; E =
evolution
B) A = asymmetry; B = irregular borders; C = color changes, especially blue; D = diameter >6 mm;
E = evolution
C) A = actinic; B = irregular borders; C = keratoses; D = dystrophic nails; E = evolution
D) A = asymmetry; B = regular borders; C = color changes, especially orange; D = diameter >6 mm;
E = evolution
Ans: B
Feedback: This is the correct description for the mnemonic.
3. You are beginning the examination of the skin on a 25-year-old teacher. You have previously
elicited that she came to the office for evaluation of fatigue, weight gain, and hair loss. You strongly
suspect that she has hypothyroidism. What is the expected moisture and texture of the skin of a
patient with hypothyroidism?
A) Moist and smooth
B) Moist and rough
C) Dry and smooth
D) Dry and rough
Ans: D
Feedback: A patient with hypothyroidism is expected to have skin that is dry as well as rough. This
is a good example of how the skin can give clues to systemic diseases.
4. A 28-year-old patient comes to the office for evaluation of a rash. At first there was only one large
patch, but then more lesions erupted suddenly on the back and torso; the lesions itch. On physical
examination, you note that the pattern of eruption is like a Christmas tree and that there are a variety
of erythematous papules and macules on the cleavage lines of the back. Based on this description,
what is the most likely diagnosis?
A) Pityriasis rosea
B) Tinea versicolor
C) Psoriasis
D) Atopic eczema
Ans: A
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Feedback: This is a classic description of pityriasis rosea. The description of a large single or
―herald‖ patch preceding the eruption is a good way to distinguish this rash from other conditions.
5. A 19-year-old construction worker presents for evaluation of a rash. He notes that it started on his
back with a multitude of spots and is also on his arms, chest, and neck. It itches a lot. He does sweat
more than before because being outdoors is part of his job. On physical examination, you note dark
tan patches with a reddish cast that has sharp borders and fine scales, scattered more prominently
around the upper back, chest, neck, and upper arms as well as under the arms. Based on this
description, what is your most likely diagnosis?
A) Pityriasis rosea
B) Tinea versicolor
C) Psoriasis
D) Atopic eczema
Ans: B
Feedback: This is a typical description of tinea versicolor. The information that the patient is sweating
more also helps support this diagnosis, because tinea is a fungal infection and is promoted by moisture.
6. A 68-year-old retired farmer comes to your office for evaluation of a skin lesion. On the right
temporal area of the forehead, you see a flattened papule the same color as his skin, covered by a dry
scale that is round and feels hard. He has several more of these scattered on the forehead, arms, and
legs. Based on this description, what is your most likely diagnosis?
A) Actinic keratosis
B) Seborrheic keratosis
C) Basal cell carcinoma
D) Squamous cell carcinoma
Ans: A
Feedback: This is a typical description of actinic keratosis. Actinic keratosis may be easier to feel
than to see. If left untreated, approximately 1% of cases can develop into squamous cell carcinoma.
7. A 58-year-old gardener comes to your office for evaluation of a new lesion on her upper chest.
The lesion appears to be ―stuck on‖ and is oval, brown, and slightly elevated with a flat surface. It
has a rough, wartlike texture on palpation. Based on this description, what is your most likely
diagnosis?
A) Actinic keratosis
B) Seborrheic keratosis
C) Basal cell carcinoma
D) Squamous cell carcinoma
Ans: B
Feedback: This is a typical description for seborrheic keratosis. The ―stuck on‖ appearance and the
rough, wartlike texture are key features for the diagnosis. They often produce a greasy scale when
scratched with a fingernail, which further helps to distinguish them from other lesions.
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Frequently, these benign lesions actually meet several of the ABCDEs of melanoma, so it is important
to distinguish these lesions to prevent unnecessary biopsy. It is important to consider biopsy whenever
there is any doubt, though.
8. A 72-year-old teacher comes to a skilled nursing facility for rehabilitation after being in the
hospital for 6 weeks. She was treated for sepsis and respiratory failure and had to be on the ventilator
for 3 weeks. You are completing your initial assessment and are evaluating her skin condition. On
her sacrum there is full-thickness skin loss that is 5 cm in diameter, with damage to the subcutaneous
tissue. The underlying muscle is not affected. You diagnose this as a pressure ulcer. What is the stage of this
ulcer?
A) Stage 1
B) Stage 2
C) Stage 3
D) Stage 4 Ans:
C
Feedback: A stage 3 ulcer is a full-thickness skin loss with damage to or necrosis of subcutaneous
tissue that may extend to, but not through, the underlying muscle.
9. An 8-year-old girl comes with her mother for evaluation of hair loss. She denies pulling or
twisting her hair, and her mother has not noted this behavior at all. She does not put her hair in
braids. On physical examination, you note a clearly demarcated, round patch of hair loss without
visible scaling or inflammation. There are no hair shafts visible. Based on this description, what is
your most likely diagnosis?
A) Alopecia areata
B) Trichotillomania
C) Tinea capitis
D) Traction alopecia Ans:
A
Feedback: This is a typical description for alopecia areata. There are no risk factors for
trichotillomania or for traction alopecia. The physical examination is not consistent with tinea capitis
because the skin is intact.
10. A mother brings her 11 month old to you because her mother-in-law and others have told her that
her baby is jaundiced. She is eating and growing well and performing the developmental milestones
she should for her age. On examination you indeed notice a yellow tone to her skin from head to toe.
Her sclerae are white. To which area should your next questions be related?
A) Diet
B) Family history of liver diseases
C) Family history of blood diseases
D) Ethnicity of the child
Ans: A
Feedback: The lack of jaundice in the sclerae is an important clue. Typically, this is the first place
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where one sees jaundice. This examination should also be carried out in natural light (sunlight) as
opposed to fluorescent lighting, which can alter perceived colors. Many infants this age have a large
proportion of carrots, tomatoes, and yellow squash, which are rich in carotene. Liver and blood
diseases can cause jaundice, but this should involve the sclerae. The ethnicity of the child should not
cause a perceived change from her usual skin tone.
11. A new mother is concerned that her child occasionally ―turns blue.‖ On further questioning, she
mentions that this is at her hands and feet. She does not remember the child's lips turning blue. She is
otherwise eating and growing well. What would you do now?
A) Reassure her that this is normal
B) Obtain an echocardiogram to check for structural heart disease and consult cardiology
C) Admit the child to the hospital for further observation
D) Question the validity of her story Ans:
A
Feedback: This is an example of peripheral cyanosis. This is a very common and benign condition
which typically occurs when the child is slightly cold and his peripheral circulation is adjusting to
keep his core warm. Without other problems, there is no need for further workup. If the lips or other
central locations are involved, you must consider other etiologies.
12. You are examining an unconscious patient from another region and notice Beau's lines, a
transverse groove across all of her nails, about 1 cm from the proximal nail fold. What would you
do next?
A) Conclude this is caused by a cultural practice.
B) Conclude this finding is most likely secondary to trauma.
C) Look for information from family and records regarding any problems which occurred 3
months ago.
D) Ask about dietary intake.
Ans: C
Feedback: These lines can provide valuable information about previous significant illnesses, some of
which are forgotten or are not able to be reported by the patient. Because the fingernails grow at about
0.1 mm per day, you would ask about an illness 100 days ago. This patient may have been
hospitalized for endocarditis or may have had another significant illness which should be sought.
Trauma to all 10 nails in the same location is unlikely. Dietary intake at this time would not be related
to this finding. Do not assume a finding is necessarily related to a patient's culture unless you have
good knowledge of that culture.
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13. Dakota is a 14-year-old boy who just noticed a rash at his ankles. There is no history of exposure
to ill people or other agents in the environment. He has a slight fever in the office. The rash consists
of small, bright red marks. When they are pressed, the red color remains. What should you do?
A) Prescribe a steroid cream to decrease inflammation.
B) Consider admitting the patient to the hospital.
C) Reassure the parents and the patient that this should resolve within a week.
D) Tell him not to scratch them, and follow up in 3 days.
Ans: B
Feedback: Although this may not be an impressive rash, the fact that they do not ―blanch‖ with
pressure is very concerning. This generally means that there is pinpoint bleeding under the skin, and
while this can be benign, it can be associated with life-threatening illnesses like meningococcemia and
low platelet counts (thrombocytopenia) associated with serious blood disorders like leukemia. You
should always report this feature of a rash immediately to a supervisor or teacher.
14. Mrs. Hill is a 28-year-old African-American with a history of SLE (systemic lupus
erythematosus). She has noticed a raised, dark red rash on her legs. When you press on the rash, it
doesn't blanch. What would you tell her regarding her rash?
A) It is likely to be related to her lupus.
B) It is likely to be related to an exposure to a chemical.
C) It is likely to be related to an allergic reaction.
D) It should not cause any problems.
Ans: A
Feedback: A ―palpable purpura‖ is usually associated with a vasculitis. This is an inflammatory
condition of the blood vessels often associated with systemic rheumatic disease. It can cut off
circulation to any portion of the body and can mimic many other diseases in this manner. While
allergic and chemical exposures may be a possible cause of the rash, this patient's SLE should make
you consider vasculitis.
15. Jacob, a 33-year-old construction worker, complains of a ―lump on his back‖ over his scapula. It
has been there for about a year and is getting larger. He says his wife has been able to squeeze out a
cheesy-textured substance on occasion. He worries this may be cancer. When gently pinched from
the side, a prominent dimple forms in the middle of the mass. What is most
likely?
A) An enlarged lymph node
B) A sebaceous cyst
C) An actinic keratosis
D) A malignant lesion
Ans: B
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Feedback: This is a classic description of an epidermal inclusion cyst resulting from a blocked
sebaceous gland. The fact that any lesion is enlarging is worrisome, but the other descriptors are so
distinctive that cancer is highly unlikely. This would be an unusual location for a lymph node, and
these do not usually drain to the skin.
16. A young man comes to you with an extremely pruritic rash over his knees and elbows which has
come and gone for several years. It seems to be worse in the winter and improves with some sun
exposure. On examination, you notice scabbing and crusting with some silvery scale, and you are
observant enough to notice small ―pits‖ in his nails. What would account for these findings?
A) Eczema
B) Pityriasis rosea
C) Psoriasis
D) Tinea infection Ans:
C
Feedback: This is a classic presentation of plaque psoriasis. Eczema is usually over the flexor surfaces
and does not scale, whereas psoriasis affects the extensor surfaces. Pityriasis usually is limited to the
trunk and proximal extremities. Tinea has a much finer scale associated with it, almost like powder,
and is found in dark and moist areas.
17. Mrs. Anderson presents with an itchy rash which is raised and appears and disappears in various
locations. Each lesion lasts for many minutes. What most likely accounts for this rash?
A) Insect bites
B) Urticaria, or hives
C) Psoriasis
D) Purpura
Ans: B
Feedback: This is a typical case of urticaria. The most unusual aspect of this condition is that the
lesions ―move‖ from place to place. This would be distinctly unusual for the other causes listed.
18. Ms. Whiting is a 68 year old who comes in for her usual follow-up visit. You notice a few flat
red and purple lesions, about 6 centimeters in diameter, on the ulnar aspect of her forearms but
nowhere else. She doesn't mention them. They are tender when you examine them. What should
you do?
A) Conclude that these are lesions she has had for a long time.
B) Wait for her to mention them before asking further questions.
C) Ask how she acquired them.
D) Conduct the visit as usual for the patient.
Ans: C
Feedback: These are consistent with ecchymoses, or bruises. It is important to ask about antiplatelet
medications such as aspirin, trauma history, and history of blood disorders in the patient and her
family. Because of the different ages of the bruises and the isolation of them to the ulnar forearms,
these may be a result of abuse or other violence. It is your duty to investigate the cause of these
lesions.
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19. A middle-aged man comes in because he has noticed multiple small, blood-red, raised lesions
over his anterior chest and abdomen for the past several months. They are not painful and he has
not noted any bleeding or bruising. He is concerned this may be consistent with a dangerous
condition. What should you do?
A) Reassure him that there is nothing to worry about.
B) Do laboratory work to check for platelet problems.
C) Obtain an extensive history regarding blood problems and bleeding disorders.
D) Do a skin biopsy in the office.
Ans: A
Feedback: These represent cherry angiomas, which are very common, benign lesions. Further
workup such as laboratory work, skin biopsy, or even further questions are not necessary at this time.
It would be wise to ask the patient to report any changes in any of his skin lesions, and tell him that
you would need to see him at that time.
Chapter 10 The Head and Neck
Multiple Choice
1. A 38-year-old accountant comes to your clinic for evaluation of a headache. The throbbing
sensation is located in the right temporal region and is an 8 on a scale of 1 to 10. It started a few
hours ago, and she has noted nausea with sensitivity to light; she has had headaches like this in the
past, usually less than one per week, but not as severe. She does not know of any inciting factors.
There has been no change in the frequency of her headaches. She usually takes an over- the-counter
analgesic and this results in resolution of the headache. Based on this description, what is the most
likely diagnosis of the type of headache?
A) Tension
B) Migraine
C) Cluster
D) Analgesic rebound
Ans: B
Feedback: This is a description of a common migraine (no aura). Distinctive features of a migraine
include phonophobia and photophobia, nausea, resolution with sleep, and unilateral distribution. Only
some of these features may be present.
2. A 29-year-old computer programmer comes to your office for evaluation of a headache. The
tightening sensation is located all over the head and is of moderate intensity. It used to last minutes,
but this time it has lasted for 5 days. He denies photophobia and nausea. He spends several hours
each day at a computer monitor/keyboard. He has tried over-the-counter medication; it has dulled
the pain but not taken it away. Based on this description, what is your most likely diagnosis?
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A)
B)
C)
D)
Tension
Migraine
Cluster
Analgesic rebound
Ans: A
Feedback: This is a description of a typical tension headache.
3. Which of the following is a symptom involving the eye?
A) Scotomas
B) Tinnitus
C) Dysphagia
D) Rhinorrhea
Ans: A
Feedback: Scotomas are specks in the vision or areas where the patient cannot see; therefore, this is a
common/concerning symptom of the eye.
4. A 49-year-old administrative assistant comes to your office for evaluation of dizziness. You elicit
the information that the dizziness is a spinning sensation of sudden onset, worse with head position
changes. The episodes last a few seconds and then go away, and they are accompanied by intense
nausea. She has vomited one time. She denies tinnitus. You perform a physical examination of the
head and neck and note that the patient's hearing is intact to Weber and Rinne and that there is
nystagmus. Her gait is normal. Based on this description, what is the most likely diagnosis?
A) Benign positional vertigo
B) Vestibular neuronitis
C) Ménière's disease
D) Acoustic neuroma
Ans: A
Feedback: This is a classic description of benign positional vertigo. The vertigo is episodic, lasting a
few seconds to minutes, instead of continuous as in vestibular neuronitis. Also, there is no tinnitus or
sensorineural hearing loss as occurs in Ménière's disease and acoustic neuroma.
You may choose to learn about Hallpike maneuvers, which are also helpful in the evaluation of vertigo.
5. A 55-year-old bank teller comes to your office for persistent episodes of dizziness. The first
episode started suddenly and lasted 3 to 4 hours. He experienced a lot of nausea with vomiting; the
episode resolved spontaneously. He has had five episodes in the past 1½ weeks. He does note some
tinnitus that comes and goes. Upon physical examination, you note that he has a normal gait. The
Weber localizes to the right side and the air conduction is equal to the bone conduction in the right
ear. Nystagmus is present. Based on this description, what is the most likely diagnosis?
A) Benign positional vertigo
B) Vestibular neuronitis
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C) Ménière's disease
D) Acoustic neuroma
Ans: C
Feedback: Ménière's disease is characterized by sudden onset of vertiginous episodes that last several
hours to a day or more, then spontaneously resolve; the episodes then recur. On physical examination,
sensorineural hearing loss is present. The patient does complain of tinnitus.
6. A 73-year-old nurse comes to your office for evaluation of new onset of tremors. She is not on any
medications and does not take herbs or supplements. She has no chronic medical conditions. She does
not smoke or drink alcohol. She walks into the examination room with slow movements and shuffling
steps. She has decreased facial mobility and a blunt expression, without any changes in hair
distribution on her face. Based on this description, what is the most likely reason for the patient's
symptoms?
A) Cushing's syndrome
B) Nephrotic syndrome
C) Myxedema
D) Parkinson's disease
Ans: D
Feedback: This is a typical description for a patient with Parkinson's disease. Facial mobility is
decreased, which results in a blunt expression—a ―masked‖ appearance. The patient also has decreased
blinking and a characteristic stare with an upward gaze. In combination with the findings of slow
movements and a shuffling gait, the diagnosis of Parkinson's is almost clinched.
7. A 29-year-old physical therapist presents for evaluation of an eyelid problem. On observation, the
right eyeball appears to be protruding forward. Based on this description, what is the most likely
diagnosis?
A) Ptosis
B) Exophthalmos
C) Ectropion
D) Epicanthus
Ans: B
Feedback: Exophthalmos is the condition when the eyeball protrudes forward. If it is bilateral, it
suggests the presence of Graves' disease. If it is unilateral, it could still be caused by Graves' disease.
Alternatively, it could be caused by a tumor or inflammation in the orbit.
8. A 12-year-old presents to the clinic with his father for evaluation of a painful lump in the left eye.
It started this morning. He denies any trauma or injury. There is no visual disturbance. Upon physical
examination, there is a red raised area at the margin of the eyelid that is tender to palpation; no tearing
occurs with palpation of the lesion. Based on this description, what is the most likely diagnosis?
A) Dacryocystitis
B) Chalazion
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C) Hordeolum
D) Xanthelasma
Ans: C
Feedback: A hordeolum, or sty, is a painful, tender, erythematous infection in a gland at the margin of
the eyelid.
9. A 15-year-old high school sophomore presents to the emergency room with his mother for
evaluation of an area of blood in the left eye. He denies trauma or injury but has been coughing
forcefully with a recent cold. He denies visual disturbances, eye pain, or discharge from the eye. On
physical examination, the pupils are equal, round, and reactive to light, with a visual acuity of 20/20 in
each eye and 20/20 bilaterally. There is a homogeneous, sharply demarcated area at the lateral aspect
of the base of the left eye. The cornea is clear. Based on this description, what is the most likely
diagnosis?
A) Conjunctivitis
B) Acute iritis
C) Corneal abrasion
D) Subconjunctival hemorrhage
Ans: D
Feedback: A subconjunctival hemorrhage is a leakage of blood outside of the vessels, which produces
a homogenous, sharply demarcated bright red area; it fades over several days, turning yellow, then
disappears. There is no associated eye pain, ocular discharge, or changes in visual acuity; the cornea is
clear. Many times it is associated with severe cough, choking, or vomiting, which increase venous
pressure. It is rarely caused by a serious condition, so reassurance is usually the only treatment
necessary.
10. A 67-year-old lawyer comes to your clinic for an annual examination. He denies any history of
eye trauma. He denies any visual changes. You inspect his eyes and find a triangular thickening of
the bulbar conjunctiva across the outer surface of the cornea. He has a normal pupillary reaction to
light and accommodation. Based on this description, what is the most likely diagnosis?
A) Corneal arcus
B) Cataracts
C) Corneal scar
D) Pterygium
Ans: D
Feedback: A pterygium is a triangular thickening of the bulbar conjunctiva that grows slowly across
the outer surface of the cornea, usually from the nasal side. Reddening may occur, and it may interfere
with vision as it encroaches on the pupil. Otherwise, treatment is unnecessary.
11. Which of the following is a ―red flag‖ regarding patients presenting with headache?
A) Unilateral headache
B) Pain over the sinuses
C) Age over 50
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D) Phonophobia and photophobia
Ans: C
Feedback: A unilateral headache is often seen with migraines and may commonly be accompanied
by phonophobia and photophobia. Pain over the sinuses from sinus congestion may also be
unilateral and produce pain. Migraine and sinus headaches are common and generally benign. A
new severe headache in someone over 50 can be associated with more serious etiologies for
headache. Other red flags include: acute onset, ―the worst headache of my life‖; very high blood
pressure; rash or signs of infection; known presence of cancer, HIV, or pregnancy; vomiting; recent
head trauma; and persistent neurologic problems.
12. A sudden, painless unilateral vision loss may be caused by which of the following?
A) Retinal detachment
B) Corneal ulcer
C) Acute glaucoma
D) Uveitis
Ans: A
Feedback: Corneal ulcer, acute glaucoma, and uveitis are almost always accompanied by pain. Retinal
detachment is generally painless, as is chronic glaucoma.
13. Sudden, painful unilateral loss of vision may be caused by which of the following
conditions?
A) Vitreous hemorrhage
B) Central retinal artery occlusion
C) Macular degeneration
D) Optic neuritis Ans:
D
Feedback: In multiple sclerosis, sudden painful loss of vision may accompany optic neuritis. The
other conditions are usually painless.
14. Diplopia, which is present with one eye covered, can be caused by which of the following
problems?
A) Weakness of CN III
B) Weakness of CN IV
C) A lesion of the brainstem
D) An irregularity in the cornea or lens Ans:
D
Feedback: Double vision in one eye alone points to a problem in ―processing‖ the light rays of an
incoming image. The other causes of diplopia result in a misalignment of the two eyes.
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15. A patient complains of epistaxis. Which other cause should be considered?
A) Intracranial hemorrhage
B) Hematemesis
C) Intestinal hemorrhage
D) Hematoma of the nasal septum
Ans: B
Feedback: Although the source of epistaxis may seem obvious, other bleeding locations should be on
the differential. Hematemesis can mimic this and cause delay in life-saving therapies if not
considered. Intracranial hemorrhage and septal hematoma are instances of contained bleeding.
Intestinal hemorrhage may cause hematemesis if there is obstruction distal to the bleeding, but this is
unlikely.
16. Glaucoma is the leading cause of blindness in African-Americans and the second leading
cause of blindness overall. What features would be noted on funduscopic examination?
A) Increased cup-to-disc ratio
B) AV nicking
C) Cotton wool spots
D) Microaneurysms Ans:
A
Feedback: It is important to screen for glaucoma on funduscopic examination. The cup and disc are
among the easiest features to find. AV nicking and cotton wool spots are seen in hypertension.
Microaneurysms are seen in diabetes.
17. Very sensitive methods for detecting hearing loss include which of the following?
A) The whisper test
B) The finger rub test
C) The tuning fork test
D) Audiometric testing Ans:
D
Feedback: While it is important to screen for hearing complaints with methods available to you, it
should be realized that some physical examination techniques are limited. Nonetheless, you should
be comfortable performing these tests, as audiometric testing is not always available.
18. Which area of the fundus is the central focal point for incoming images?
A) The fovea
B) The macula
C) The optic disk
D) The physiologic cup
Ans: A
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Feedback: The fovea is the area of the retina which is responsible for central vision. It is surrounded
by the macula, which is responsible for more peripheral vision. The optic disc and physiologic cup are
where the optic nerve enters the eye.
19. A light is pointed at a patient's pupil, which contracts. It is also noted that the other pupil
contracts as well, though it is not exposed to bright light. Which of the following terms describes
this latter phenomenon?
A) Direct reaction
B) Consensual reaction
C) Near reaction
D) Accommodation
Ans: B
Feedback: The constriction of the contralateral pupil is called the consensual reaction. The response
of the ipsilateral eye is the direct response. The dilation of the pupil when focusing on a close object
is the near reaction. Accommodation is the changing of the shape of the lens to sharply focus on an
object.
20. A patient is assigned a visual acuity of 20/100 in her left eye. Which of the following is true?
A) She obtains a 20% correct score at 100 feet.
B) She can accurately name 20% of the letters at 20 feet.
C) She can see at 20 feet what a normal person could see at 100 feet.
D) She can see at 100 feet what a normal person could see at 20 feet.
Ans: C
Feedback: The denominator of an acuity score represents the line on the chart the patient can read.
In the example above, the patient could read the larger letters corresponding with what a normal
person could see at 100 feet.
21. On visual confrontation testing, a stroke patient is unable to see your fingers on his entire right
side with either eye covered. Which of the following terms would describe this finding?
A) Bitemporal hemianopsia
B) Right temporal hemianopsia
C) Right homonymous hemianopsia
D) Binasal hemianopsia
Ans: C
Feedback: Because the right visual field in both eyes is affected, this is a right homonymous
hemianopsia. A bitemporal hemianopsia refers to loss of both lateral visual fields. A right temporal
hemianopsia is unilateral and binasal hemianopsia is the loss of the nasal visual fields bilaterally.
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22. You note that a patient has anisocoria on examination. Pathologic causes of this include
which of the following?
A) Horner's syndrome
B) Benign anisocoria
C) Differing light intensities for each eye
D) Eye prosthesis
Ans: A
Feedback: Anisocoria can be associated with serious pathology. Remember to exclude benign causes
before embarking on an intensive workup. Testing the near reaction in this case may help you to find
an Argyll Robertson or tonic (Adie's) pupil.
23. A patient is examined with the ophthalmoscope and found to have red reflexes bilaterally.
Which of the following have you essentially excluded from your differential?
A) Retinoblastoma
B) Cataract
C) Artificial eye
D) Hypertensive retinopathy
Ans: D
Feedback: Hypertensive retinopathy requires a careful examination of the optic fundus. It cannot be
diagnosed or excluded merely from the red reflex. Typically, the red reflex would be normal in this
case. The other conditions are all associated with an abnormal red reflex.
24. A patient presents with ear pain. She is an avid swimmer. The history includes pain and
drainage from the left ear. On examination, she has pain when the ear is manipulated, including
manipulation of the tragus. The canal is narrowed and erythematous, with some white debris in the
canal. The rest of the examination is normal. What diagnosis would you assign this patient?
A) Otitis media
B) External otitis
C) Perforation of the tympanum
D) Cholesteatoma
Ans: B
Feedback: These are classic history and examination findings for a patient suffering from external
otitis. Otitis media would not usually have pain with movement of the external ear, nor drainage
unless the eardrum was perforated. In this case the examination of the eardrum is recorded as normal.
Cholesteatoma is a growth behind the eardrum and would not account for these symptoms. Otitis
media would classically be accompanied by a bulging, erythematous eardrum.
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25. A patient with hearing loss by whisper test is further examined with a tuning fork, using the
Weber and Rinne maneuvers. The abnormal results are as follows: bone conduction is greater than
air on the left, and the patient hears the sound of the tuning fork better on the left. Which of the
following is most likely?
A) Otosclerosis of the left ear
B) Exposure to chronic loud noise of the right ear
C) Otitis media of the right ear
D) Perforation of the right eardrum Ans:
A
Feedback: The above pattern is consistent with a conductive loss on the left side. Causes would
include: foreign body, otitis media, perforation, and otosclerosis of the involved side.
26. A young man is concerned about a hard mass he has just noticed in the midline of his palate. On
examination, it is indeed hard and in the midline. There are no mucosal abnormalities associated with
this lesion. He is experiencing no other symptoms. What will you tell him is the most likely
diagnosis?
A) Leukoplakia
B) Torus palatinus
C) Thrush (candidiasis)
D) Kaposi's sarcoma
Ans: B
Feedback: Torus palatinus is relatively common and benign but can go unnoticed by the patient for
many years. The appearance of a bony mass can be concerning. Leukoplakia is a white lesion on the
mucosal surfaces corresponding to chronic mechanical or chemical irritation. It can be premalignant.
Thrush is usually painful and is seen in immunosuppressed patients or those taking inhaled steroids
for COPD or asthma. Kaposi's sarcoma is usually seen in HIV-positive individuals and is classically a
deep purple.
27. A young woman undergoes cranial nerve testing. On touching the soft palate, her uvula
deviates to the left. Which of the following is likely?
A) CN IX lesion on the left
B) CN IX lesion on the right
C) CN X lesion on the left
D) CN X lesion on the right Ans:
D
Feedback: The failure of the right side of the palate to rise denotes a problem with the right 10th
cranial nerve. The uvula deviates toward the properly functioning side.
28. A college student presents with a sore throat, fever, and fatigue for several days. You notice
exudates on her enlarged tonsils. You do a careful lymphatic examination and notice some scattered
small, mobile lymph nodes just behind her sternocleidomastoid muscles bilaterally. What group of
nodes is this?
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A)
B)
C)
D)
Submandibular
Tonsillar
Occipital
Posterior cervical
Ans: D
Feedback: The group of nodes posterior to the sternocleidomastoid muscle is the posterior cervical
chain. These are common in mononucleosis.
29. You feel a small mass that you think is a lymph node. It is mobile in both the up-and-down and
side-to-side directions. Which of the following is most likely?
A) Cancer
B) Lymph node
C) Deep scar
D) Muscle
Ans: B
Feedback: A useful maneuver for discerning lymph nodes from other masses in the neck is to check
for their mobility in all directions. Many other masses are mobile in only two directions. Cancerous
masses may also be ―fixed,‖ or immobile.
30. You are conducting a pupillary examination on a 34-year-old man. You note that both pupils
dilate slightly. Both are noted to constrict briskly when the light is placed on the right eye. What
is the most likely problem?
A) Optic nerve damage on the right
B) Optic nerve damage on the left
C) Efferent nerve damage on the right
D) Efferent nerve damage on the left
Ans: B
Feedback: Because both pupils can constrict, efferent nerve damage is unlikely. When the light is
placed on the left eye, neither a direct nor a consensual response is seen. This indicates that the left
eye is not perceiving incoming light.
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Chapter 11 The Eyes
MULTIPLE CHOICE
1. When examining the eye, the nurse notices that the patients eyelid margins approximate
completely. The nurse recognizes that this assessment finding:
a.
b.
c.
d.
Is expected.
May indicate a problem with extraocular muscles.
May result in problems with tearing.
Indicates increased intraocular pressure.
ANS: A
The palpebral fissure is the elliptical open space between the eyelids, and, when closed, the lid margins
approximate completely, which is a normal finding.
2. During ocular examinations, the nurse keeps in mind that movement of the extraocular
muscles is:
a.
b.
c.
d.
Decreased in the older adult.
Impaired in a patient with cataracts.
Stimulated by cranial nerves (CNs) I and II.
Stimulated by CNs III, IV, and VI.
ANS: D
Movement of the extraocular muscles is stimulated by three CNs: III, IV, and VI.
3. The nurse is performing an external eye examination. Which statement regarding the outer layer
of the eye is true?
a. The outer layer of the eye is very sensitive to touch.
b. The outer layer of the eye is darkly pigmented to prevent light from reflecting
internally.
c. The trigeminal nerve (CN V) and the trochlear nerve (CN IV) are stimulated
when the outer surface of the eye is stimulated.
d. The visual receptive layer of the eye in which light waves are changed into nerve
impulses is located in the outer layer of the eye.
ANS: A
The cornea and the sclera make up the outer layer of the eye. The cornea is very sensitive to touch.
The middle layer, the choroid, has dark pigmentation to prevent light from reflecting internally. The
trigeminal nerve (CN V) and the facial nerve (CN VII) are stimulated when the outer surface of the
eye is stimulated. The retina, in the inner layer of the eye, is where light waves are changed into
nerve impulses.
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4. When examining a patients eyes, the nurse recalls that stimulation of the sympathetic branch of
the autonomic nervous system:
a.
b.
c.
d.
Causes pupillary constriction.
Adjusts the eye for near vision.
Elevates the eyelid and dilates the pupil.
Causes contraction of the ciliary body.
ANS: C
Stimulation of the sympathetic branch of the autonomic nervous system dilates the pupil and
elevates the eyelid. Parasympathetic nervous system stimulation causes the pupil to constrict. The
muscle fibers of the iris contract the pupil in bright light to accommodate for near vision. The
ciliary body controls the thickness of the lens.
5. The nurse is reviewing causes of increased intraocular pressure. Which of these factors
determines intraocular pressure?
a.
b.
c.
d.
Thickness or bulging of the lens
Posterior chamber as it accommodates increased fluid
Contraction of the ciliary body in response to the aqueous within the eye
Amount of aqueous produced and resistance to its outflow at the angle of the
anterior chamber
ANS: D
Intraocular pressure is determined by a balance between the amount of aqueous produced and the
resistance to its outflow at the angle of the anterior chamber. The other responses are incorrect.
6. The nurse is conducting a visual examination. Which of these statements regarding visual
pathways and visual fields is true?
a. The right side of the brain interprets the vision for the right eye.
b. The image formed on the retina is upside down and reversed from its actual
appearance in the outside world.
c. Light rays are refracted through the transparent media of the eye before striking the
pupil.
d. Light impulses are conducted through the optic nerve to the temporal lobes of the
brain.
ANS: B
The image formed on the retina is upside down and reversed from its actual appearance in the
outside world. The light rays are refracted through the transparent media of the eye before striking
the retina, and the nerve impulses are conducted through the optic nerve tract to the visual cortex of
the occipital lobe of the brain. The left side of the brain interprets vision for the right eye.
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7. The nurse is testing a patients visual accommodation, which refers to which action?
a. Pupillary constriction when looking at a near object
b. Pupillary dilation when looking at a far object
c. Changes in peripheral vision in response to light
d. Involuntary blinking in the presence of bright light
ANS: A
The muscle fibers of the iris contract the pupil in bright light and accommodate for near vision, which
also results in pupil constriction. The other responses are not correct.
8. A patient has a normal pupillary light reflex. The nurse recognizes that this reflex indicates that:
a.
b.
c.
d.
The eyes converge to focus on the light.
Light is reflected at the same spot in both eyes.
The eye focuses the image in the center of the pupil.
Constriction of both pupils occurs in response to bright light.
ANS: D
The pupillary light reflex is the normal constriction of the pupils when bright light shines on the retina.
The other responses are not correct.
9. A mother asks when her newborn infants eyesight will be developed. The nurse should reply:
a. Vision is not totally developed until 2 years of age.
b. Infants develop the ability to focus on an object at approximately 8 months of age.
c. By approximately 3 months of age, infants develop more coordinated eye
movements and can fixate on an object.
d. Most infants have uncoordinated eye movements for the first year of life.
ANS: C
Eye movements may be poorly coordinated at birth, but by 3 to 4 months of age, the infant should
establish binocularity and should be able to fixate simultaneously on a single image with both eyes.
10. The nurse is reviewing in age-related changes in the eye for a class. Which of these
physiologic changes is responsible for presbyopia?
a.
b.
c.
d.
Degeneration of the cornea
Loss of lens elasticity
Decreased adaptation to darkness
Decreased distance vision abilities
ANS: B
The lens loses elasticity and decreases its ability to change shape to accommodate for near vision.
This condition is called presbyopia.
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11. Which of these assessment findings would the nurse expect to see when examining the eyes of a
black patient?
a.
b.
c.
d.
Increased night vision
Dark retinal background
Increased photosensitivity
Narrowed palpebral fissures
ANS: B
An ethnically based variability in the color of the iris and in retinal pigmentation exists, with darker
irides having darker retinas behind them.
12. A 52-year-old patient describes the presence of occasional floaters or spots moving in front of
his eyes. The nurse should:
a.
b.
c.
d.
Examine the retina to determine the number of floaters.
Presume the patient has glaucoma and refer him for further testing.
Consider these to be abnormal findings, and refer him to an ophthalmologist.
Know that floaters are usually insignificant and are caused by condensed vitreous
fibers.
ANS: D
Floaters are a common sensation with myopia or after middle age and are attributable to condensed
vitreous fibers. Floaters or spots are not usually significant, but the acute onset of floaters may occur
with retinal detachment.
13. The nurse is preparing to assess the visual acuity of a 16-year-old patient. How should the
nurse proceed?
a.
b.
c.
d.
Perform the confrontation test.
Ask the patient to read the print on a handheld Jaeger card.
Use the Snellen chart positioned 20 feet away from the patient.
Determine the patients ability to read newsprint at a distance of 12 to 14 inches.
ANS: C
The Snellen alphabet chart is the most commonly used and most accurate measure of visual acuity.
The confrontation test is a gross measure of peripheral vision. The Jaeger card or newspaper tests are
used to test near vision.
14. A patients vision is recorded as 20/30 when the Snellen eye chart is used. The nurse
interprets these results to indicate that:
a.
b.
c.
d.
At 30 feet the patient can read the entire chart.
The patient can read at 20 feet what a person with normal vision can read at 30 feet.
The patient can read the chart from 20 feet in the left eye and 30 feet in the right eye.
The patient can read from 30 feet what a person with normal vision can read from 20
feet.
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ANS: B
The top number indicates the distance the person is standing from the chart; the denominator gives
the distance at which a normal eye can see.
15. A patient is unable to read even the largest letters on the Snellen chart. The nurse should take
which action next?
a. Refer the patient to an ophthalmologist or optometrist for further evaluation.
b. Assess whether the patient can count the nurses fingers when they are placed in front
of his or her eyes.
c. Ask the patient to put on his or her reading glasses and attempt to read the Snellen chart
again.
d. Shorten the distance between the patient and the chart until the letters are seen, and
record that distance.
ANS: D
If the person is unable to see even the largest letters when standing 20 feet from the chart, then the
nurse should shorten the distance to the chart until the letters are seen, and record that distance (e.g.,
10/200). If visual acuity is even lower, then the nurse should assess whether the person can count
fingers when they are spread in front of the eyes or can distinguish light perception from a penlight.
If vision is poorer than 20/30, then a referral to an ophthalmologist or optometrist is necessary, but
the nurse must first assess the visual acuity.
16. A patients vision is recorded as 20/80 in each eye. The nurse interprets this finding to mean that
the patient:
a.
b.
c.
d.
Has poor vision.
Has acute vision.
Has normal vision.
Is presbyopic.
ANS: A
Normal visual acuity is 20/20 in each eye; the larger the denominator, the poorer the vision.
17. When performing the corneal light reflex assessment, the nurse notes that the light is
reflected at 2 oclock in each eye. The nurse should:
a.
b.
c.
d.
Consider this a normal finding.
Refer the individual for further evaluation.
Document this finding as an asymmetric light reflex.
Perform the confrontation test to validate the findings.
ANS: A
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Reflection of the light on the corneas should be in exactly the same spot on each eye, or symmetric.
If asymmetry is noted, then the nurse should administer the cover test.
18. The nurse is performing the diagnostic positions test. Normal findings would be which of
these results?
a.
b.
c.
d.
Convergence of the eyes
Parallel movement of both eyes
Nystagmus in extreme superior gaze
Slight amount of lid lag when moving the eyes from a superior to an inferior
position
ANS: B
A normal response for the diagnostic positions test is parallel tracking of the object with both eyes.
Eye movement that is not parallel indicates a weakness of an extraocular muscle or dysfunction of
the CN that innervates it.
19. During an assessment of the sclera of a black patient, the nurse would consider which of
these an expected finding?
a.
b.
c.
d.
Yellow fatty deposits over the cornea
Pallor near the outer canthus of the lower lid
Yellow color of the sclera that extends up to the iris
Presence of small brown macules on the sclera
ANS: D
Normally in dark-skinned people, small brown macules may be observed in the sclera.
20. A 60-year-old man is at the clinic for an eye examination. The nurse suspects that he has
ptosis of one eye. How should the nurse check for this?
a.
b.
c.
d.
Perform the confrontation test.
Assess the individuals near vision.
Observe the distance between the palpebral fissures.
Perform the corneal light test, and look for symmetry of the light reflex.
ANS: C
Ptosis is a drooping of the upper eyelid that would be apparent by observing the distance
between the upper and lower eyelids. The confrontation test measures peripheral vision.
Measuring near vision or the corneal light test does not check for ptosis.
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21. During an examination of the eye, the nurse would expect what normal finding when
assessing the lacrimal apparatus?
a.
b.
c.
d.
Presence of tears along the inner canthus
Blocked nasolacrimal duct in a newborn infant
Slight swelling over the upper lid and along the bony orbit if the individual has a cold
Absence of drainage from the puncta when pressing against the inner orbital rim
ANS: D
No swelling, redness, or drainage from the puncta should be observed when it is pressed.
Regurgitation of fluid from the puncta, when pressed, indicates duct blockage. The lacrimal glands
are not functional at birth.
22. When assessing the pupillary light reflex, the nurse should use which technique?
a. Shine a penlight from directly in front of the patient, and inspect for pupillary
constriction.
b. Ask the patient to follow the penlight in eight directions, and observe for bilateral
pupil constriction.
c. Shine a light across the pupil from the side, and observe for direct and consensual
pupillary constriction.
d. Ask the patient to focus on a distant object. Then ask the patient to follow the
penlight to approximately 7 cm from the nose.
ANS: C
To test the pupillary light reflex, the nurse should advance a light in from the side and note the direct
and consensual pupillary constriction.
23. The nurse is assessing a patients eyes for the accommodation response and would expect to see
which normal finding?
a.
b.
c.
d.
Dilation of the pupils
Consensual light reflex
Conjugate movement of the eyes
Convergence of the axes of the eyes
ANS: D
The accommodation reaction includes pupillary constriction and convergence of the axes of the eyes.
The other responses are not correct.
24. In using the ophthalmoscope to assess a patients eyes, the nurse notices a red glow in the
patients pupils. On the basis of this finding, the nurse would:
a. Suspect that an opacity is present in the lens or cornea.
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b. Check the light source of the ophthalmoscope to verify that it is functioning.
c. Consider the red glow a normal reflection of the ophthalmoscope light off the
inner retina.
d. Continue with the ophthalmoscopic examination, and refer the patient for further
evaluation.
ANS: C
The red glow filling the persons pupil is the red reflex and is a normal finding caused by the reflection
of the ophthalmoscope light off the inner retina. The other responses are not correct.
25. The nurse is examining a patients retina with an ophthalmoscope. Which finding is
considered normal?
a.
b.
c.
d.
Optic disc that is a yellow-orange color
Optic disc margins that are blurred around the edges
Presence of pigmented crescents in the macular area
Presence of the macula located on the nasal side of the retina
ANS: A
The optic disc is located on the nasal side of the retina. Its color is a creamy yellow-orange to a pink,
and the edges are distinct and sharply demarcated, not blurred. A pigmented crescent is black and is
due to the accumulation of pigment in the choroid.
Chapter 12 Ears, Nose, Mouth, and Throat
MULTIPLE CHOICE
1. The primary purpose of the ciliated mucous membrane in the nose is to:
a.
b.
c.
d.
Warm the inhaled air.
Filter out dust and bacteria.
Filter coarse particles from inhaled air.
Facilitate the movement of air through the nares.
ANS: B
The nasal hairs filter the coarsest matter from inhaled air, whereas the mucous blanket filters out dust
and bacteria. The rich blood supply of the nasal mucosa warms the inhaled air.
2. The projections in the nasal cavity that increase the surface area are called the:
a.
b.
c.
d.
Meatus.
Septum.
Turbinates.
Kiesselbach plexus.
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ANS: C
The lateral walls of each nasal cavity contain three parallel bony projections: the superior, middle,
and inferior turbinates. These increase the surface area, making more blood vessels and mucous
membrane available to warm, humidify, and filter the inhaled air.
3. The nurse is reviewing the development of the newborn infant. Regarding the sinuses, which
statement is true in relation to a newborn infant?
a. Sphenoid sinuses are full size at birth.
b. Maxillary sinuses reach full size after puberty.
c. Frontal sinuses are fairly well developed at birth.
d. Maxillary and ethmoid sinuses are the only sinuses present at birth.
ANS: D
Only the maxillary and ethmoid sinuses are present at birth. The sphenoid sinuses are minute at birth
and develop after puberty. The frontal sinuses are absent at birth, are fairly well developed at age 7 to
8 years, and reach full size after puberty.
4. The tissue that connects the tongue to the floor of the mouth is the:
a.
b.
c.
d.
Uvula.
Palate.
Papillae.
Frenulum.
ANS: D
The frenulum is a midline fold of tissue that connects the tongue to the floor of the mouth. The uvula
is the free projection hanging down from the middle of the soft palate. The palate is the arching roof
of the mouth. Papillae are the rough, bumpy elevations on the tongues dorsal surface.
5. The salivary gland that is the largest and located in the cheek in front of the ear is the
gland.
a. Parotid
b. Stensens
c. Sublingual
d. Submandibular
ANS: A
The mouth contains three pairs of salivary glands. The largest, the parotid gland, lies within the cheeks
in front of the ear extending from the zygomatic arch down to the angle of the jaw. The Stensens duct
(not gland) drains the parotid gland onto the buccal mucosa opposite the second molar. The
sublingual gland is located within the floor of the mouth under the tongue. The submandibular gland
lies beneath the mandible at the angle of the jaw.
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6. In assessing the tonsils of a 30 year old, the nurse notices that they are involuted, granular in
appearance, and appear to have deep crypts. What is correct response to these findings?
a.
b.
c.
d.
Refer the patient to a throat specialist.
No response is needed; this appearance is normal for the tonsils.
Continue with the assessment, looking for any other abnormal findings.
Obtain a throat culture on the patient for possible streptococcal (strep) infection.
ANS: B
The tonsils are the same color as the surrounding mucous membrane, although they look more
granular and their surface shows deep crypts. Tonsillar tissue enlarges during childhood until puberty
and then involutes.
7. The nurse is obtaining a health history on a 3-month-old infant. During the interview, the
mother states, I think she is getting her first tooth because she has started drooling a lot. The
nurses best response would be:
a.
b.
c.
d.
Youre right, drooling is usually a sign of the first tooth.
It would be unusual for a 3 month old to be getting her first tooth.
This could be the sign of a problem with the salivary glands.
She is just starting to salivate and hasnt learned to swallow the saliva.
ANS: D
In the infant, salivation starts at 3 months. The baby will drool for a few months before learning to
swallow the saliva. This drooling does not herald the eruption of the first tooth, although many parents
think it does.
8. The nurse is assessing an 80-year-old patient. Which of these findings would be expected for this
patient?
a.
b.
c.
d.
Hypertrophy of the gums
Increased production of saliva
Decreased ability to identify odors
Finer and less prominent nasal hair
ANS: C
The sense of smell may be reduced because of a decrease in the number of olfactory nerve fibers. Nasal
hairs grow coarser and stiffer with aging. The gums may recede with aging, not hypertrophy, and saliva
production decreases.
9. The nurse is performing an oral assessment on a 40-year-old Black patient and notices the
presence of a 1 cm, nontender, grayish-white lesion on the left buccal mucosa. Which one of
these statements is true? This lesion is:
a. Leukoedema and is common in dark-pigmented persons.
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b. The result of hyperpigmentation and is normal.
c. Torus palatinus and would normally be found only in smokers.
d. Indicative of cancer and should be immediately tested.
ANS: A
Leukoedema, a grayish-white benign lesion occurring on the buccal mucosa, is most often observed in
Blacks.
10. While obtaining a health history, a patient tells the nurse that he has frequent nosebleeds and asks
the best way to get them to stop. What would be the nurses best response?
a.
b.
c.
d.
While sitting up, place a cold compress over your nose.
Sit up with your head tilted forward and pinch your nose.
Just allow the bleeding to stop on its own, but dont blow your nose.
Lie on your back with your head tilted back and pinch your nose.
ANS: B
With a nosebleed, the person should sit up with the head tilted forward and pinch the nose between
the thumb and forefinger for 5 to 15 minutes.
11. A 92-year-old patient has had a stroke. The right side of his face is drooping. The nurse
might also suspect which of these assessment findings?
a.
b.
c.
d.
Epistaxis
Rhinorrhea
Dysphagia
Xerostomia
ANS: C
Dysphagia is difficulty with swallowing and may occur with a variety of disorders, including stroke
and other neurologic diseases. Rhinorrhea is a runny nose, epistaxis is a bloody nose, and xerostomia is
a dry mouth.
12. While obtaining a health history from the mother of a 1-year-old child, the nurse notices that the
baby has had a bottle in his mouth the entire time. The mother states, It makes a great pacifier. The
best response by the nurse would be:
a.
b.
c.
d.
Youre right. Bottles make very good pacifiers.
Using a bottle as a pacifier is better for the teeth than thumb-sucking.
Its okay to use a bottle as long as it contains milk and not juice.
Prolonged use of a bottle can increase the risk for tooth decay and ear infections.
ANS: D
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Prolonged bottle use during the day or when going to sleep places the infant at risk for tooth decay
and middle ear infections.
13. A 72-year-old patient has a history of hypertension and chronic lung disease. An important
question for the nurse to include in the health history would be:
a.
b.
c.
d.
Do you use a fluoride supplement?
Have you had tonsillitis in the last year?
At what age did you get your first tooth?
Have you noticed any dryness in your mouth?
ANS: D
Xerostomia (dry mouth) is a side effect of many drugs taken by older people, including
antidepressants,
anticholinergics,
antispasmodics,
antihypertensives,
antipsychotics,
and
bronchodilators.
14. The nurse is using an otoscope to assess the nasal cavity. Which of these techniques is
correct?
a.
b.
c.
d.
Inserting the speculum at least 3 cm into the vestibule
Avoiding touching the nasal septum with the speculum
Gently displacing the nose to the side that is being examined
Keeping the speculum tip medial to avoid touching the floor of the nares
ANS: B
The correct technique for using an otoscope is to insert the apparatus into the nasal vestibule, avoiding
pressure on the sensitive nasal septum. The tip of the nose should be lifted up before inserting the
speculum.
15. The nurse is performing an assessment on a 21-year-old patient and notices that his nasal mucosa
appears pale, gray, and swollen. What would be the most appropriate question to ask the patient?
a.
b.
c.
d.
Are you aware of having any allergies?
Do you have an elevated temperature?
Have you had any symptoms of a cold?
Have you been having frequent nosebleeds?
ANS: A
With chronic allergies, the mucosa looks swollen, boggy, pale, and gray. Elevated body temperature,
colds, and nosebleeds do not cause these mucosal changes.
16. The nurse needs to pull the portion of the ear that consists of movable cartilage and skin
down and back when administering eardrops. This portion of the ear is called the:
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a.
b.
c.
d.
Auricle.
Concha.
Outer meatus.
Mastoid process.
ANS: A
The external ear is called the auricle or pinna and consists of movable cartilage and skin.
17. The nurse is examining a patients ears and notices cerumen in the external canal. Which of
these statements about cerumen is correct?
a.
b.
c.
d.
Sticky honey-colored cerumen is a sign of infection.
The presence of cerumen is indicative of poor hygiene.
The purpose of cerumen is to protect and lubricate the ear.
Cerumen is necessary for transmitting sound through the auditory canal.
ANS: C
The ear is lined with glands that secrete cerumen, which is a yellow waxy material that lubricates and
protects the ear.
18. When examining the ear with an otoscope, the nurse notes that the tympanic membrane
should appear:
a. Light pink with a slight bulge.
b. Pearly gray and slightly concave.
c. Pulled in at the base of the cone of light.
d. Whitish with a small fleck of light in the superior portion.
ANS: B
The tympanic membrane is a translucent membrane with a pearly gray color and a prominent cone of
light in the anteroinferior quadrant, which is the reflection of the otoscope light. The tympanic
membrane is oval and slightly concave, pulled in at its center by the malleus, which is one of the
middle ear ossicles.
19. The nurse is reviewing the structures of the ear. Which of these statements concerning the
eustachian tube is true?
a.
b.
c.
d.
The eustachian tube is responsible for the production of cerumen.
It remains open except when swallowing or yawning.
The eustachian tube allows passage of air between the middle and outer ear.
It helps equalize air pressure on both sides of the tympanic membrane.
ANS: D
The eustachian tube allows an equalization of air pressure on each side of the tympanic membrane so
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that the membrane does not rupture during, for example, altitude changes in an airplane. The tube is
normally closed, but it opens with swallowing or yawning.
20. A patient with a middle ear infection asks the nurse, What does the middle ear do? The nurse
responds by telling the patient that the middle ear functions to:
a.Maintain balance.
b.Interpret sounds as they enter the ear.
c.Conduct vibrations of sounds to the inner ear.
d.Increase amplitude of sound for the inner ear to function.
ANS: C
Among its other functions, the middle ear conducts sound vibrations from the outer ear to the
central hearing apparatus in the inner ear. The other responses are not functions of the middle ear.
21. The nurse is reviewing the function of the cranial nerves (CNs). Which CN is responsible for
conducting nerve impulses to the brain from the organ of Corti?
a.
b.
c.
d.
I
III
VIII
XI
ANS: C
The nerve impulses are conducted by the auditory portion of CN VIII to the brain.
Chapter 13 The Respiratory System
Multiple Choice
1. A 21-year-old college senior presents to your clinic, complaining of shortness of breath and a
nonproductive nocturnal cough. She states she used to feel this way only with extreme exercise, but
lately she has felt this way continuously. She denies any other upper respiratory symptoms, chest
pain, gastrointestinal symptoms, or urinary tract symptoms. Her past medical history is significant
only for seasonal allergies, for which she takes a nasal steroid spray but is otherwise on no other
medications. She has had no surgeries. Her mother has allergies and eczema and her father has high
blood pressure. She is an only child. She denies smoking and illegal drug use but drinks three to four
alcoholic beverages per weekend. She is a junior in finance at a local university and she has recently
started a job as a bartender in town. On examination she is in no acute distress and her temperature is
98.6. Her blood pressure is 120/80, her pulse is 80, and her respirations are 20. Her head, eyes, ears,
nose, and throat examinations are essentially normal. Inspection of her anterior and posterior chest
shows no abnormalities. On auscultation of her chest, there is decreased air movement and a highpitched whistling on expiration in all lobes. Percussion reveals resonant lungs.
Which disorder of the thorax or lung does this best describe?
A) Spontaneous pneumothorax
B) Chronic obstructive pulmonary disease (COPD)
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C) Asthma
D) Pneumonia
Ans: C
Feedback: Asthma causes shortness of breath and a nocturnal cough. It is often associated with a
history of allergies and can be made worse by exercise or irritants such as smoke in a bar. On
auscultation there can be normal to decreased air movement. Wheezing is heard on expiration and
sometimes inspiration. The duration of wheezing in expiration usually correlates with severity of
illness, so it is important to document this length (e.g., wheezes heard halfway through exhalation).
Realize that in severe asthma, wheezes may not be heard because of the lack of air movement.
Paradoxically, these patients may have more wheezes after treatment, which actually indicates an
improvement in condition. Peak flow measurements help to discern this.
2. A 47-year-old receptionist comes to your office, complaining of fever, shortness of breath, and a
productive cough with golden sputum. She says she had a cold last week and her symptoms have
only gotten worse, despite using over-the-counter cold remedies. She denies any weight gain, weight
loss, or cardiac or gastrointestinal symptoms. Her past medical history includes type 2 diabetes for 5
years and high cholesterol. She takes an oral medication for both diseases. She has had no surgeries.
She denies tobacco, alcohol, or drug use. Her mother has diabetes and high blood pressure. Her father
passed away from colon cancer. On examination you see a middle-aged woman appearing her stated
age. She looks ill and her temperature is elevated, at 101. Her blood pressure and pulse are
unremarkable. Her head, eyes, ears, nose, and throat examinations are unremarkable except for
edema of the nasal turbinates. On auscultation she has decreased air movement, and coarse crackles
are heard over the left lower lobe. There is dullness on percussion, increased fremitus during
palpation, and egophony and whispered pectoriloquy on auscultation.
What disorder of the thorax or lung best describes her symptoms?
A) Spontaneous pneumothorax
B) Chronic obstructive pulmonary disease (COPD)
C) Asthma
D) Pneumonia
Ans: D
Feedback: Pneumonia is usually associated with dyspnea, cough, and fever. On auscultation there
can be coarse or fine crackles heard over the affected lobe. Percussion over the affected area is dull
and there is often an increase in fremitus. Egophony and pectoriloquy are heard because of increased
transmission of high-pitched components of sounds. These higher frequencies are usually filtered out
by the multiple air-filled chambers of the alveoli.
3. A 17-year-old high school senior presents to your clinic in acute respiratory distress. Between
shallow breaths he states he was at home finishing his homework when he suddenly began having
right-sided chest pain and severe shortness of breath. He denies any recent traumas or illnesses. His
past medical history is unremarkable. He doesn't smoke but drinks several beers on the weekend. He
has tried marijuana several times but denies any other illegal drugs. He is an honors student and is on
the basketball team. His parents are both in good health. He denies any recent weight gain, weight
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loss, fever, or night sweats. On examination you see a tall, thin young man in obvious distress. He is
diaphoretic and is breathing at a rate of 35 breaths per minute. On auscultation you hear no breath
sounds on the right side of his superior chest wall. On percussion he is hyperresonant over the right
upper lobe. With palpation he has absent fremitus over the right upper lobe.
What disorder of the thorax or lung best describes his symptoms?
A) Spontaneous pneumothorax
B) Chronic obstructive pulmonary disease (COPD)
C) Asthma
D) Pneumonia
Ans: A
Feedback: Spontaneous pneumothorax occurs suddenly, causing severe dyspnea and chest pain on the
affected side. It is more common in thin young males. On auscultation of the affected side there will
be no breath sounds and on percussion there is hyperresonance or tympany. There will be an absence
of fremitus to palpation. Given this young man's habitus and pneumothorax, you may consider
looking for features of Marfan's syndrome. Read more about this condition.
4. A 62-year-old construction worker presents to your clinic, complaining of almost a year of chronic
cough and occasional shortness of breath. Although he has had worsening of symptoms occasionally
with a cold, his symptoms have stayed about the same. The cough has occasional mucous drainage
but never any blood. He denies any chest pain. He has had no weight gain, weight loss, fever, or night
sweats. His past medical history is significant for high blood pressure and arthritis. He has smoked
two packs a day for the past 45 years. He drinks occasionally but denies any illegal drug use. He is
married and has two children. He denies any foreign travel. His father died of a heart attack and his
mother died of Alzheimer's disease. On examination you see a man looking slightly older than his
stated age. His blood pressure is 130/80 and his pulse is 88. He is breathing comfortably with
respirations of 12. His head, eyes, ears, nose, and throat examinations are unremarkable. His cardiac
examination is normal. On examination of his chest, the diameter seems enlarged. Breath sounds are
decreased throughout all lobes. Rhonchi are heard over all lung fields. There is no area of dullness
and no increased or decreased fremitus. What thorax or lung disorder is most likely causing his
symptoms?
A) Spontaneous pneumothorax
B) Chronic obstructive pulmonary disease (COPD)
C) Asthma
D) Pneumonia
Ans: B
Feedback: This disorder is insidious in onset and generally affects the older population with a
smoking history. The diameter of the chest is often enlarged like a barrel. Percussing the chest elicits
hyperresonance, and during auscultation there are often distant breath sounds. Coarse breath sounds
of rhonchi are also often heard. It is important to quantify this patient's exercise capacity because it
may affect his employment and also allows you to follow for progression of his disease. You must
offer smoking cessation as an option.
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5. A 36-year-old teacher presents to your clinic, complaining of sharp, knifelike pain on the left side
of her chest for the last 2 days. Breathing and lying down make the pain worse, while sitting forward
helps her pain. Tylenol and ibuprofen have not helped. Her pain does not radiate to any other area.
She denies any upper respiratory or gastrointestinal symptoms. Her past medical history consists of
systemic lupus. She is divorced and has one child. She denies any tobacco, alcohol, or drug use. Her
mother has hypothyroidism and her father has high blood pressure. On examination you find her to be
distressed, leaning over and holding her left arm and hand to her left chest. Her blood pressure is
130/70, her respirations are 12, and her pulse is 90. On auscultation her lung fields have normal
breath sounds with no rhonchi, wheezes, or crackles. Percussion and palpation are unremarkable.
Auscultation of the heart has an S1 and S2 with no S3 or S4. A scratching noise is heard at the lower
left sternal border, coincident with systole; leaning forward relieves some of her pain. She is
nontender with palpation of the chest wall.
What disorder of the chest best describes this disorder?
A) Angina pectoris
B) Pericarditis
C) Dissecting aortic aneurysm
D) Pleural pain
Ans: B
Feedback: The pain from pericarditis is usually sharp and knifelike and is located over the left side
of the chest. Change of position, breathing, and coughing often make the pain worse, whereas
leaning forward improves the pain. Pericarditis is often seen in rheumatologic diseases such as
systemic lupus and in patients with chronic kidney disease. Patients also experience this after a
myocardial infarction. You can read more about Dressler's syndrome.
6. A 68-year-old retired postman presents to your clinic, complaining of dull, intermittent left- sided
chest pain over the last few weeks. The pain occurs after he mows his lawn or chops wood. He says
that the pain radiates to the left side of his jaw but nowhere else. He has felt light-headed
and nauseated with the pain but has had no other symptoms. He states when he sits down for several
minutes the pain goes away. Ibuprofen, Tylenol, and antacids have not improved his symptoms. He
reports no recent weight gain, weight loss, fever, or night sweats. He has a past medical history of high
blood pressure and arthritis. He quit smoking 10 years ago after smoking one pack a day for 40 years.
He denies any recent alcohol use and reports no drug use. He is married and has two healthy children.
His mother died of breast cancer and his father died of a stroke. His younger brother has had bypass
surgery. On examination you find him healthy- appearing and breathing comfortably. His blood
pressure is 140/90 and he has a pulse of 80. His head, eyes, ears, nose, and throat examinations are
unremarkable. His lungs have normal breath sounds and there are no abnormalities with percussion and
palpation of the chest. His heart has a normal S1 and S2 and no S3 or S4. Further workup is pending.
Which disorder of the chest best describes these symptoms?
A) Angina pectoris
B) Pericarditis
C) Dissecting aortic aneurysm
D) Pleural pain
Ans: A
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Feedback: Angina causes dull chest pain felt in the retrosternal area or anterior chest. It often
radiates to the shoulders, arms, neck, and jaw. It is associated with shortness of breath, nausea, and
sweating. The pain is generally relieved by rest or medication after several minutes. This patient
needs to be admitted to the hospital for further workup for his accelerating symptoms.
7. A 75-year-old retired teacher presents to your clinic, complaining of severe, unrelenting anterior
chest pain radiating to her back. She describes it as if someone is ―ripping out her heart.‖ It began less
than an hour ago. She states she is feeling very nauseated and may pass out. She denies any trauma or
recent illnesses. She states she has never had pain like this before. Nothing seems to make the pain
better or worse. Her medical history consists of difficult-to-control hypertension and coronary artery
disease requiring two stents in the past. She is a widow. She denies any alcohol, tobacco, or illegal
drug use. Her mother died of a stroke and her father died of a heart attack. She has one younger
brother who has had bypass surgery. On examination you see an elderly female in a great deal of
distress. She is lying on the table, curled up, holding her left and right arms against her chest and is
restless, trying to find a comfortable position. Her blood pressure is 180/110 in the right arm and
130/60 in the left arm, and her pulse is 120. Her right carotid pulse is bounding but the left carotid
pulse is weak. She is afebrile but her respirations are 24 times a minute. On auscultation her lungs are
clear and her cardiac examination is unremarkable. You call EMS and have her taken to the hospital's
ER for further evaluation.
What disorder of the chest best describes her symptoms?
A) Angina pectoris
B) Pericarditis
C) Dissecting aortic aneurysm
D) Pleural pain
Ans: C
Feedback: A dissecting aortic aneurysm is associated with a ripping or tearing sensation that radiates
to the neck, back, or abdomen. Because blood supply to the brain and extremities is disrupted,
syncope and paraplegia or hemiplegia can occur. Blood pressure will usually be different between
the two arms, and the carotid pulses often show an asymmetry. This is because the aneurysm
decreases flow distally and causes inequality of flow between sides.
8. A 25-year-old accountant presents to your clinic, complaining of intermittent lower right- sided
chest pain for several days. He describes it as knifelike and states it only lasts for 3 to 5 seconds,
taking his breath away. He states he feels like he has to breathe shallowly to keep it from recurring.
The only thing that makes it better is lying quietly on his right side. It is much worse when he takes a
deep breath. He has taken some Tylenol and put a heating pad on his side but neither has helped. He
remembers that 2 weeks ago he had an upper respiratory infection with a severe hacking cough. He
denies any recent trauma. His past medical history is unremarkable. His parents and siblings are in
good health. He has recently married, and his wife has a baby due in 2 months. He denies any
smoking or illegal drug use. He drinks two to three beers once a month. He states that he eats a
healthy diet and runs regularly, but not since his recent illness. He denies any cardiac,
gastrointestinal, or musculoskeletal symptoms. On examination he is lying on his right side but
appears quite comfortable. His temperature, blood pressure, pulse, and respirations are unremarkable.
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His chest has normal breath sounds on auscultation. Percussion of the chest is unremarkable. During
palpation the ribs are nontender. What disorder of the chest best describes his symptoms?
A) Pericarditis
B) Chest wall pain
C) Pleural pain
D) Angina pectoralis Ans:
C
Feedback: This pain is sharp and knifelike and occurs over the affected area of pleura. Breathing
deeply usually makes the pain worse, whereas lying quietly on the affected side makes the pain better.
Pleurisy often occurs from inflammation due to an infection, neoplasm, or autoimmune disease.
9. A 60-year-old baker presents to your clinic, complaining of increasing shortness of breath and
nonproductive cough over the last month. She feels like she can't do as much activity as she used to do
without becoming tired. She even has to sleep upright in her recliner at night to be able to breathe
comfortably. She denies any chest pain, nausea, or sweating. Her past medical history is significant for high
blood pressure and coronary artery disease. She had a hysterectomy in her 40s for heavy vaginal bleeding. She
is married and is retiring from the local bakery soon. She denies any tobacco, alcohol, or drug use. Her mother
died of a stroke and her father died from prostate cancer. She denies any recent upper respiratory illness, and
she has had no other symptoms. On examination she is in no acute distress. Her blood pressure is 160/100 and
her pulse is 100. She is afebrile and her respiratory rate is 16. With auscultation she has distant air sounds and
she has late inspiratory crackles in both lower lobes. On cardiac examination the S1 and S2 are distant and an
S3 is heard over the apex.
What disorder of the chest best describes her symptoms?
A) Pneumonia
B) Chronic obstructive pulmonary disease (COPD)
C) Pleural pain
D) Left-sided heart failure
Ans: D
Feedback: In left-sided heart failure, fluid starts ―backing up‖ into the lungs because the heart is unable
to handle the volume. The excess fluid collects in the dependent areas, causing crackles in the bases of
the lower lobes. Sitting up allows patients to breathe easier. The two main causes are chronic high
blood pressure and coronary artery disease, which lead to myocardial ischemia and decreased
contractility of the heart.
10. A grandmother brings her 13-year-old grandson to you for evaluation. She noticed last week
when he took off his shirt that his breastbone seemed collapsed. He seems embarrassed and tells you
that it has been that way for quite awhile. He states he has no symptoms from it and he just tries not
to take off his shirt in front of anyone. He denies any shortness of breath, chest pain, or
lightheadedness on exertion. His past medical history is unremarkable. He is in sixth grade and just
moved in with his grandmother after his father was deployed to the Middle East. His mother died
several years ago in a car accident. He states that he does not smoke and has never touched alcohol.
On examination you see a teenage boy appearing his stated age. On visual examination of his chest
you see that the lower portion of the sternum is depressed. Auscultation of the lungs and heart are
unremarkable.
What disorder of the thorax best describes your findings?
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A)
B)
C)
D)
Barrel chest
Funnel chest (pectus excavatum)
Pigeon chest (pectus carinatum)
Thoracic kyphoscoliosis
Ans: B
Feedback: Funnel chest is caused by a depression in the lower portion of the sternum. If severe enough
there can be compression of the heart and great vessels, leading to murmurs on auscultation. This is
usually only a cosmetic problem, but corrective surgeries can be performed
if necessary.
11. Which of the following anatomic landmark associations is correct?
A) 2nd intercostal space for needle insertion in tension pneumothorax
B) T6 for lower margin of endotracheal tube
C) Sternal angle marks the 4th rib
D) 5th intercostal space for chest tube insertion
Ans: A
Feedback: The 2nd intercostal space is indeed the correct location for insertion of a needle in tension
pneumothorax. The other answers are incorrect. T4 marks the approximate bifurcation of the trachea
and therefore marks the inferior limit for an endotracheal tube on chest X-ray. The sternal angle
marks the 2nd rib, which helps establish the 2nd interspace for needle insertion as above or locations
for cardiac auscultation (aortic and pulmonary areas). Finally, the 4th intercostal space is normally
used for chest tube insertion.
12. A 55–year-old smoker complains of chest pain and gestures with a closed fist over her
sternum to describe it. Which of the following diagnoses should you consider because of her
gesture?
A) Bronchitis
B) Costochondritis
C) Pericarditis
D) Angina pectoris
Ans: D
Feedback: The clenched fist of Levine's sign, while not completely specific for ischemic pain, should
definitely cause you to consider this etiology. Bronchitis is usually painless and pericarditis can
produce a sharp pain which worsens with inspiration. This is called pleuritic pain and can be
associated with pneumonia and other chest diseases. Costochondritis is a parasternal pain, usually
well localized. It is exquisitely tender.
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13. A 62-year-old smoker complains of ―coughing up small amounts of blood,‖ so you consider
hemoptysis. Which of the following should you also consider?
A) Intestinal bleeding
B) Hematoma of the nasal septum
C) Epistaxis
D) Bruising of the tongue
Ans: C
Feedback: When you suspect hemoptysis, you must consider other etiologies for bleeding. Commonly,
epistaxis can mimic this as well as bleeding from the gastrointestinal tract. The other answers, although
they involve bleeding, are contained or distant from the pharynx.
14. Which of the following occurs in respiratory distress?
A) Speaking in sentences of 10–20 words
B) Skin between the ribs moves inward with inspiration
C) Neck muscles are relaxed
D) Patient torso leans posteriorly
Ans: B
Feedback: This description is consistent with retractions that occur with respiratory distress. Other
features include speaking in short sentences, use of accessory muscles, leaning forward to gain
mechanical advantage for the diaphragm, and pursed lip breathing, in which the patient exhales
against his lips, which are pressed together.
15. Which of the following is consistent with good percussion technique?
A) Allow all of the fingers to touch the chest while performing percussion.
B) Maintain a stiff wrist and hand.
C) Leave the plexor finger on the pleximeter after each strike.
D) Strike the pleximeter over the distal interphalangeal joint.
Ans: D
Feedback: Percussion takes practice to master. Most struggle initially with keeping the wrist and
hand relaxed. Other challenges include removing the plexor quickly and keeping the other fingers off
the chest wall. These can dampen the sound you are trying to obtain. The ideal target for the plexor is
the distal interphalangeal joint.
16. Which of the following percussion notes would you obtain over the gastric bubble?
A) Resonance
B) Tympany
C) Hyperresonance
D) Flatness
Ans: B
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Feedback: The gastric bubble produces one of the longest percussion notes. A patient with COPD
may have hyperresonance over his chest, while a normal person would have resonance. Dullness is
heard over a normal liver, and flatness is heard if one percusses a large muscle.
17. Which of the following conditions would produce a hyperresonant percussion note?
A) Large pneumothorax
B) Lobar pneumonia
C) Pleural effusion
D) Empyema
Ans: A
Feedback: There is a great deal of free air in the chest with a large pneumothorax, which produces a
hyperresonant note. The other three conditions produce dullness by dampening the percussion note
with fluid.
18. Which lung sound possesses the characteristics of being louder and higher in pitch, with a short
silence between inspiration and expiration and with expiration being longer than inspiration?
A) Bronchovesicular
B) Vesicular
C) Bronchial
D) Tracheal
Ans: C
Feedback: These sounds are consistent with bronchial breath sounds. Be alert for these, as they may
occur elsewhere and indicate a pneumonia or other pathology. The current explanation for this
phenomenon is that the sound from the trachea is carried very well to the chest wall by fluid. This
same explanation explains ―ee‖ to ―aa‖ changes, whispered pectoriloquy, bronchophony, and other
circumstances in which high-frequency sounds, normally blocked by the air-filled alveoli, could be
transmitted to the chest wall.
19. A patient complains of shortness of breath for the past few days. On examination, you note late
inspiratory crackles in the lower third of the chest that were not present a week ago. What is the most
likely explanation for these?
A) Asthma
B) COPD
C) Bronchiectasis
D) Heart failure
Ans: D
Feedback: The timing of crackles within inspiration provides important clues. These late inspiratory
crackles that appeared suddenly would be most consistent with heart failure. COPD and asthma usually
produce early inspiratory crackles. Bronchiectasis, as seen in cystic fibrosis, classically produces midinspiratory crackles, but this is not always reliable. Interestingly, end- expiratory crackles can be heard
in asthma on occasion.
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20. When crackles, wheezes, or rhonchi clear with a cough, which of the following is a likely
etiology?
A) Bronchitis
B) Simple asthma
C) Cystic fibrosis
D) Heart failure
Ans: A
Feedback: Adventitious sounds that clear with cough are usually consistent with bronchitis or
atelectasis. The other conditions would not be associated with findings that cleared with a cough.
21. A patient with longstanding COPD was told by another practitioner that his liver was
enlarged and this needed to be assessed. Which of the following would be reasonable to do
next?
A) Percuss the lower border of the liver
B) Measure the span of the liver
C) Order a hepatitis panel
D) Obtain an ultrasound of the liver
Ans: B
Feedback: In this patient, measuring the span of the liver saved the patient an involved workup,
because it was normal. His history of COPD is consistent with flattening of the diaphragms,
which pushed the liver edge down while the actual size of the liver remained the same. Percussing
the lower border of the liver alone caused this referral, because it was assumed that the liver was
enlarged.
22. You are at your family reunion playing football when your uncle takes a hit to his right lateral
thorax and is in pain. He asks you if you think he has a rib fracture. You are in a very remote
area. What would your next step be?
A) Call a medevac helicopter
B) Drive him to the city (4 hours away)
C) Press on his sternum and spine simultaneously
D) Examine him for tenderness over the injured area Ans:
C
Feedback: The area involved in the injury will of course be tender. If you press in an area remote to
the injury, but over the same bone which may be involved, you can produce tenderness at the site of
injury. This would indicate that there may be a fracture at the lateral ribs.
Fortunately, this maneuver did not reproduce pain remotely, and your uncle simply sat on the sidelines
for the rest of the game.
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Chapter 14 The Cardiovascular System
Multiple Choice
1. You are performing a thorough cardiac examination. Which of the following chambers of the heart
can you assess by palpation?
A) Left atrium
B) Right atrium
C) Right ventricle
D) Sinus node
Ans: C
Feedback: The right ventricle occupies most of the anterior cardiac surface and is easily accessible to
palpation. The other structures are less likely to have findings on palpation and the sinus node is an
intracardiac structure. You may be able to diagnose abnormal rhythms caused by the sinus node
indirectly by palpation, but this is less obvious.
2. What is responsible for the inspiratory splitting of S2?
A) Closure of aortic, then pulmonic valves
B) Closure of mitral, then tricuspid valves
C) Closure of aortic, then tricuspid valves
D) Closure of mitral, then pulmonic valves
Ans: A
Feedback: During inspiration, the closure of the aortic valve and the closure of the pulmonic valve
separate slightly, and this may be heard as two audible components, instead of a single sound.
Current explanations of inspiratory splitting include increased capacitance in the pulmonary vascular
bed during inspiration, which prolongs ejection of blood from the right ventricle, delaying closure of
the pulmonic valve. Because the pulmonic component is soft, you may not hear it away from the left
second intercostal space. Because it is a low-pitched sound, you may not hear it unless you use the
bell of your stethoscope. It is generally easy to hear in school-aged children, and it is easy to notice
the respiratory variation of the splitting.
3. A 25-year-old optical technician comes to your clinic for evaluation of fatigue. As part of your
physical examination, you listen to her heart and hear a murmur only at the cardiac apex. Which
valve is most likely to be involved, based on the location of the murmur?
A) Mitral
B) Tricuspid
C) Aortic
D) Pulmonic Ans:
A
Feedback: Mitral valve sounds are usually heard best at and around the cardiac apex.
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4. A 58-year-old teacher presents to your clinic with a complaint of breathlessness with activity. The
patient has no chronic conditions and does not take any medications, herbs, or supplements. Which of
the following symptoms is appropriate to ask about in the cardiovascular review of systems?
A) Abdominal pain
B) Orthopnea
C) Hematochezia
D) Tenesmus
Ans: B
Feedback: Orthopnea, which is dyspnea that occurs when the patient is lying down and improves
when the patient sits up, is part of the cardiovascular review of systems and, if positive, may indicate
congestive heart failure.
5. You are screening people at the mall as part of a health fair. The first person who comes for
screening has a blood pressure of 132/85. How would you categorize this?
A) Normal
B) Prehypertension
C) Stage 1 hypertension
D) Stage 2 hypertension
Ans: B
Feedback: Prehypertension is considered to be a systolic blood pressure from 120 to 139 and a
diastolic BP from 80 to 89. Previously, this was considered normal. JNC 7 recommends taking action
at this point to prevent worsening hypertension. Research shows that this population is likely to
progress to more serious stages of hypertension.
6. You are participating in a health fair and performing cholesterol screens. One person has a
cholesterol of 225. She is concerned about her risk for developing heart disease. Which of the
following factors is used to estimate the 10-year risk of developing coronary heart disease?
A) Ethnicity
B) Alcohol intake
C) Gender
D) Asthma
Ans: C
Feedback: Gender is used in the calculation of the 10-year risk for developing coronary heart disease,
because men have a higher risk than women.
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7. You are evaluating a 40-year-old banker for coronary heart disease risk factors. He has a history of
hypertension, which is well-controlled on his current medications. He does not smoke; he does 45
minutes of aerobic exercise five times weekly. You are calculating his 10-year coronary heart disease
risk. Which of the following conditions is considered to be a coronary heart disease risk equivalent?
A) Hypertension
B) Peripheral arterial disease
C) Systemic lupus erythematosus
D) Chronic obstructive pulmonary disease (COPD)
Ans: B
Feedback: Peripheral arterial disease is considered to be a coronary heart disease risk equivalent, as are
abdominal aortic aneurysm, carotid atherosclerotic disease, and diabetes mellitus.
8. You are conducting a workshop on the measurement of jugular venous pulsation. As part of your
instruction, you tell the students to make sure that they can distinguish between the jugular venous
pulsation and the carotid pulse. Which one of the following characteristics is typical of the carotid
pulse?
A) Palpable
B) Soft, rapid, undulating quality
C) Pulsation eliminated by light pressure on the vessel
D) Level of pulsation changes with changes in position
Ans: A
Feedback: The carotid pulse is palpable; the jugular venous pulsation is rarely palpable. The carotid
upstroke is normally brisk, but it may be delayed and decreased as in aortic stenosis or bounding as in
aortic insufficiency.
9. A 68-year-old mechanic presents to the emergency room for shortness of breath. You are
concerned about a cardiac cause and measure his jugular venous pressure (JVP). It is elevated.
Which one of the following conditions is a potential cause of elevated JVP?
A) Left-sided heart failure
B) Mitral stenosis
C) Constrictive pericarditis
D) Aortic aneurysm
Ans: C
Feedback: One cause of increased jugular venous pressure is constrictive pericarditis. Others include
right-sided heart failure, tricuspid stenosis, and superior vena cava syndrome. You may wish to read
about these conditions.
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10. You are palpating the apical impulse in a patient with heart disease and find that the amplitude is
diffuse and increased. Which of the following conditions could be a potential cause of an increase in
the amplitude of the impulse?
A) Hypothyroidism
B) Aortic stenosis, with pressure overload of the left ventricle
C) Mitral stenosis, with volume overload of the left atrium
D) Cardiomyopathy
Ans: B
Feedback: Pressure overload of the left ventricle, such as occurs in aortic stenosis, may result in an
increase in amplitude of the apical impulse. The other conditions should decrease amplitude of the
apical impulse or not be palpable at all.
11. You are performing a cardiac examination on a patient with shortness of breath and
palpitations. You listen to the heart with the patient sitting upright, then have him change to a supine
position, and finally have him turn onto his left side in the left lateral decubitus position. Which of
the following valvular defects is best heard in this position?
A) Aortic
B) Pulmonic
C) Mitral
D) Tricuspid
Ans: C
Feedback: The left lateral decubitus position brings the left ventricle closer to the chest wall, allowing
mitral valve murmurs to be better heard. If you do not listen to the heart in this position with both the
diaphragm and bell in a quiet room, it is possible to miss significant murmurs such as mitral stenosis.
12. You are concerned that a patient has an aortic regurgitation murmur. Which is the best
position to accentuate the murmur?
A) Upright
B) Upright, but leaning forward
C) Supine
D) Left lateral decubitus
Ans: B
Feedback: Leaning forward slightly in the upright position brings the aortic valve and the left
ventricular outflow tract closer to the chest wall, so it will be easier to hear the soft diastolic
decrescendo murmur of aortic insufficiency (regurgitation). You can further your ability to hear this
soft murmur by having the patient hold his breath in exhalation.
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13. A 68-year-old retired waiter comes to your clinic for evaluation of fatigue. You perform a
cardiac examination and find that his pulse rate is less than 60. Which of the following conditions
could be responsible for this heart rate?
A) Second-degree A-V block
B) Atrial flutter
C) Sinus arrhythmia
D) Atrial fibrillation
Ans: A
Feedback: A second-degree A-V block can result in a pulse rate less than 60. Atrial flutter and atrial
fibrillation do not cause bradycardia unless there is a significant accompanying block.
Sinus arrhythmia does not cause bradycardia and represents respiratory variation of the heart rate.
14. Where is the point of maximal impulse (PMI) normally located?
A) In the left 5th intercostal space, 7 to 9 cm lateral to the sternum
B) In the left 5th intercostal space, 10 to 12 cm lateral to the sternum
C) In the left 5th intercostal space, in the anterior axillary line
D) In the left 5th intercostal space, in the midaxillary line
Ans: A
Feedback: The PMI is usually located in the left 5th intercostal space, 7 to 9 centimeters lateral to the
sternal border. If it is located more laterally, it usually represents cardiac enlargement. Its size should
not be greater than the size of a US quarter, or about an inch. Left ventricular enlargement should be
suspected if it is larger. The PMI is often the best place to listen for mitral valve murmurs as well as
S3 and S4. The PMI is often difficult to feel in normal patients.
15. Which of the following events occurs at the start of diastole?
A) Closure of the tricuspid valve
B) Opening of the pulmonic valve
C) Closure of the aortic valve
D) Production of the first heart sound (S1)
Ans: C
Feedback: At the beginning of diastole, the valves which allow blood to exit the heart close. It is
thought that the closure of the aortic valve produces the second heart sound (S2). Closure of the
mitral valve is thought to produce the first heart sound (S1).
16. Which is true of a third heart sound (S3)?
A) It marks atrial contraction.
B) It reflects normal compliance of the left ventricle.
C) It is caused by rapid deceleration of blood against the ventricular wall.
D) It is not heard in atrial fibrillation.
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Ans: C
Feedback: The S3 gallop is caused by rapid deceleration of blood against the ventricular wall. S4 is
heard with atrial contraction and is absent in atrial fibrillation for this reason. It usually indicates a
stiff or thickened left ventricle as in hypertension or left ventricular hypertrophy.
17. Which is true of splitting of the second heart sound?
A) It is best heard over the pulmonic area with the bell of the stethoscope.
B) It normally increases with exhalation.
C) It is best heard over the apex.
D) It does not vary with respiration.
Ans: A
Feedback: S2 splitting is best heard over the pulmonic area because this is the only place where both
of its components can be heard well. The closure of the pulmonic valve is normally not loud because
the right heart is a low-pressure system. The bell is best used because it is a low- pitched sound. S2
splitting normally increases with inhalation.
18. Which of the following is true of jugular venous pressure (JVP) measurement?
A) It is measured with the patient at a 45-degree angle.
B) The vertical height of the blood column in centimeters, plus 5 cm, is the JVP.
C) A JVP below 9 cm is abnormal.
D) It is measured above the sternal notch.
Ans: B
Feedback: Measurement of the JVP is important to assess a patient's fluid status. Although it may be
measured at 45°, it is important to adjust the level of the patient's torso so that the blood column is
visible. This may be with the patient completely supine or sitting completely upright, depending on
the patient. Any measurement greater than 4 cm above the sternal angle is abnormal. This would
correspond to a JVP of 9 cm because we add a constant of 5 cm, which is an estimate of the height of
the sternal notch above the right atrium.
19. Which of the following regarding jugular venous pulsations is a systolic phenomenon?
A) The ―y‖ descent
B) The ―x‖ descent
C) The upstroke of the ―a‖ wave
D) The downstroke of the ―v‖ wave
Ans: B
Feedback: The most prominent upstrokes of jugular venous pulsations are diastolic phenomena. These
can be timed using the carotid pulse. The only event listed above which is a systolic phenomenon is
the ―x‖ descent.
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20. How much does cardiovascular risk increase for each increment of 20 mm Hg systolic and 10
mm Hg diastolic in blood pressure?
A) 25%
B) 50%
C) 75%
D) 100%
Ans: D
Feedback: Each increase of BP by 20 systolic and 10 diastolic doubles the risk of cardiovascular
disease. Being ―low risk‖ by JNC 7 criteria confers a 72%–85% reduction in CVD mortality and
40%–58% reduction in overall mortality.
21. In healthy adults over 20, how often should blood pressure, body mass index, waist
circumference, and pulse be assessed, according to American Heart Association guidelines?
A) Every 6 months
B) Every year
C) Every 2 years
D) Every 5 years Ans:
C
Feedback: AHA guidelines recommend screening every 2 years in patients over 20 for blood pressure,
body mass index, waist circumference, and pulse.
22. Which of the following is a clinical identifier of metabolic syndrome?
A) Waist circumference of 38 inches for a male
B) Waist circumference of 34 inches for a female
C) BP of 134/88 for a male
D) BP of 128/84 for a female
Ans: C
Feedback: The physical examination criteria for identifying metabolic syndrome include a waist of 40
inches or greater for a male, a waist of 35 inches or greater for a female, and a blood pressure of
130/85 or greater. Other criteria include triglycerides greater than or equal to 150 mg/dL, fasting
glucose greater than or equal to 110 mg/dL, and HDL less than 40 for men or less than 50 for women.
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Chapter 15 The Peripheral Vascular System
Multiple Choice
1. A 57-year-old maintenance worker comes to your office for evaluation of pain in his legs. He has
smoked two packs per day since the age of 16, but he is otherwise healthy. You are concerned that he
may have peripheral vascular disease. Which of the following is part of common or concerning
symptoms for the peripheral vascular system?
A) Intermittent claudication
B) Chest pressure with exertion
C) Shortness of breath
D) Knee pain
Ans: A
Feedback: Intermittent claudication is leg pain that occurs with walking and is relieved by rest. It is
a key symptom of peripheral vascular disease. This symptom is present in only about one third of
patients with significant arterial disease and, if found, calls for more aggressive management of
cardiovascular risk factors. Screening with ankle brachial index can help detect this problem.
2. A 72-year-old teacher comes to your clinic for an annual examination. She is concerned about her
risk for peripheral vascular disease and states that there is a place in town that does tests to let her
know her if she has this or not. Which of the following disease processes is a risk factor for peripheral
vascular disease?
A) Gastroesophageal reflux disease
B) Coronary artery disease
C) Migraine headaches
D) Osteoarthritis
Ans: B
Feedback: Evidence of coronary artery disease implies that there is most likely disease in other
vessels; therefore, this is a risk factor for peripheral vascular disease. Conversely, the presence of
peripheral vascular disease is also a risk factor for coronary artery disease, and if present, it should
be considered in reduction of cardiac risk factors.
3. A 68-year-old retired truck driver comes to your office for evaluation of swelling in his legs. He is
a smoker and has been taking medications to control his hypertension for the past 25 years. You are
concerned about his risk for peripheral vascular disease. Which of the following tests are appropriate
to order to initially evaluate for this condition?
A) Venogram
B) CT scan of the lower legs
C) Ankle–brachial index (ABI)
D) PET scan
Ans: C
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Feedback: The ankle–brachial index is a good test for obtaining information about significant
stenosis in the vessels of the lower extremities. Sixteen percent of patients with known peripheral
vascular disease also have coronary artery disease.
4. A 55-year-old secretary with a recent history of breast cancer, for which she underwent surgery
and radiation therapy, and a history of hypertension comes to your office for a routine checkup.
Which of the following aspects of the physical are important to note when assessing the patient for
peripheral vascular disease in the arms?
A) Femoral pulse, popliteal pulse
B) Dorsalis pedis pulse, posterior tibial pulse
C) Carotid pulse
D) Radial pulse, brachial pulse
Ans: D
Feedback: This is an important aspect of physical examination to assess for peripheral vascular disease.
This patient is at risk for disease in this distribution because of her recent radiation therapy.
5. You are a student in the vascular surgery clinic. You are asked to perform a physical
examination on a patient with known peripheral vascular disease in the legs. Which of the
following aspects is important to note when you perform your examination?
A) Size, symmetry, and skin color
B) Muscle bulk and tone
C) Nodules in joints
D) Lower extremity strength
Ans: A
Feedback: This is an important aspect to note in physical examination. Swelling in the legs, cyanosis,
and lack of appropriate hair growth are all signs of peripheral vascular disease.
6. You are assessing a patient for peripheral vascular disease in the arms, secondary to a complaint
of increased weakness and a history of coronary artery disease and diabetes. You assess the brachial
and radial pulses and note that they are bounding. What does that translate to on a scale of 0 to 3?
A) 0
B) 3+
C) 2+
D) 1+
Ans: B
Feedback: A pulse of 3+ is considered to be bounding.
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7. You are obtaining an arterial blood gas in the radial artery on a retired cab driver who has been
hospitalized in the intensive care unit for a stroke. You are concerned about the possibility of arterial
insufficiency. You perform the Allen test. This means that you:
A) Checked for patency of the radial artery
B) Checked for patency of the brachial artery
C) Checked for patency of the ulnar artery
D) Checked for patency of the femoral artery
Ans: C
Feedback: The Allen test is for determining patency of the ulnar artery before puncturing the radial
artery. In the event of an occlusion in the radial artery system, the ulnar artery can provide adequate
blood flow.
8. You are assessing a 59-year-old gas station owner for atherosclerosis in the lower extremities. In
which of the following locations would the patient's pain make you concerned for this disease
process?
A) Thigh
B) Knee
C) Calf
D) Ankle
Ans: C
Feedback: Pain in the calf is the most common site for claudication; however, there could be pain in
the buttock, hip, thigh, or foot, depending on the level of the obstruction. The absence of this pain
does not rule out significant vascular disease, and actually the minority of these patients are
symptomatic.
9. You are performing a routine check-up on an 81-year-old retired cotton farmer in the vascular
surgery clinic. You note that he has a history of chronic arterial insufficiency. Which of the following
physical examination findings in the lower extremities would be expected with this disease?
A) Normal pulsation
B) Normal temperature
C) Marked edema
D) Thin, shiny, atrophic skin
Ans: D
Feedback: Thin, shiny, atrophic skin is more commonly seen in chronic arterial insufficiency; in
chronic venous insufficiency the skin often has a brown pigmentation and may be thickened.
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10. A 77-year-old retired nurse has an ulcer on a lower extremity that you are asked to evaluate
when you do your weekly rounds at a local long-term care facility. All of the following are
responsible for causing ulcers in the lower extremities except for which condition?
A) Arterial insufficiency
B) Venous insufficiency
C) Diminished sensation in pressure points
D) Hypertension
Ans: D
Feedback: Hypertension is not directly associated with the formation of ulcers. It is an indirect risk
factor if it is uncontrolled for a long time and associated with atherosclerosis, because it can lead to
arterial insufficiency or neuropathy.
11. As the internal diameter of a blood vessel changes, the resistance changes as well. Which of the
following descriptions depicts this relationship?
A) Resistance varies linearly with the diameter.
B) Resistance varies proportionally to the second power of the diameter.
C) Resistance varies proportionally to the third power of the diameter.
D) Resistance varies proportionally to the fourth power of the diameter.
Ans: D
Feedback: The body is able to make significant changes in blood vessel resistance with very small
changes to diameter. LaPlace's law tells us that the resistance varies proportionally to the fourth
power of the diameter.
12. Which area of the arm drains to the epitrochlear nodes?
A) Ulnar surface of the forearm and hand, little and ring fingers, and ulnar middle finger
B) Radial surface of the forearm and hand, thumb and index fingers, and radial middle finger
C) Ulnar surface of the forearm and hand; second, third, and fourth fingers
D) Radial surface of the forearm and hand; second, third, and fourth fingers
Ans: A
Feedback: The epitrochlear node receives lymphatic drainage from the ulnar surface of the forearm
and hand, little and ring fingers, and ulnar middle finger. More importantly, it is generally a sign of
generalized lymphadenopathy as seen in syphilis and HIV infection.
13. Mr. Edwards complains of cramps and difficulties with walking. The cramps occur in his
calves consistently after walking about 100 yards. After a period of rest, he can start to walk again,
but after 100 yards these same symptoms recur. Which of the following would suggest spinal
stenosis as a cause of this pain?
A) Coldness and pallor of the legs
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B) Relief of the pain with bending at the waist
C) Color changes of the skin
D) Swelling with tenderness of the skin
Ans: B
Feedback: While these symptoms are classic for claudication, they may also be accounted for by
spinal stenosis. Relief with bending at the waist would be consistent with this etiology. Some will
state that they must lean over the shopping cart while shopping to avoid these symptoms.
Bending stretches the spinal cord and presumably decreases compression. The other symptoms would
lead one to suspect a vascular etiology.
14. Which of the following pairs of ischemic symptoms versus vascular supply is correct?
A) Lower calf/superficial femoral
B) Erectile dysfunction/iliac or pudendal
C) Buttock/common femoral
D) Upper calf/tibial or peroneal
Ans: B
Feedback: The ischemia from the iliac or pudendal arteries results in erectile dysfunction. The lower
calf is supplied by the popliteal artery, the buttock is supplied by the common femoral artery, and the
upper calf is supplied by the superficial femoral artery.
15. The ankle–brachial index (ABI) is calculated by dividing the systolic BP at the dorsalis
pedis by the systolic BP at the brachial artery. Which of the following values would be
consistent with mild peripheral arterial disease?
A) 1.1
B) 0.85
C) 0.65
D) 0.35
Ans: B
Feedback: The mild disease is represented by an ABI of 0.71 to 0.9. Any value above 0.9 is normal.
Moderate disease is defined as between 0.7 and 0.41, and severe disease is defined as
0.4 or less. Patients in the ―severe‖ category have a 20% to 25% annual risk of death.
16. Asymmetric BPs are seen in which of the following conditions?
A) Coronary artery disease
B) Congenital narrowing of the aorta
C) Diffuse atherosclerosis
D) Vasculitis, as seen in systemic lupus erythematosus
Ans: B
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Feedback: A difference of as little as 10 mm Hg in the systolic blood pressure may be significant.
Coarctation and dissecting aortic aneurysm are causes of asymmetric blood pressures. Coarctation
represents a congenital narrowing of the aorta. While some forms of vasculitis can affect large
vessels where we measure the blood pressure, lupus is generally a small-vessel vasculitis.
Usually, neither diffuse atherosclerosis nor coronary artery disease is responsible for a focal
difference in blood pressure.
17. Diminished radial pulses may be seen in patients with which of the following?
A) Aortic insufficiency
B) Hyperthyroidism
C) Arterial emboli
D) Early ―warm‖ septic shock
Ans: C
Feedback: Arterial emboli would decrease flow to a region, and therefore pulses would decrease as
well. The other conditions actually cause bounding pulses. Aortic insufficiency can cause significant
leakage of blood back to the heart, so the heart compensates by increasing forward flow. Stroke
volume can increase dramatically with hyperthyroidism, especially in ―thyroid storm.‖ This also
results in bounding pulses. Although shock generally causes decreased blood pressure and pulses,
early septic shock can produce increased peripheral circulation and increase pulses.
18. When assessing temperature of the skin, which portion of your hand should be used?
A) Fingertips
B) Palms
C) Backs of fingers
D) Ulnar aspect of the hand
Ans: C
Feedback: The backs of the fingers are thought to be the most temperature sensitive, perhaps because
the skin is thinnest there. You may have difficulty detecting subtle differences if you do not use the
backs of the fingers.
19. A patient presents with claudication symptoms and diminished pulses. Which of the
following is consistent with chronic arterial insufficiency?
A) Pallor of the foot when raised to 60 degrees for one minute
B) Return of color to the skin within 5 seconds of allowing legs to dangle
C) Filling of the veins of the ankles within 10 seconds of allowing the legs to dangle
D) Hyperpigmentation of the skin
Ans: A
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Feedback: Pallor of the soles after one minute of elevation is a reliable sign of arterial insufficiency.
Return of the color to the skin should occur within 10 seconds of dangling, and the filling of veins
should occur within 15 seconds. Hyperpigmentation of the skin is usually seen in venous
insufficiency.
20. You note a painful ulcerative lesion near the medial malleolus, with accompanying
hyperpigmentation. Which of the following etiologies is most likely?
A) Arterial insufficiency
B) Neuropathic ulcer
C) Venous insufficiency
D) Trauma Ans:
C
Feedback: These features are most consistent with venous insufficiency. You may also see scaling,
redness, varicosities, and other findings. Arterial insufficiency usually affects distal or traumatized
areas. Other clues of arterial insufficiency would most likely be present.
Neuropathic ulcers occur because of decreased sensation and are common in patients with neuropathy.
They are often over bony prominences with surrounding calluses.
Chapter 16 The Gastrointestinal and Renal Systems
Multiple Choice
1. A 52-year-old secretary comes to your office, complaining about accidentally leaking urine when
she coughs or sneezes. She says this has been going on for about a year now. She relates that she has
not had a period for 2 years. She denies any recent illness or injuries. Her past medical history is
significant for four spontaneous vaginal deliveries. She is married and has four children. She denies
alcohol, tobacco, or drug use. During her pelvic examination you note some atrophic vaginal tissue,
but the remainder of her pelvic, abdominal, and rectal examinations are unremarkable.
Which type of urinary incontinence does she have?
A) Stress incontinence
B) Urge incontinence
C) Overflow incontinence
Ans: A
Feedback: Stress incontinence usually occurs when the intra-abdominal pressure goes up during
coughing, sneezing, or laughing. This is usually due to a weakness of the pelvic floor, with inadequate
muscle support of the bladder. Vaginal deliveries and pelvic surgery are often associated with these
symptoms. Usually female patients are postmenopausal when stress incontinence begins. Kegel
exercises are usually recommended to strengthen the pelvic floor muscles.
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2. A 46-year-old former salesman presents to the ER, complaining of black stools for the past few
weeks. His past medical history is significant for cirrhosis. He has gained weight recently, especially
around his abdomen. He has smoked two packs of cigarettes a day for 30 years and has drunk
approximately 10 alcoholic beverages a day for 25 years. He has used IV heroin and smoked crack in
the past. He denies any recent use. He is currently unemployed and has never been married. On
examination you find a man appearing older than his stated age. His skin has a yellowish tint and he is
thin, with a prominent abdomen. You note multiple ―spider angiomas‖ at the base of his neck.
Otherwise, his heart and lung examinations are normal. On inspection he has dilated veins around his
umbilicus. Increased bowel sounds are heard during auscultation. Palpation reveals diffuse tenderness
that is more severe in the epigastric area. His liver is small and hard to palpation and he has a positive
fluid wave. He is positive for occult blood on his rectal examination.
What cause of black stools most likely describes his symptoms and signs?
A) Infectious diarrhea
B) Mallory-Weiss tear
C) Esophageal varices
Ans: C
Feedback: Varices are often found in alcoholic patients, but only when they have a diagnosis of
significant cirrhosis. This patient has symptoms of cirrhosis, including jaundice, ascites, spider
hemangiomas, and dilated veins on his abdomen (caput medusa).
3. A 21-year-old receptionist comes to your clinic, complaining of frequent diarrhea. She states that
the stools are very loose and there is some cramping beforehand. She states this has occurred on and
off since she was in high school. She denies any nausea, vomiting, or blood in her stool. Occasionally
she has periods of constipation, but that is rare. She thinks the diarrhea is much worse when she is
nervous. Her past medical history is not significant. She is single and a junior in college majoring in
accounting. She smokes when she drinks alcohol but denies using any illegal drugs. Both of her
parents are healthy. Her entire physical examination is unremarkable. What is most likely the etiology
of her diarrhea?
A) Secretory infections
B) Inflammatory infections
C) Irritable bowel syndrome
D) Malabsorption syndrome
Ans: C
Feedback: Irritable bowel syndrome will cause loose bowel movements with cramps but no
systemic symptoms of fever, weight loss, or malaise. This syndrome is more likely in young
women with alternating symptoms of loose stools and constipation. Stress usually makes the
symptoms worse, as do certain foods.
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4. A 42-year-old florist comes to your office, complaining of chronic constipation for the last 6
months. She has had no nausea, vomiting, or diarrhea and no abdominal pain or cramping. She denies
any recent illnesses or injuries. She denies any changes to her diet or exercise program. She is on no
new medications. During the review of systems you note that she has felt fatigued, had some weight
gain, has irregular periods, and has cold intolerance. Her past medical history is significant for one
vaginal delivery and two cesarean sections. She is married, has three children, and owns a flower
shop. She denies tobacco, alcohol, or drug use. Her mother has type 2 diabetes and her father has
coronary artery disease. There is no family history of cancers. On examination she appears her stated
age. Her vital signs are normal. Her head, eyes, ears, nose, throat, and neck examinations are normal.
Her cardiac, lung, and abdominal examinations are also unremarkable. Her rectal occult blood test is
negative. Her deep tendon reflexes are delayed in response to a blow with the hammer, especially the
Achilles tendons.
What is the best choice for the cause of her constipation?
A) Large bowel obstruction
B) Irritable bowel syndrome
C) Rectal cancer
D) Hypothyroidism
Ans: D
Feedback: Many metabolic conditions can interfere with bowel motility. In this case the patient has
many symptoms of hypothyroidism, including cold intolerance, weight gain, fatigue, constipation,
and irregular menstrual cycles. On examination, thyromegaly and delayed reflexes can help to make
the diagnosis. Medication will usually correct these symptoms.
5. A 22-year-old law student comes to your office, complaining of severe abdominal pain radiating to
his back. He states it began last night after hours of heavy drinking. He has had abdominal pain and
vomiting in the past after drinking but never as bad as this. He cannot keep any food or water down,
and these symptoms have been going on for almost 12 hours. He has had no recent illnesses or
injuries. His past medical history is unremarkable. He denies smoking or using illegal drugs but
admits to drinking 6 to 10 beers per weekend night. He admits that last night he drank something like
14 drinks. On examination you find a young male appearing his stated age in some distress. He is
leaning over on the examination table and holding his abdomen with his arms. His blood pressure is
90/60 and his pulse is 120. He is afebrile. His abdominal examination reveals normal bowel sounds,
but he is very tender in the left upper quadrant and epigastric area. He has no Murphy's sign or
tenderness in the right lower quadrant. The remainder of his abdominal examination is normal. His
rectal, prostate, penile, and testicular examinations are normal. He has no inguinal hernias or
tenderness with that examination. Blood work is pending.
What etiology of abdominal pain is most likely causing his symptoms?
A) Peptic ulcer disease
B) Biliary colic
C) Acute cholecystitis
D) Acute pancreatitis
Ans: D
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Feedback: Acute pancreatitis causes epigastric and left upper quadrant pain and often radiates into the
back. There is often a history of long-standing gallbladder disease or recent alcohol ingestion. Severe
abdominal pain and vomiting are often seen. Medications such as proton pump inhibitors can also
cause pancreatitis in people without these other risk factors. Treatment includes hydration, pain
management, and bowel rest.
6. A 76-year-old retired farmer comes to your office complaining of abdominal pain, constipation,
and a low-grade fever for about 3 days. He denies any nausea, vomiting, or diarrhea. The only unusual
thing he remembers eating is two bags of popcorn at the movies with his grandson, 3 days before his
symptoms began. He denies any other recent illnesses. His past medical history is significant for
coronary artery disease and high blood pressure. He has been married for over 50 years. He denies any
tobacco, alcohol, or drug use. His mother died of colon cancer and his father had a stroke. On
examination he appears his stated age and is in no acute distress. His temperature is 100.9 degrees and
his other vital signs are unremarkable. His head, cardiac, and pulmonary examinations are normal. He
has normal bowel sounds and is tender over the left lower quadrant. He has no rebound or guarding.
His rectal examination is unremarkable and his fecal occult blood test is negative. His prostate is
slightly enlarged but his testicular, penile, and inguinal examinations are all normal. Blood work is
pending.
What diagnosis for abdominal pain best describes his symptoms and signs?
A) Acute diverticulitis
B) Acute cholecystitis
C) Acute appendicitis
D) Mesenteric ischemia Ans:
A
Feedback: Diverticulitis is caused by localized infections within the colonic diverticula. Constipation,
fever, and abdominal pain are common. Mesenteric ischemia classically presents in older people with a
history of vascular disease elsewhere. The typical pain is unusual in that it is not made worse by
examination despite being severe. Some mistake this feature to indicate malingering, with bad results.
7. A 77-year-old retired bus driver comes to your clinic for a physical examination at his wife's
request. He has recently been losing weight and has felt very fatigued. He has had no chest pain,
shortness of breath, nausea, vomiting, or fever. His past medical history includes colon cancer, for
which he had surgery, and arthritis. He has been married for over 40 years. He denies any tobacco or
drug use and has not drunk alcohol in over 40 years. His parents both died of cancer in their 60s. On
examination his vital signs are normal. His head, cardiac, and pulmonary examinations are
unremarkable. On abdominal examination you hear normal bowel sounds, but when you palpate his
liver it is abnormal. His rectal examination is positive for occult blood. What further abnormality of
the liver was likely found on examination?
A) Smooth, large, nontender liver
B) Irregular, large liver
C) Smooth, large, tender liver
Ans: B
Feedback: With his past history of colon cancer and with recent weight loss and fatigue, a relapse of
his colon cancer would be expected. Colon cancer usually metastasizes to the liver, creating hard,
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irregular nodules, which can sometimes be palpated on examination. A smooth, large liver which is
tender is often seen in hepatitis.
8. A 26-year-old sports store manager comes to your clinic, complaining of severe right-sided
abdominal pain for 12 hours. He began having a stomachache yesterday, with a decreased appetite,
but today the pain seems to be just on the lower right side. He has had some nausea and vomiting but
no constipation or diarrhea. His last bowel movement was last night and was normal. He has had no
fever or chills. He denies any recent illnesses or injuries. His past medical history is unremarkable. He
is engaged. He denies any tobacco or drug use and drinks four to six beers per week. His mother has
breast cancer and his father has coronary artery disease. On examination he appears ill and is lying on
his right side. His temperature is 100.4 and his heart rate is 110. His bowel sounds are decreased and
he has rebound and involuntary guarding, one third of the way between the anterior superior iliac
spine and the umbilicus in the right lower quadrant. His rectal, inguinal, prostate, penile, and
testicular examinations are normal.
What is the most likely cause of his pain?
A) Acute appendicitis
B) Acute mechanical intestinal obstruction
C) Acute cholecystitis
D) Mesenteric ischemia
Ans: A
Feedback: Appendicitis is common in the young and usually presents with periumbilical pain that
localizes to the right lower quadrant in an area known as McBurney's Point, described above as one
third of the way between the anterior superior iliac spine and the umbilicus on the right.
Rebound and guarding are common. Remote rebound or Rovsing's sign is also seen commonly
when the course of appendicitis is advanced. Bowel movements are usually unaffected.
9. A 15-year-old high school freshman is brought to the clinic by his mother because of chronic
diarrhea. The mother states that for the past couple of years her son has had diarrhea after many
meals. The patient states that the diarrhea seems the absolute worst after his school lunches. He
describes his symptoms as cramping abdominal pain and gas followed by diarrhea. His stools are
watery with no specific smell. He denies any nausea, vomiting, constipation, weight loss, or fatigue.
He has had no recent illness, injuries, or foreign travel. His past medical history is unremarkable. He
denies tobacco, alcohol, or drug use. His parents are both healthy. On examination you see a relaxed
young man breathing comfortably. His vital signs are normal and his head, eyes, ears, throat, neck,
cardiac, and pulmonary examinations are normal. His abdomen is soft and nondistended. His bowel
sounds are active and he has no tenderness, no enlarged organs, and no rebound or guarding. His
rectal examination is nontender with no blood on the glove. You collect a stool sample for further
study.
What is the most likely explanation for this patient's chronic diarrhea?
A) Malabsorption syndrome
B) Osmotic diarrhea
C) Secretory diarrhea
Ans: B
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Feedback: Usually related to lactose intolerance, watery diarrhea often follows meal ingestion.
Crampy abdominal pain, distension, and gas often accompany symptoms. Diarrhea is often provoked
by pizza, milkshakes, yogurt, and other lactose-containing foods. This condition is more common in
African-Americans, Latinos, Native Americans, and Asians.
10. A 27-year-old policewoman comes to your clinic, complaining of severe left-sided back pain
radiating down into her groin. It began in the middle of the night and woke her up suddenly. It hurts in
her bladder to urinate but she has no burning on the outside. She has had no frequency or urgency with
urination but she has seen blood in her urine. She has had nausea with the pain but no vomiting or
fever. She denies any other recent illness or injuries. Her past medical history is unremarkable. She
denies tobacco or drug use and drinks alcohol rarely. Her mother has high blood pressure and her
father is healthy. On examination she looks her stated age and is in obvious pain. She is lying on her
left side trying to remain very still. Her cardiac, pulmonary, and abdominal examinations are
unremarkable. She has tenderness just inferior to the left costovertebral angle. Her urine pregnancy
test is negative and her urine analysis shows red blood cells.
What type of urinary tract pain is she most likely to have?
A) Kidney pain (from pyelonephritis)
B) Ureteral pain (from a kidney stone)
C) Musculoskeletal pain
D) Ischemic bowel pain
Ans: B
Feedback: The pain from a kidney stone causes dramatic, severe, colicky pain at the costovertebral
angle that radiates across the flank and down into the groin.
11. Chris is a 20-year-old college student who has had abdominal pain for 3 days. It started at his
umbilicus and was associated with nausea and vomiting. He was unable to find a comfortable
position. Yesterday, the pain became more severe and constant. Now, he hesitates to walk, because
any motion makes the pain much worse. It is localized just medial and inferior to his iliac crest on the
right. Which of the following is most likely?
A) Peptic ulcer
B) Cholecystitis
C) Pancreatitis
D) Appendicitis
Ans: D
Feedback: This is a classic history for appendicitis. Notice that the pain has changed from visceral to
parietal. It is well localized to the right lower quadrant, making appendicitis a strong consideration.
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12. Bill, a 55-year-old man, presents with pain in his epigastrium which lasts for 30 minutes or
more at a time and has started recently. Which of the following should be considered?
A) Peptic ulcer
B) Pancreatitis
C) Myocardial ischemia
D) All of the above
Ans: D
Feedback: Epigastric pain can have many causes. History and physical will help discern which causes
are most likely, but it is important to realize that any of the above, including myocardial ischemia, is
always a possibility. Pneumonia and gallbladder pain can also cause pain in this location.
13. Monique is a 33-year-old administrative assistant who has had intermittent lower abdominal pain
approximately one week a month for the past year. It is not related to her menses. She notes relief
with defecation, and a change in form and frequency of her bowel movements with these episodes.
Which of the following is most likely?
A) Colon cancer
B) Cholecystitis
C) Inflammatory bowel disease
D) Irritable bowel syndrome
Ans: D
Feedback: Although colon cancer should be a consideration, these symptoms are intermittent and no
note is made of progression. Cholecystitis usually presents with right upper quadrant pain.
Inflammatory bowel disease is often associated with fever and hematochezia. Because there is relief
with defecation and there are no mentioned structural or biochemical abnormalities, irritable bowel
syndrome seems most likely. This is a very common condition which can be triggered by certain
foods and stress.
14. Jim is a 60-year-old man who presents with vomiting. He denies seeing any blood with emesis,
which has been occurring for 2 days. He does note a dark, granular substance resembling the coffee
left in the filter after brewing. What do you suspect?
A) Bleeding from a diverticulum
B) Bleeding from a peptic ulcer
C) Bleeding from a colon cancer
D) Bleeding from cholecystitis
Ans: B
Feedback: When blood is exposed to the environment of the stomach, it often resembles ―coffee
grounds.‖ This is not always recognized by patients as blood, so it is important to inquire about this.
This symptom is not common in cholecystitis, and the other possibilities occur lower in the intestine.
It should be noted that conversely, rapid bleeding from the stomach or other upper gastrointestinal
source can produce bright red blood in the stool. Do not rule out proximal bleeding on the basis of the
absence of ―coffee grounds.‖ Likewise, bright red blood seen with emesis may originate from the
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stomach. Black, sticky stools also can accompany upper GI bleeding.
15. A daycare worker presents to your office with jaundice. She denies IV drug use, blood
transfusion, and travel and has not been sexually active for the past 10 months. Which type of
hepatitis is most likely?
A) Hepatitis A
B) Hepatitis B
C) Hepatitis C
D) Hepatitis D
Ans: A
Feedback: The lack of contact with blood and body fluids makes hepatitis B, C, and D unlikely. She
regularly changes the diapers of her clients and is at risk for hepatitis A. Vaccine against hepatitis A is
recommended for daycare workers.
16. Linda is a 29-year-old who had excruciating pain which started under her lower ribs on the right
side. The pain eventually moved to her lateral abdomen and then into her right lower quadrant.
Which is most likely, given this presentation?
A) Appendicitis
B) Dysmenorrhea
C) Ureteral stone
D) Ovarian cyst
Ans: C
Feedback: The presentation of right flank pain spiraling down to the groin is typical of a ureteral stone.
There would most likely be microscopic hematuria as well. The migration pattern of this condition
makes the others less likely.
17. Mrs. LaFarge is a 60-year-old who presents with urinary incontinence. She is unable to get to
the bathroom quickly enough when she senses the need to urinate. She has normal mobility. Which
of the following is most likely?
A) Stress incontinence
B) Urge incontinence
C) Overflow incontinence
D) Functional incontinence
Ans: B
Feedback: Stress incontinence occurs with increased intra-abdominal pressure such as with coughing,
sneezing, or laughing. This history is most consistent with urge incontinence secondary to detrusor
overactivity. Overflow incontinence occurs with anatomic obstruction such as prostatic hypertrophy
(obviously not in this case, as the patient is a woman), urethral stricture, or neurogenic bladder.
Functional incontinence results from lack of mobility severe enough to impair getting to the bathroom
quickly enough.
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18. Which is the proper sequence of examination for the abdomen?
A) Auscultation, inspection, palpation, percussion
B) Inspection, percussion, palpation, auscultation
C) Inspection, auscultation, percussion, palpation
D) Auscultation, percussion, inspection, palpation
Ans: C
Feedback: The abdominal examination is conducted in a sequence different from other systems, for
which the usual order is inspection, percussion, palpation, and auscultation. Because palpation may
actually cause some bowel noise when the bowels are not moving, auscultation is performed before
percussion and palpation in an abdominal examination.
19. A 62-year-old woman has been followed by you for 3 years and has had recent onset of
hypertension. She is still not at goal despite three antihypertensive medicines, and you strongly doubt
nonadherence. Her father died of a heart attack at age 58. Today her pressure is 168/94 and pressure
on the other arm is similar. What would you do next?
A) Add a fourth medicine
B) Refer to nephrology
C) Get a CT scan
D) Listen closely to her abdomen
Ans: D
Feedback: At this point, it is important to consider secondary causes for this woman's hypertension
because of its severity, rapidity of progression, and lack of response to therapy. While you will most
likely add a fourth medicine, it is important to carefully examine the abdomen for the presence of
renal artery bruits. These are usually heard best in the upper quadrants. It may be necessary to have
the patient hold her breath, to have a very quiet room, and to listen with the diaphragm for a very soft,
high-pitched sound with systole. It may also help to simultaneously feel the patient's pulse (a bruit
with both a systolic and diastolic component is very specific for a significant blockage, while a lone
systolic bruit may not be abnormal).
Obtaining a CT scan is not likely to be useful, and you may save the delay, expense, and inconvenience
of a nephrology referral if you can hear a bruit.
20. Mr. Patel is a 64-year-old man who was told by another care provider that his liver is enlarged.
Although he is a life-long smoker, he has never used drugs or alcohol and has no knowledge of liver
disease. Indeed, on examination, a liver edge is palpable 4 centimeters below the costal arch. Which
of the following would you do next?
A) Check an ultrasound of the liver
B) Obtain a hepatitis panel
C) Determine liver span by percussion
D) Adopt a ―watchful waiting‖ approach
Ans: C
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Feedback: A liver edge palpable this far below the costal arch should not be ignored. Ultrasound and
laboratory investigation are reasonable if the liver is actually enlarged. Mr. Patel has developed
emphysema with flattening of the diaphragms. This pushes a normal-sized liver below the costal arch
so that it appears to be enlarged. A liver span should be determined by percussing down the chest wall
until dullness is heard. A measurement is then made between this point and the lower border of the
liver to determine its span; 6–12 centimeters in the mid-clavicular line is normal. Percussion is the
only way to assess liver size on examination, and in this case it saved the patient much inconvenience
and expense.
21. Cody is a teenager with a history of leukemia and an enlarged spleen. Today he presents with
fairly significant left upper quadrant pain. On examination of this area a rough grating noise is heard.
What is this sound?
A) It is a splenic rub.
B) It is a variant of bowel noise.
C) It represents borborygmi.
D) It is a vascular noise.
Ans: A
Feedback: A rough, grating noise over this area represents a splenic rub, which can accompany splenic
infarction. Rubs also occur over the liver and pleura and pericardium.
22. You are palpating the abdomen and feel a small mass. Which of the following would you do
next?
A) Ultrasound
B) Examination with the abdominal muscles tensed
C) Surgery referral
D) Determine size by percussion
Ans: B
Feedback: It is easy to determine whether the mass is actually in the abdominal wall versus in the
abdomen by palpating with the abdominal wall tensed. This can be accomplished by having the
patient lift her head off the bed while supine. Usually, abdominal wall masses can be observed,
whereas intra-abdominal masses are more concerning.
23. Josh is a 14-year-old boy who presents with a sore throat. On examination, you notice
dullness in the last intercostal space in the anterior axillary line on his left side with a deep
breath. What does this indicate?
A) His spleen is definitely enlarged and further workup is warranted.
B) His spleen is possibly enlarged and close attention should be paid to further examination.
C) His spleen is possibly enlarged and further workup is warranted.
D) His spleen is definitely normal.
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Ans: B
Feedback: This scenario is not uncommon in infectious mononucleosis. The presence of dullness
with inspiration should definitely increase your attention to further examination of the spleen,
although dullness can occur in normal patients too.
24. A young patient presents with a left-sided mass in her abdomen. You confirm that it is present
in the left upper quadrant. Which of the following would support that this represents an enlarged
kidney rather than her spleen?
A) A palpable ―notch‖ along its edge
B) The inability to push your fingers between the mass and the costal margin
C) The presence of normal tympany over this area
D) The ability to push your fingers medial and deep to the mass
Ans: C
Feedback: A left upper quadrant mass is more likely to be a kidney if there is no palpable ―notch,‖
you can push your fingers between the mass and the costal margin, there is normal tympany over this
area, and you cannot push your fingers medial and deep to the mass. These findings are very difficult
to appreciate in an obese patient.
25. Mr. Kruger is an 84-year-old who presents with a smooth lower abdominal mass in the midline
which is minimally tender. There is dullness to percussion up to 6 centimeters above the symphysis pubis.
What does this most likely represent?
A)
B)
C)
D)
Sigmoid mass
Tumor in the abdominal wall
Hernia
Enlarged bladder
Ans: D
Feedback: It is possible that this represents a sigmoid colon mass, but this is less likely than an
enlarged bladder. Prostatic hypertrophy is very common in this age group and can frequently cause
partial urinary obstruction with bladder enlargement. If the mass resolves with catheterization, this is
a likely cause. Other forms of urinary obstruction such as neurogenic bladder, urethral stricture, and
side effects of drugs can also be contributing to the problem. A hernia would most likely not be dull
to percussion. Midline abdominal wall tumors of this size would be unusual but could be discerned
by having the patient tense his abdominal muscles.
26. Mr. Martin is a 72-year-old smoker who comes to you for his hypertension visit. You note that
with deep palpation you feel a pulsatile mass which is about 4 centimeters in diameter. What should
you do next?
A) Obtain abdominal ultrasound
B) Reassess by examination in 6 months
C) Reassess by examination in 3 months
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D) Refer to a vascular surgeon
Ans: A
Feedback: A pulsatile mass in this man should be followed up with ultrasound as soon as possible.
His risk of aortic rupture is at least 15 times greater if his aorta measures more than 4 centimeters. It
would be inappropriate to recheck him at a later time without taking action.
Likewise, referral to a vascular surgeon before ultrasound may be premature.
27. Mr. Maxwell has noticed that he is gaining weight and has increasing girth. Which of the
following would argue for the presence of ascites?
A) Bilateral flank tympany
B) Dullness which remains despite change in position
C) Dullness centrally when the patient is supine
D) Tympany which changes location with patient position
Ans: D
Feedback: A diagnosis of ascites is supported by findings that are consistent with movement of fluid
and gas with changes in position. Gas-filled loops of bowel tend to float so that dullness when supine
would argue against this. Likewise, because fluid gathers in dependent areas, the flanks should
ordinarily be dull with ascites. Tympany which changes location with patient position (―shifting
dullness‖) would support the presence of ascites. A fluid wave and edema would support this diagnosis
as well.
28. Which of the following is consistent with obturator sign?
A) Pain distant from the site used to check rebound tenderness
B) Right hypogastric pain with the right hip and knee flexed and the hip internally rotated
C) Pain with extension of the right thigh while the patient is on her left side or while pressing her
knee against your hand with thigh flexion
D) Pain that stops inhalation in the right upper quadrant
Ans: B
Feedback: Obturator sign is seen in appendicitis. It is pain with the stretching of the internal
obturator muscle because of inflammation. Pain distant from the site used to check rebound
tenderness is Rovsing's sign and is a reliable sign of peritonitis. Answer ―C‖ describes psoas sign,
which is also seen in appendicitis. Palpation in the right upper quadrant that causes pain severe
enough to stop inhalation is consistent with inflammation of the gallbladder and is called Murphy's
sign.
29. An elderly woman with a history of coronary bypass comes in with severe, diffuse, abdominal
pain. Strangely, during your examination, the pain is not made worse by pressing on the abdomen.
What do you suspect?
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A)
B)
C)
D)
Malingering
Neuropathy
Ischemia
Physical abuse
Ans: C
Feedback: Ischemic pain can be severe but is not made worse with palpation. The history of bypass
could be a clue that there is vascular narrowing elsewhere. Malingering is less likely, and neuropathic
pain, as seen in herpes zoster, would worsen with touch. You are to be commended if you considered
elder abuse, because this is frequently missed. Ordinarily, this pain would be worse with examination
because of the preceding trauma.
Chapter 17 The Breasts and Axillae
Multiple Choice
1. A 72-year-old retired saleswoman comes to your office, complaining of a bloody discharge from
her left breast for 3 months. She denies any trauma to her breast. Her past medical history includes
high blood pressure and abdominal surgery for colon cancer. Her aunt died of ovarian cancer and her
father died of colon cancer. Her mother died of a stroke. The patient denies tobacco, alcohol, or drug
use. She is a widow and has three healthy children. On examination her breasts are symmetric, with
no skin changes. You are able to express bloody discharge from her left nipple. You feel no discrete
masses, but her left axilla has a hard, 1-cm fixed node. The remainder of her heart, lung, abdominal,
and pelvic examinations are unremarkable.
What cause of nipple discharge is the most likely in her circumstance?
A) Benign breast abnormality
B) Breast cancer
C) Galactorrhea
Ans: B
Feedback: Nipple discharge in breast cancer is usually unilateral and can be clear or bloody.
Although a breast mass is not palpated, in this case a fixed lymph node is palpated. Other forms of
breast cancer can present as a chronic rash on the breast.
2. A 44-year-old female comes to your clinic, complaining of severe dry skin in the area over her
right nipple. She denies any trauma to the area. She noticed the skin change during a selfexamination 2 months ago. She also admits that she had felt a lump under the nipple but kept putting
off making an appointment. She does admit to 6 months of fatigue but no weight loss, weight gain,
fever, or night sweats. Her past medical history is significant for hypothyroidism. She does not have
a history of eczema or allergies. She denies any tobacco, alcohol, or drug use. On examination you
find a middle-aged woman appearing her stated age. Inspection of her right breast reveals a scaly
eczema-like crust around her nipple. Underneath you palpate a nontender
2-cm mass. The axilla contains only soft, moveable nodes. The left breast and axilla examination
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findings are unremarkable.
What visible skin change of the breast does she have?
A) Nipple retraction
B) Paget's disease
C) Peau d'orange sign
Ans: B
Feedback: This uncommon form of breast cancer starts as an eczema-like, scaly skin change around
the areola. The lesion may weep, crust, or erode. It can be associated with an underlying mass, but the
skin change can also be found alone. Any eczema-like area around the nipple that does not respond to
topical treatment needs to be evaluated for breast cancer.
3. A 56-year-old female comes to your clinic, complaining of her left breast looking unusual. She
says that for 2 months the angle of the nipple has changed direction. She does not do selfexaminations, so she doesn't know if she has a lump. She has no history of weight loss, weight gain,
fever, or night sweats. Her past medical history is significant for high blood pressure. She smokes
two packs of cigarettes a day and has three to four drinks per weekend night. Her paternal aunt died
of breast cancer in her forties. Her mother is healthy but her father died of prostate cancer. On
examination you find a middle-aged woman appearing older than her stated age. Inspection of her
left breast reveals a flattened nipple deviating toward the lateral side. On palpation the nipple feels
thickened. Lateral to the areola you palpate a nontender 4-cm mass. The axilla contains several fixed
nodes. The right breast and axilla examinations are unremarkable.
What visible skin change of the breast does she have?
A) Nipple retraction
B) Paget's disease
C) Peau d'orange sign
Ans: A
Feedback: A retracted nipple is flattened or pulled inward or toward the medial, lateral, anterior, or
posterior side of the breast. The surrounding skin can be thickened. This is a relatively late finding in
breast cancer.
4. A 19-year-old female comes to your office, complaining of a clear discharge from her right breast
for 2 months. She states that she noticed it when she and her boyfriend were ―messing around‖ and
he squeezed her nipple. She continues to have this discharge anytime she squeezes that nipple. She
denies any trauma to her breasts. Her past medical history is unremarkable. She denies any
pregnancies. Both of her parents are healthy. She denies using tobacco or illegal drugs and drinks
three to four beers a week. On examination her breasts are symmetric with no skin changes. You are
able to express clear discharge from her right nipple. You feel no discrete masses and her axillae are
normal. The remainder of her heart, lung, abdominal, and pelvic examinations are unremarkable. A
urine pregnancy test is negative.
What cause of nipple discharge is the most likely in her circumstance?
A) Benign breast abnormality
B) Breast cancer
C) Nonpuerperal galactorrhea
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Ans: A
Feedback: Nipple discharge in benign breast abnormalities tends to be clear and unilateral. The
discharge is usually not spontaneous. This patient needs to be told to stop compressing her nipple. If
the problem still persists after the patient has stopped compressing the nipple, further workup is
warranted.
5. A 23-year-old computer programmer comes to your office for an annual examination. She has
recently become sexually active and wants to be placed on birth control. Her only complaint is that the
skin in her armpits has become darker. She states it looks like dirt, and she scrubs her skin nightly
with soap and water but the color stays. Her past medical symptoms consist of acne and mild obesity.
Her periods have been irregular for 3 years. Her mother has type 2 diabetes and her father has high
blood pressure. The patient denies using tobacco but has four to five drinks on Friday and Saturday
nights. She denies any illegal drug use. On examination you see a mildly obese female who is
breathing comfortably. Her vital signs are unremarkable. Looking under her axilla, you see dark,
velvet-like skin. Her annual examination is otherwise unremarkable.
What disorder of the breast or axilla is she most likely to have?
A) Peau d'orange
B) Acanthosis nigricans
C) Hidradenitis suppurativa
Ans: B
Feedback: Acanthosis nigricans can be associated with an internal malignancy, but in most cases it is
a benign dermatologic condition associated with polycystic ovarian syndrome, consisting of acne,
hirsutism, obesity, irregular periods, infertility, ovarian cysts, and early onset type 2 diabetes. It is
also known to correlate with insulin resistance.
6. A 43-year-old store clerk comes to your office upset because she has found an enlarged lymph
node under her left arm. She states she found it yesterday when she was feeling pain under her arm
during movement. She states the lymph node is about an inch long and is very painful. She checks her
breasts monthly and gets a yearly mammogram (her last was 2 months ago), and until now everything
has been normal. She states she is so upset because her mother died in her 50s of breast cancer. The
patient does not smoke, drink, or use illegal drugs. Her father is in good health. On examination you
see a tense female appearing her stated age. On visual inspection of her left axilla you see a tense red
area. There is no scarring around the axilla. Palpating this area, you feel a 2-cm tender, movable
lymph node underlying hot skin. Other shotty nodes are also in the area. Visualization of both breasts
is normal. Palpation of her right axilla and both breasts is unremarkable. Examining her left arm, you
see a scabbed-over superficial laceration over her left hand. Upon your questioning, she remembers she cut
her hand gardening last week.
What disorder of the axilla is most likely responsible for her symptoms?
A) Breast cancer
B) Lymphadenopathy of infectious origin
C) Hidradenitis suppurativa
Ans: B
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Feedback: A lymph node enlarged because of infection is generally hot, tender, and red. Close
examination of the skin that drains to that lymph node region is advised. Often there will be a cut or
scratch over the involved arm that has an infectious agent. An example is cat scratch disease.
7. A 63-year-old nurse comes to your office, upset because she has found an enlarged lymph node
under her right arm. She states she found it last week while taking a shower. She isn't sure if she has
any breast lumps because she doesn't know how to do self-exams. She states her last mammogram
was 5 years ago and it was normal. Her past medical history is significant for high blood pressure and
chronic obstructive pulmonary disease. She quit smoking 2 years ago after a 55-packs/year history.
She denies using any illegal drugs and drinks alcohol rarely. Her mother died of a heart attack and
her father died of a stroke. She has no children. On examination you see an older female appearing
her stated age. On visual inspection of her right axilla you see nothing unusual. Palpating this area,
you feel a 2-cm hard, fixed lymph node. She denies any tenderness. Visualization of both breasts is
normal. Palpation of her left axilla and breast is unremarkable. On palpation of her right breast you
feel a nontender 1-cm lump in the tail of Spence.
What disorder of the axilla is most likely responsible for her symptoms?
A) Breast cancer
B) Lymphadenopathy of infectious origin
C) Hidradenitis suppurativa
Ans: A
Feedback: Metastatic lymph nodes tend to be hard, nontender, and fixed, often to the rib cage.
Although the patient has no family history of breast cancer, she is at a slightly increased risk due to
her never having had children.
8. A 40-year-old mother of two presents to your office for consultation. She is interested in knowing
what her relative risks are for developing breast cancer. She is concerned because her sister had
unilateral breast cancer 6 years ago at age 38. The patient reports on her history that she began
having periods at age 11 and has been fairly regular ever since, except during her two pregnancies. Her
first child arrived when she was 26 and her second at age 28. Otherwise she has had no health problems. Her
father has high blood pressure. Her mother had unilateral breast cancer in her 70s. The patient denies tobacco,
alcohol, or drug use. She is a family law attorney and is married. Her examination is essentially unremarkable.
Which risk factor of her personal and family history most puts her in danger of getting breast cancer?
A) First-degree relative with premenopausal breast cancer
B) Age at menarche of less than 12
C) First live birth between the ages of 25 and 29
D) First-degree relative with postmenopausal breast cancer
Ans: A
Feedback: Having a first-degree relative with cancer before menopause gives a relative risk of 3.1.
9. A 51-year-old cook comes to your office for consultation. She recently found out that her 44year-old sister with premenopausal breast cancer is positive for the BRCA1 gene. Your patient has
been doing research on the Internet and saw that her chance of having also inherited the BRCA1
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gene is 50%. She is interested in knowing what her risk of developing breast cancer would be if she
were positive for the gene. She denies any lumps in her breasts and has had normal mammograms.
She has had no weight loss, fever, or night sweats. Her mother is healthy and her father has prostate
cancer. Two of her paternal aunts died of breast cancer. She is married. She denies using tobacco or
illegal drugs and rarely drinks alcohol. Her breast and axilla examinations are unremarkable.
At her age, what is her risk of getting breast cancer if she has the BRCA1 gene?
A) 10%
B) 50%
C) 80%
Ans: B
Feedback: At the age of 50, the risk of breast cancer for someone with the BRCA1 gene is 50%.
10. A 14-year-old junior high school student is brought in by his mother and father because he seems
to be developing breasts. The mother is upset because she read on the Internet that smoking marijuana
leads to breast enlargement in males. The young man adamantly denies using any tobacco, alcohol, or
drugs. He has recently noticed changes in his penis, testicles, and pubic hair pattern. Otherwise, his
past medical history is unremarkable. His parents are both in good health. He has two older brothers
who never had this problem. On examination you see a mildly overweight teenager with enlarged
breast tissue that is slightly tender on both sides. Otherwise his examination is normal. He is
agreeable to taking a drug test.
What is the most likely cause of his gynecomastia?
A) Breast cancer
B) Imbalance of hormones of puberty
C) Drug use
Ans: B
Feedback: Approximately one third of teenage boys develop gynecomastia during puberty. It is not
surprising that the two older brothers did not have this.
11. A patient is concerned about a dark skin lesion on her anterolateral abdomen. It has not
changed, and there is no discharge or bleeding. On examination there is a medium brown circular
lesion on the anterolateral wall of the abdomen. It is soft, has regular borders, is evenly pigmented,
and is about 7 mm in diameter. What is this lesion?
A) Melanoma
B) Dysplastic nevus
C) Supernumerary nipple
D) Dermatofibroma
Ans: C
Feedback: This represents a supernumerary nipple. These occur along the ―milk line‖ and do not
exhibit features of more concerning lesions.
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12. A 30-year-old man notices a firm, 2-cm mass under his areola. He has no other symptoms and no
diagnosis of breast cancer in his first-degree relatives. What is the most likely diagnosis?
A) Breast tissue
B) Fibrocystic disease
C) Breast cancer
D) Lymph node
Ans: A
Feedback: Approximately one third of adult men will have palpable breast tissue under the areola.
While males can have breast cancer, this is much less common. There are no lymph nodes in this
area.
13. Which of the following lymph node groups is most commonly involved in breast cancer?
A) Lateral
B) Subscapular
C) Pectoral
D) Central
Ans: D
Feedback: The central nodes at the apex of the axilla are most commonly involved in breast cancer.
The axilla can be viewed roughly as a four-sided pyramid. An examination covering all sides and the
apex is unlikely to miss a significant node.
14. When should a woman conduct breast self-examination with respect to her menses?
A) Five to seven days following her menses
B) Midcycle
C) Immediately prior to menses
D) During her menses
Ans: A
Feedback: The breast examination should be conducted during the time with the least estrogen
stimulation of the breast tissue. This corresponds to five to seven days following menses.
15. Mrs. Patton, a 48-year-old woman, comes to your office with a complaint of a breast mass.
Without any other information, what is the risk of this mass being cancerous?
A) About 10%
B) About 20%
C) About 30%
D) About 40%
Ans: A
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Feedback: Eleven percent of women presenting with a breast mass will have breast cancer. This
statistic can be reassuring to a patient, but the importance of further studies must be emphasized.
16. How often, according to American Cancer Society recommendations, should a woman
undergo a screening breast examination by a skilled clinician?
A) Every year
B) Every 2 years
C) Every 3 years
D) Every 4 years
Ans: C
Feedback: The current recommendation for screening by breast examination is every 3 years.
17. Which of the following is most likely benign on breast examination?
A) Dimpling of the skin resembling that of an orange
B) One breast larger than the other
C) One nipple inverted
D) One breast with dimple when the patient leans forward
Ans: B
Feedback: Asymmetry in size of the breasts is a common benign finding. The others are concerning
for underlying malignancy.
18. Which is the most effective pattern of palpation for breast cancer?
A) Beginning at the nipple, make an ever-enlarging spiral.
B) Divide the breast into quadrants and inspect each systematically.
C) Examine in lines resembling the back and forth pattern of mowing a lawn.
D) Beginning at the nipple, palpate outward in a stripe pattern.
Ans: C
Feedback: The vertical strip pattern has been shown to be the most effective pattern for palpation of
the breast. The most important aspect, however, is to be systematic. The tail of Spence, located on
the upper anterior chest, is an area commonly missed on examination.
19. Which is true of women who have had a unilateral mastectomy?
A) They no longer require breast examination.
B) They should be examined carefully along the surgical scar for masses.
C) Lymphedema of the ipsilateral arm usually suggests recurrence of breast cancer.
D) Women with breast reconstruction over their mastectomy site no longer require examination.
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Ans: B
Feedback: A woman who has had breast cancer remains at high risk for recurrence, especially in the
contralateral breast. The mastectomy site should be carefully examined for local recurrence as well.
Lymphedema or swelling of the ipsilateral arm following mastectomy is common and does not
usually indicate recurrence. Women with breast reconstruction must also undergo careful
examination.
20. Which of the following is true regarding breast self-examination?
A) It has been shown to reduce mortality from breast cancer.
B) It is recommended unanimously by organizations making screening recommendations.
C) A high proportion of breast masses are detected by breast self-examination.
D) The undue fear caused by finding a mass justifies omitting instruction in breast selfexamination.
Ans: C
Feedback: Although self-examination has not been shown to reduce mortality and is not
recommended by all groups making screening recommendations, many choose to teach women a
systematic method in which to examine their breasts. A high proportion of breast masses are detected
by breast self-examination.
Chapter 18 The Musculoskeletal System
Multiple Choice
1. You are assessing a patient with joint pain and are trying to decide whether it is inflammatory or
noninflammatory in nature. Which one of the following symptoms is consistent with an inflammatory
process?
A) Tenderness
B) Cool temperature
C) Ecchymosis
D) Nodules Ans:
A
Feedback: Tenderness implies an inflammatory process along with increased temperature and
tenderness.
2. You are assessing a patient with diffuse joint pains and want to make sure that only the joints are
the problem, and that the pain is not related to other diseases. Which of the following is a systemic
cause of joint pain?
A) Gout
B) Osteoarthritis
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C) Lupus
D) Spondylosis
Ans: C
Feedback: Lupus is a systemic disease, one symptom of which may be joint pain. It is important to
consider the presence of a systemic illness when a patient presents with arthritis.
3. A 19-year-old college sophomore comes to the clinic for evaluation of joint pains. The student has
been back from spring break for 2 weeks; during her holiday, she went camping. She notes that she
had a red spot, shaped like a target, but then it started spreading, and then the joint pains started. She
used insect repellant but was in an area known to have ticks. She has never been sick and takes no
medications routinely; she has never been sexually active. What is the most likely cause of her joint
pain?
A) Trauma
B) Gonococcal arthritis
C) Psoriatic arthritis
D) Lyme disease
Ans: D
Feedback: Lyme disease is characterized by a target-shaped red spot at the site of the bite, which
disappears, then reappears and starts spreading (erythema migrans). Lyme disease can also result in
joint pain as well as cardiac and neurologic manifestations.
4. An 85-year-old retired housewife comes with her daughter to establish care. Her daughter is
concerned because her mother has started to fall more. As part of her physical examination, you ask
her to walk across the examination room. Which of the following is not part of the stance phase of
gait?
A) Foot arched
B) Heel strike
C) Mid-stance
D) Push-off
Ans: A
Feedback: The foot when it is flat is part of the stance phase of gait, not the foot when it is arched.
5. A 32-year-old warehouse worker presents for evaluation of low back pain. He notes a sudden
onset of pain after lifting a set of boxes that were heavier than usual. He also states that he has
numbness and tingling in the left leg. He wants to know if he needs to be off of work. What test
should you perform to assess for a herniated disc?
A) Leg-length test
B) Straight-leg raise
C) Tinel's test
D) Phalen's test
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Ans: B
Feedback: The straight-leg raise involves having the patient lie supine with the examiner raising the
leg. If the patient experiences a sharp pain radiating from the back down the leg in an L5 or S1
distribution, that suggests the presence of a herniated disc.
6. A 33-year-old construction worker comes for evaluation and treatment of acute onset of low back
pain. He notes that the pain is an aching located in the lumbosacral area. It has been present
intermittently for several years; there is no known trauma or injury. He points to the left lower back.
The pain does not radiate and there is no numbness or tingling in the legs or incontinence. He was
moving furniture for a friend over the weekend. On physical examination, you note muscle spasm,
with normal deep tendon reflexes and muscle strength. What is the most likely cause of this patient's
low back pain?
A) Herniated disc
B) Compression fracture
C) Mechanical low back pain
D) Ankylosing spondylitis
Ans: C
Feedback: The case is an example of mechanical low back pain; in a large percentage of cases there is
no known underlying cause. The pain is often precipitated by moving, lifting, or twisting motions and
relieved by rest.
7. A 50-year-old realtor comes to your office for evaluation of neck pain. She was in a motor
vehicle collision 2 days ago and was assessed by the emergency medical technicians on site, but she
didn't think that she needed to go to the emergency room at that time. Now, she has severe pain and
stiffness in her neck. On physical examination, you note pain and spasm over the paraspinous
muscles on the left side of the neck, and pain when you make the patient do active range of motion
of the cervical spine. What is the most likely cause of this neck pain?
A) Simple stiff neck
B) Aching neck
C) Cervical sprain
D) Cervical herniated disc
Ans: C
Feedback: The patient most likely has an acute whiplash injury secondary to the collision. The
features of the physical examination, local tenderness and pain on movement, are consistent with
cervical sprain.
8. A 28-year-old graduate student comes to your clinic for evaluation of pain ―all over.‖ With
further questioning, she is able to relate that the pain is worse in the neck, shoulders, hands, low
back, and knees. She denies swelling in her joints; she states that the pain is worse in the morning;
there is no limitation in her range of motion. On physical examination, she has several points on the
muscles of the neck, shoulders, and back that are tender to palpation; muscle strength and range of
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motion are normal. Which of the following is likely the cause of her pain?
A) Rheumatoid arthritis
B) Osteoarthritis
C) Fibromyalgia
D) Polymyalgia rheumatica
Ans: C
Feedback: The patient has pain in specific trigger point areas on the muscles, with normal strength
and range of motion. This is an indication for fibromyalgia.
9. A 68-year-old retired banker comes to your clinic for evaluation of left shoulder pain. He swims
for 30 minutes daily, early in the morning. He notes a sharp, catching pain and a sensation of
something grating when he tries overhead movements of his arm. On physical examination, you note
tenderness just below the tip of the acromion in the area of the tendon insertions. The drop arm test is
negative, and there is no limitation with shoulder shrug. The patient is not holding his arm close to his side,
and there is no tenderness to palpation in the bicipital groove when the arm is at the patient's side, flexed to 90
degrees, and then supinated against resistance. Based on this description, what is the most likely cause of his
shoulder pain?
A)
B)
C)
D)
Rotator cuff tendinitis
Rotator cuff tear
Calcific tendinitis
Bicipital tendinitis
Ans: A
Feedback: Rotator cuff tendinitis is typically precipitated by repetitive motions, such as occurs with
throwing or swimming. Crepitus/grating is noted in the shoulder with range of motion.
10. A high school soccer player ―blew out his knee‖ when the opposing goalie's head and
shoulder struck his flexed knee while the goalie was diving for the ball. All of the following
structures were involved in some way in his injury, but which of the following is actually an
extra-articular structure?
A) Synovium
B) Joint capsule
C) Juxta-articular bone
D) Tendons
Ans: D
Feedback: Extra-articular structures include the periarticular ligaments, tendons, bursae, muscle, fascia,
bone, nerve, and overlying skin. The articular structures include the joint capsule and articular
cartilage, the synovium and synovial fluid, intra-articular ligaments, and juxta-articular bone.
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11. Ray works a physical job and notes pain when he attempts to lift his arm over his head. When
you move the shoulder passively, he has full range of motion without pain and there is no gross
swelling or tenderness. What type of joint disease does this most likely represent?
A) Articular
B) Extra-articular
C) Neither
D) Both
Ans: B
Feedback: This description fits extra-articular disease. Articular disease typically involves swelling
and tenderness of the entire joint and limits both active and passive range of motion. This is most
likely extra-articular because it affects a certain portion of the range of motion, is not painful with
passive range of motion, and is not associated with gross swelling or tenderness
12. Mark is a contractor who recently injured his back. He was told he had a ―bulging disc‖ to
account for the burning pain down his right leg and slight foot drop. The vertebral bodies of the
spine involve which type of joint?
A) Synovial
B) Cartilaginous
C) Fibrous
D) Synostosis
Ans: B
Feedback: The vertebral bodies of the spine are connected by cartilaginous joints involving the discs.
The elbow would be an example of a synovial joint, and the sutures of the skull are an example of a
fibrous joint.
13. Which of the following synovial joints would be an example of a condylar joint?
A) Hip
B) Interphalangeal joints of the hand
C) Temporomandibular joint
D) Intervertebral joint
Ans: C
Feedback: The TMJ is an example of a condylar joint because it involves the movement of two
surfaces which are not dissociable. The hip would be an example of a spheroidal joint and the
interphalangeal joints of the hand are hinge joints. The intervertebral joints are not synovial joints at
all, but rather cartilaginous joints.
14. A 58-year-old man comes to your office complaining of bilateral back pain that now awakens
him at night. This has been steadily increasing for the past 2 months. Which one of the following is
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the most reassuring in this patient with back pain?
A) Age over 50
B) Pain at night
C) Pain lasting more than 1 month or not responding to therapy
D) Pain that is bilateral
Ans: D
Feedback: While bilateral pain can be associated with serious illness, it is not one of the ―red flags‖
of back pain. Red flags should make one suspicious for serious underlying systemic disease such as
cancer, infection, or others. This list includes: age over 50, history of cancer, unexplained weight
loss, pain lasting more than 1 month or not responding to treatment, pain at night or increased by rest,
history of intravenous drug use, or presence of infection. The presence of one of these with low back
pain indicates a 10% probability of a serious systemic disease.
15. Marion presents to your office with back pain associated with constipation and urinary
retention. Which of the following is most likely?
A) Sciatica
B) Epidural abscess
C) Cauda equina
D) Idiopathic low back pain
Ans: C
Feedback: The presence of bowel and bladder symptoms associated with back pain is worrisome and
should suggest impingement of nerve roots S2–S4. For this reason idiopathic low back pain is
unlikely. Epidural abscess may present with midline pain which can be increased with percussion
over the spinous processes. Sciatica is associated with pain which radiates into the buttocks and/or
down the posterior leg in the S1 distribution.
16. Louise, a 60-year-old, complains of left knee pain associated with tenderness throughout,
redness, and warmth over the joint. Which of the following is least helpful in determining if a joint
problem is inflammatory?
A) Tenderness
B) Pain
C) Warmth
D) Redness
Ans: B
Feedback: Pain is present in both inflammatory and noninflammatory conditions. Warmth, redness,
and tenderness to palpation should lead one to consider an inflammatory etiology for the
pain.
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17. Pain, swelling, loss of both active and passive motion, locking, and deformity would be
consistent with which of the following?
A) Articular joint pain
B) Bursitis
C) Muscular injury
D) Nerve damage
Ans: A
Feedback: These features are consistent with articular joint pain, whereas the other problems are
associated with extra-articular structures.
18. You are working in a college health clinic and seeing a young woman with a red, painful,
swollen DIP joint on the left index finger. There are also a few papules, pustules, and vesicles on
reddened bases, located on the distal extremities. This would be consistent with which of the
following?
A) Lyme disease
B) Systemic lupus erythematosus
C) Hives (urticaria)
D) Gonococcal arthritis
Ans: D
Feedback: The presentation of a monoarthritis in this age group should lead one to think of gonococcal
disease. Skin findings are often seen in conjunction with arthritis. Lyme disease is associated with an
expanding erythematous patch. Lupus is associated with a ―butterfly‖ rash on the cheeks, while serum
sickness and drug reactions can be associated with hives.
19. An obese 55-year-old woman went through menarche at age 16 and menopause 2 years ago. She
is concerned because an aunt had severe osteoporosis. Which of the following is a risk factor for
osteoporosis?
A) Obesity
B) Late menopause
C) Having an aunt with osteoporosis
D) Delayed menarche
Ans: D
Feedback: Obesity and late menopause are not associated with osteoporosis. Having a first- degree
relative with osteoporosis is a risk factor, but an aunt is a second-degree relative.
Delayed menarche is the only choice which is a known risk factor for osteoporosis.
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20. A 38-year-old woman comes to you and has multiple small joints involved with pain,
swelling, and stiffness. Which of the following is the most likely explanation?
A) Rheumatoid arthritis
B) Septic arthritis
C) Gout
D) Trauma
Ans: A
Feedback: Rheumatoid arthritis is a systemic disease and accounts for multiple symmetrically
involved joints. Septic arthritis is usually monoarticular, as are gout and trauma-related joint pain.
21. Mrs. Fletcher comes to your office with unilateral pain during chewing, which is chronic. She
does not have facial tenderness or tenderness of the scalp. Which of the following is the most
likely cause of her pain?
A) Trigeminal neuralgia
B) Temporomandibular joint syndrome
C) Temporal arteritis
D) Tumor of the mandible
Ans: B
Feedback: Temporomandibular joint syndrome is a very common cause of pain with chewing.
Ischemic pain with chewing, or jaw claudication, can occur with temporal arteritis, but the lack of
tenderness of the scalp overlying the artery makes this less likely. Trigeminal neuralgia can be
associated with extreme tenderness over the branches of the trigeminal nerve. While a tumor of the
mandible is possible, is it much less likely than the other choices.
22. A man's wife is upset because when she hugs him with her hands on his left shoulder blade, ―it
feels creepy.‖ This came on gradually after a recent severe left-sided rotator cuff tear. How long
does it usually take to develop muscular atrophy with increased prominence of the scapular spine following a
rotator cuff tear?
A)
B)
C)
D)
1 week
2–3 weeks
1 month
2–3 months
Ans: B
Feedback: Prominence of the scapular spine occurs with generalized muscle wasting as well as with
specific injuries such as a rotator cuff tear. It is easily palpable, even through indoor clothing,
although the back should be exposed to make other important observations. Atrophy usually occurs
several weeks following a rotator cuff tear.
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23. Phil comes to your office with left ―shoulder pain.‖ You find that the pain is markedly worse
when his left arm is drawn across his chest (adduction). Which of the following would you
suspect?
A) Rotator cuff tear
B) Subacromial bursitis
C) Acromioclavicular joint involvement
D) Adhesive capsulitis
Ans: C
Feedback: Adduction of the patient's arm across his chest can cause pain if the acromioclavicular
joint is involved. In adhesive capsulitis, this maneuver may not be possible due to limited range of
motion. Subacromial bursitis would present with tenderness inferior to the acromion. Rotator cuff
injury would ordinarily not be associated with pain during this maneuver.
24. Two weeks ago, Mary started a job which requires carrying 40-pound buckets. She presents with
elbow pain worse on the right. On examination, it hurts her elbows to dorsiflex her hands against
resistance when her palms face the floor. What condition does she have?
A) Medial epicondylitis (golfer's elbow)
B) Olecranon bursitis
C) Lateral epicondylitis (tennis elbow)
D) Supracondylar fracture
Ans: C
Feedback: Mary's injury probably occurred by lifting heavy buckets with her palms down
(toward the bucket). This caused her chronic overuse injury at the lateral epicondyle. Medial
epicondylitis has reproducible pain when palmar flexion against resistance is performed and also
features tenderness over the involved epicondyle. Olecranon bursitis produces erythema and swelling
over the olecranon process. A supracondylar fracture of the humerus is a major injury and would
present more acutely.
25. A high school football player injured his wrist in a game. He is tender between the two
tendons at the base of the thumb. Which of the following should be considered?
A) DeQuervain's tenosynovitis
B) Scaphoid fracture
C) Wrist sprain
D) Rheumatoid arthritis
Ans: B
Feedback: The ―anatomic snuffbox‖ is found between the extensor and abductor tendons at the base
of the thumb. Tenderness should make one think of a scaphoid fracture. Not only is this the most
common carpal bone injury, but the poor blood supply puts the bone at risk for avascular necrosis
when injured. This fracture is commonly missed on x-ray, so this is an important physical finding to
support further or repeated studies.
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Chapter 19 Mental Status
Multiple Choice
1. A 19-year-old college student, Todd, is brought to your clinic by his mother. She is concerned that
there is something seriously wrong with him. She states for the past 6 months his behavior has
become peculiar and he has flunked out of college. Todd denies any recent illness or injuries. His past
medical history is remarkable only for a broken foot. His parents are both healthy. He has a paternal
uncle who had similar symptoms in college. The patient admits to smoking cigarettes and drinking
alcohol. He also admits to marijuana use but none in the last week. He denies using any other
substances. He denies any feelings of depression or anxiety. While speaking with Todd and his
mother you do a complete physical examination, which is essentially normal. When you question him
on how he is feeling, he says that he is very worried that Microsoft has stolen his software for creating
a better browser. He tells you he has seen a black van in his neighborhood at night and he is sure that it is
full of computer tech workers stealing his work through special gamma waves. You ask him why he believes
they are trying to steal his programs. He replies that the technicians have been telepathing their intents directly
into his head. He says he hears these conversations at night so he knows this is happening. Todd's mother then
tells you, ―See, I told you . . . he's crazy. What do I do about it?‖
While arranging for a psychiatry consult, what psychotic disorder do you think Todd has?
A) Schizoaffective disorder
B) Psychotic disorder due to a medical illness
C) Substance-induced psychotic disorder
D) Schizophrenia
Ans: D
Feedback: Schizophrenia generally occurs in the late teens to early 20s. It often is seen in other
family members, as in this case. Symptoms must be present for at least 6 months and must have at
least two features of (1) delusions (e.g., Microsoft is after his programs), (2) hallucinations (e.g.,
technicians sending telepathic signals), (3) disorganized speech, (4) disorganized behavior, and (5)
negative symptoms such as a flat affect.
2. A 24-year-old secretary comes to your clinic, complaining of difficulty sleeping, severe
nightmares, and irritability. She states it all began 6 months ago when she went to a fast food
restaurant at midnight. While she was waiting in her car a man entered through the passenger door and
put a gun to her head. He had her drive to a remote area, where he took her money and threatened to
kill her. When the gun jammed he panicked and ran off. Ever since this occurred the patient has been
having these symptoms. She states she jumps at every noise and refuses to drive at night. She states
her anxiety has had such a marked influence on her job performance she is afraid she will be fired. She
denies any recent illnesses or injuries. Her past medical history is unremarkable. On examination you
find a nervous woman appearing her stated age. Her physical examination is unremarkable. You
recommend medication and counseling.
What anxiety disorder to you think this young woman has?
A) Specific phobia
B) Acute stress disorder
C) Post-traumatic stress disorder
D) Generalized anxiety disorder
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Ans: C
Feedback: Post-traumatic stress disorder is the fearful response (nightmares, avoidance of areas,
irritability) to an event that occurred at least 1 month prior to presentation. The patient's fears and
reactions cause marked distress and impair social and occupational functions.
3. A 75-year-old homemaker brings her 76-year-old husband to your clinic. She states that 4 months
ago he had a stroke and ever since she has been frustrated with his problems with communication.
They were at a restaurant after church one Sunday when he suddenly became quiet. When she
realized something was wrong he was taken to the hospital by EMS. He spent 2 weeks in the hospital
with right-sided weakness and difficulty speaking. After hospitalization he was in a rehab center,
where he regained the ability to walk and most of the use of his right hand. He also began to speak
more, but she says that much of the time ―he doesn't make any sense.‖ She gives an example that
when she reminded him the car needed to be serviced he told her ―I will change the Kool-Aid out of
the sink myself with the ludrip.‖ She says that these sayings are becoming frustrating. She wants you
to tell her what is wrong and what you can do about it. While you write up a consult to neurology, you
describe the syndrome to her.
What type of aphasia does he have?
A) Wernicke's aphasia
B) Broca's aphasia
C) Dysarthria
Ans: A
Feedback: With Wernicke's aphasia the patient can speak effortlessly and fluently, but his words often
make no sense. Words can be malformed or completely invented. Wernicke's area is found on the
temporal lobes.
4. A 32-year-old white female comes to your clinic, complaining of overwhelming sadness. She says
for the past 2 months she has had crying episodes, difficulty sleeping, and problems with overeating.
She says she used to go out with her friends from work but now she just wants to go home and be by
herself. She also thinks that her work productivity has been dropping because she just is too tired to
care or concentrate. She denies any feelings of guilt or any suicidal ideation. She states that she has
never felt this way in the past. She denies any recent illness or injuries. Her past medical history
consists of an appendectomy when she was a teenager; otherwise, she has been healthy. She is single
and works as a clerk in a medical office. She denies tobacco, alcohol, or illegal drug use. Her mother
has high blood pressure and her father has had a history of mental illness. On examination you see a
woman appearing her stated age who seems quite sad. Her facial expression does not change while
you talk to her and she makes little eye contact. She speaks so softly you cannot always understand
her. Her thought processes and content seem unremarkable.
What type of mood disorder do you think she has?
A) Dysthymic disorder
B) Manic (bipolar) disorder
C) Major depressive episode
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Ans: C
Feedback: Major depression occurs in a person with a previously normal state of mood. The
symptoms often consist of a combination of sadness, decreased interest, sleeping problems (insomnia
or hypersomnia), eating problems (decreased or increased appetite), feelings of guilt, decreased
energy, decreased concentration, psychomotor changes (retardation or agitation), and a preoccupation
with thoughts of death or suicide. There must be at least five symptoms for a diagnosis of major
depression. This patient has six: (1) sadness, (2) trouble sleeping, (3) overeating, (4) fatigue, (5)
difficulty with concentration, and (6) no interest in doing things.
5. A 27-year-old woman is brought to your office by her mother. The mother tells you that her
daughter has been schizophrenic for the last 8 years and is starting to decompensate despite
medication. The patient states that she has been taking her antipsychotic and she is doing just fine.
Her mother retorts that her daughter has become quite paranoid. When asked why, the mother gives
an example about the mailman. She says that her daughter goes and gets the mail every day and then
microwaves the letters. The patient agrees that she does this but only because she sees the mailman
flipping through the envelopes and she knows he's putting anthrax on the letters. Her mother turns to
her and says, ―He's only sorting the mail!‖
Which best describes the patient's abnormality of perception?
A) Illusion
B) Hallucination
C) Fugue state
Ans: A
Feedback: An illusion is merely a misinterpretation of real external stimuli. In this case, the mailman
is looking through the letters before he puts them in the box. The mother correctly assumes he is
sorting the mail but her schizophrenic daughter attributes his actions to being part of a nefarious
bioterrorism plot.
6. A 22-year-old man is brought to your office by his father to discuss his son's mental health
disorder. The patient was diagnosed with schizophrenia 6 months ago and has been taking
medication since. The father states that his son's dose isn't high enough and you need to raise it. He
states that his son has been hearing things that don't exist. You ask the young man what is going on
and he tells you that his father is just jealous because his sister talks only to him. His father turns to
him and says, ―Son, you know your sister died 2 years ago!‖ His son replies ―Well, she still talks to
me in my head all the time!‖
Which best describes this patient's abnormality of perception?
A) Illusion
B) Hallucination
C) Fugue state
Ans: B
Feedback: A hallucination is a subjective sensory perception in the absence of real external stimuli.
The patient can hear, see, smell, taste, or feel something that does not exist in reality. In this case, his
sister has passed away and cannot be speaking to him, although in his mind he can hear her. This is
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an example of an auditory hallucination, but hallucinations can occur with any of the five senses.
7. A 26-year-old violinist comes to your clinic, complaining of anxiety. He is a first chair violinist in
the local symphony orchestra and has started having symptoms during performances, such as
sweating, shaking, and hyperventilating. It has gotten so bad that he has thought about giving up his
first chair status so he does not have to play the solo during one of the movements. He says that he
never has these symptoms during rehearsals or when he is practicing. He denies having any of these
symptoms at any other time. His past medical history is unremarkable. He denies any tobacco use,
drug use, or alcohol abuse. His parents are both healthy. On examination you see a young man who
appears worried. His vital signs and physical examination are unremarkable.
What type of anxiety disorder best describes his situation?
A) Panic disorder
B) Specific phobia
C) Social phobia
D) Generalized anxiety disorder
Ans: C
Feedback: Social phobia is a marked, persistent fear of social or performance situations.
8. A 23-year-old ticket agent is brought in by her husband because he is concerned about her recent
behavior. He states that for the last 2 weeks she has been completely out of control. He says that she
hasn't showered in days, stays awake most of the night cleaning their apartment, and has run up over
$1,000 on their credit cards. While he is talking, the patient interrupts him frequently and declares
this is all untrue and she has never been so happy and fulfilled in her whole life. She speaks very
quickly, changing the subject often. After a longer than normal interview you find out she has had no
recent illnesses or injuries. Her past medical history is unremarkable. Both her parents are healthy but
the husband has heard rumors about an aunt with similar symptoms. She and her husband have no
children. She smokes one pack of cigarettes a day (although she has been chain-smoking in the last 2
weeks), drinks four to six drinks a week, and smokes marijuana occasionally. On examination she is
very loud and outspoken. Her physical examination is unremarkable.
Which mood disorder does she most likely have?
A) Major depressive episode
B) Manic episode
C) Dysthymic disorder
Ans: B
Feedback: Mania consists of a persistently elevated mood for at least 1 week with symptoms such as
inflated self-esteem, decreased need for sleep, pressured speech, racing thoughts, and involvement in
high-risk activities (such as drug use, spending sprees, and indiscriminate sexual activity). In this case,
the patient has racing thoughts and pressured speech, has a decreased need for sleep, and is engaging
in high-risk activities (spending sprees).
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9. A 72-year-old African-American male is brought to your clinic by his daughter for a follow- up
visit after his recent hospitalization. He had been admitted to the local hospital for speech problems
and weakness in his right arm and leg. On admission his MRI showed a small stroke. The patient was
in rehab for 1 month following his initial presentation. He is now walking with a walker and has good
use of his arm. His daughter complains, however, that everyone is still having trouble communicating
with the patient. You ask the patient how he thinks he is doing. Although it is hard for you to make
out his words you believe his answer is ―well . . . fine . . . doing . . . okay.‖ His prior medical history
involved high blood pressure and coronary artery disease. He is a widower and retired handyman. He
has three children who are healthy. He denies tobacco, alcohol, or drug use. He has no other current
symptoms. On examination he is in no acute distress but does seem embarrassed when it takes him so
long to answer. His blood pressure is 150/90 and his other vital signs are normal. Other than his weak
right arm and leg his physical examination is unremarkable.
What disorder of speech does he have?
A) Wernicke's aphasia
B) Broca's aphasia
C) Dysarthria
Ans: B
Feedback: In Broca's aphasia patients articulate very slowly and with a great deal of effort. Nouns,
verbs, and important adjectives are usually present and only small grammatical words are dropped
from speech. Broca's area is on the lateral portion of the frontal lobes.
10. A 35-year-old stockbroker comes to your office, complaining of feeling tired and irritable. She
also says she feels like nothing ever goes her way and that nothing good ever happens. When you ask
her how long she has felt this way she laughs and says, ―Since when have I not?‖ She relates that she
has felt pessimistic about life in general since she was in high school. She denies any problems with
sleep, appetite, or concentration, and states she hasn't thought about killing herself. She reports no
recent illnesses or injuries. She is single. She smokes one pack of cigarettes a day, drinks occasionally,
and hasn't taken any illegal drugs since college. Her mother suffers from depression and her father has high
blood pressure. On examination her vital signs and physical examination are unremarkable.
What mental health disorder best describes her symptoms?
A) Major depressive episode
B) Dysthymic disorder
C) Cyclothymic disorder
Ans: B
Feedback: Someone with dysthymia has a depressed mood and symptoms for most of the day, more
days than not, for at least 2 years. The disorder generally begins in adolescence and is fairly stable
throughout life. Although the symptoms are similar to those of major depression (in this case, fatigue
and irritability), they are milder and fewer.
11. Susanne is a 27 year old who has had headaches, muscle aches, and fatigue for the last 2
months. You have completed a thorough history, examination, and laboratory workup but have not
found a cause. What would your next action be?
A) A referral to a neurologist
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B) A referral to a rheumatologist
C) To tell the patient you can't find anything
D) To screen for depression
Ans: D
Feedback: Although you may consider referrals to help with the diagnosis and treatment for this
patient, screening is a time-efficient way to recognize depression. This will allow her to be treated
more expediently. You may tell the patient you have not found an answer yet, but you must also tell
her that you will not stop looking until you have helped her.
12. You ask a patient to draw a clock. He fills in all the numbers on the right half of the circle.
What do you suspect?
A) Hemianopsia
B) Fatigue
C) Oppositional defiant disorder
D) Depression
Ans: A
Feedback: You should suspect a visual problem because there is no writing on one half of the circle.
This is consistent with a hemianopsia, sometimes seen in stroke. These patients may also eat food on
only one half of their plate. The other conditions would not account for this pattern.
13. A young woman comes to you with a cut on her finger caused by the lid of a can she was
opening. She is pacing about the room, crying loudly, and through her sobs she says, ―My career as a
pianist is finished!‖ Which personality type exhibits these features?
A) Narcissistic
B) Paranoid
C) Histrionic
D) Avoidant
Ans: C
Feedback: The theatrical nature of her behavior as well as her overreaction lead to a diagnosis of
histrionic character disorder.
14. Adam is a very successful 15-year-old student and athlete. His mother brings him in today
because he no longer studies, works out, or sees his friends. This has gone on for a month and a half.
When you speak with him alone in the room, he states it ―would be better if he were not here.‖ What
would you do next?
A) Tell him that he has a very promising career in anything he chooses and soon he will feel
better.
B) Tell him that he needs an antidepressant and it will take about 4 weeks to work.
C) Speak with his mother about getting him together more with his friends.
D) Assess his suicide risk.
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Ans: D
Feedback: His lack of interest in usual activities and duration of symptoms should make you
suspicious for depression. Despite his very successful academic and athletic performance, you should
recognize this last phrase indicating suicide risk. You could ask if he has had thoughts about hurting
himself and, if so, how he would carry this out. Ask about firearms and other weapons at home. Adam
needs immediate psychiatric referral if these risks are found, or admission to the hospital for
observation if referral is not available in a timely fashion.
15. A 29-year-old woman comes to your office. As you take the history, you notice that she is
speaking very quickly, and jumping from topic to topic so rapidly that you have trouble following
her. You are able to find some connections between ideas, but it is difficult. Which word describes this
thought process?
A)
B)
C)
D)
Derailment
Flight of ideas
Circumstantiality
Incoherence
Ans: B
Feedback: This represents flight of ideas because the ideas are connected in some logical way.
Derailment, or loosening of associations, has more disconnection within clauses.
Circumstantiality is characterized by the patient speaking ―around‖ the subject and using excessive
detail, though thoughts are meaningfully connected. Incoherence lacks meaningful connection and
often has odd grammar or word use. Although severe flight of ideas can produce this condition,
evidence is not present in this vignette.
16. In obtaining a history, you note that a patient uses the word ―largely‖ repeatedly, to the point of
being a distraction to your task. Which word best describes this speech pattern?
A) Clanging
B) Echolalia
C) Confabulation
D) Perseveration
Ans: D
Feedback: Perseveration is the repetition of words or ideas. Echolalia differs in that the patient repeats
what is said to him. Clanging is the repetition of the same sounds in different words.
Confabulation is making up a story in response to a question. This is sometimes seen in chronic alcohol
use with Korsakoff's syndrome.
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Chapter 20 The Nervous System
Multiple Choice
1. A 28-year-old book editor comes to your clinic, complaining of strange episodes. He states that
about once a week for the last 3 months his left hand and arm will stiffen and then start jerking. He
says that after a few seconds his whole left arm and then his left leg will also start to jerk. He denies
any loss of consciousness or loss of bowel or bladder control. When the symptoms resolve, his arm
and leg feel tired but otherwise he feels fine. His past medical history is significant for a cyst in his
brain that was removed 6 months ago. He is married and has two children. His parents are both
healthy. On examination you see a scar over the right side of his head but otherwise his neurologic
examination is unremarkable. What type of seizure disorder is he most likely to have?
A) Generalized tonic–clonic seizure
B) Generalized absence seizure
C) Simple partial seizure (Jacksonian)
D) Complex partial seizure
Ans: C
Feedback: Simple partial seizures start with a unilateral symptom, involve no loss of consciousness,
and have a normal postictal state. In a Jacksonian seizure the symptoms start with one body part and
―march‖ along the same side of the body.
2. A 7-year-old child is brought to your clinic by her mother. The mother states that her daughter is
doing poorly in school because she has some kind of ―ADD‖ (attention deficit disorder). You ask the
mother what makes her think the child has ADD. The mother tells you that both at home and at school
her daughter will just zone out for several seconds and lick her lips. She states it happens at least four
to six times an hour. She says this has been happening for about a year. After several seconds of liplicking her daughter seems normal again. She states her daughter has been generally healthy with just
normal childhood colds and ear infections. The patient's parents are both healthy and no other family
members have had these symptoms.
What type of seizure disorder is she most likely to have?
A) Generalized tonic–clonic seizure
B) Generalized absence seizure
C) Simple partial seizure (Jacksonian)
D) Complex partial seizure
Ans: B
Feedback: In an absence seizure there is no tonic–clonic activity. There is a sudden, brief lapse of
consciousness with blinking, staring, lip-smacking, or hand movements that resolve quickly to full
consciousness. It is easily mistaken for daydreaming or ADD. Some will try to induce these episodes
with hyperventilation.
3. A 37-year-old insurance agent comes to your office, complaining of trembling hands. She says
that for the past 3 months when she tries to use her hands to fix her hair or cook they shake badly.
She says she doesn't feel particularly nervous when this occurs but she worries that other people will
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think she has an anxiety disorder or that she's a drinker. She admits to having some recent fatigue,
trouble with vision, and difficulty maintaining bladder control. Her past medical history is
remarkable for hypothyroidism. Her mother has lupus and her father is healthy. She has an older
brother with type 1 diabetes. She is married and has three children. She denies tobacco, alcohol, or
drug use. On examination, when she tries to reach for a pencil to fill out the health form she has
obvious tremors in her dominant hand.
What type of tremor is she most likely to have?
A) Resting tremor
B) Postural tremor
C) Intention tremor
Ans: C
Feedback: Intention tremors are absent at rest or in a postural position and occur only with intentional
movement of the hands. This is seen in cerebellar disease (stroke or alcohol use) or in multiple
sclerosis. This patient's tremor, fatigue, bladder problems, and visual problems are suggestive of
multiple sclerosis.
4. A 77-year-old retired school superintendent comes to your office, complaining of unsteady hands.
He says that for the past 6 months, when his hands are resting in his lap they shake uncontrollably.
He says when he holds them out in front of his body the shaking diminishes, and when he uses his
hands the shaking is also better. He also complains of some difficulty getting up out of his chair and
walking around. He denies any recent illnesses or injuries. His past medical history is significant for
high blood pressure and coronary artery disease, requiring a stent in the past. He has been married for
over 50 years and has five children and 12 grandchildren. He denies any tobacco, alcohol, or drug
use. His mother died of a stroke in her 70s and his father died of a heart attack in his 60s. He has a
younger sister who has arthritis problems. His children are all essentially healthy. On examination
you see a fine, pill-rolling tremor of his left hand. His right shows less movement. His cranial nerve
examination is normal. He has some difficulty rising from his chair, his gait is slow, and it takes him
time to turn around to walk back toward you. He has almost no ―arm swing‖ with his gait.
What type of tremor is he most likely to have?
A) Resting tremor
B) Postural tremor
C) Intention tremor
Ans: A
Feedback: Resting tremors occur when the hands are literally at rest, such as sitting in the lap. These
are slow, fine tremors, such as the pill-rolling seen in Parkinson's disease, which this patient most
likely has. Decreased arm swing with ambulation is one of the earliest objective findings of
Parkinson's disease.
5. A 48-year-old grocery store manager comes to your clinic, complaining of her head being ―stuck‖
to one side. She says that today she was doing her normal routine when it suddenly felt like her head
was being moved to her left and then it just stuck that way. She says it is somewhat painful because
she cannot get it moved back to normal. She denies any recent neck trauma. Her past medical history
consists of type 2 diabetes and gastroparesis (slow-moving peristalsis in the
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digestive tract, seen in diabetes). She is on oral medication for each. She is married and has three
children. She denies tobacco, alcohol, or drug use. Her father has diabetes and her mother passed
away from breast cancer. Her children are healthy. On examination you see a slightly overweight
Hispanic woman appearing her stated age. Her head is twisted grotesquely to her left but otherwise
her examination is normal.
What form of involuntary movement does she have?
A) Chorea
B) Asbestosis
C) Tic
D) Dystonia
Ans: D
Feedback: Dystonia involves large movements of the body, such as with the head or trunk, leading to
grotesque twisted postures. Some medications (such as one commonly used for gastroparesis) often
cause dystonia.
6. A 41-year-old real estate agent comes to your office, complaining that he feels like his face is
paralyzed on the left. He states that last week he felt his left eyelid was drowsy and as the day
progressed he was unable to close his eyelid all the way. Later he felt like his smile became affected
also. He denies any recent injuries but had an upper respiratory viral infection last month. His past
medical history is unremarkable. He is divorced and has one child. He smokes one pack of cigarettes
a day, occasionally drinks alcohol, and denies any illegal drug use. His mother has high blood
pressure and his father has sarcoidosis. On examination you ask him to close his eyes. He is unable to
close his left eye. You ask him to open his eyes and raise his eyebrows. His right forehead furrows
but his left remains flat. You then ask him to give you a big smile. The right corner of his mouth
raises but the left side of his mouth remains the same. What type of facial paralysis does he have?
A) Peripheral CN VII paralysis
B) Central CN VII paralysis
Ans: A
=
Feedback: In a peripheral lesion the entire side of the face will be involved. This causes the inability to
close the eye, raise the eyebrow, wrinkle the forehead, and smile on the affected side. Bell's palsy is an
example of this type of paralysis and is probably what is affecting this patient.
7. A 60-year-old retired seamstress comes to your office, complaining of decreased sensation in her
hands and feet. She states that she began to have the problems in her feet a year ago but now it has
started in her hands also. She also complains of some weakness in her grip. She has had no recent
illnesses or injuries. Her past medical history consists of having type 2 diabetes for 20 years. She now takes
insulin and oral medications for her diabetes. She has been married for 40 years. She has two healthy children.
Her mother has Alzheimer's disease and coronary artery disease. Her father died of a stroke and also had
diabetes. She denies any tobacco, alcohol, or drug use. On examination she has decreased deep tendon
reflexes in the patellar and Achilles tendons. She has decreased sensation of fine touch, pressure, and vibration
on both feet. She has decreased two-point discrimination on her hands. Her grip strength is decreased and her
plantar and dorsiflexion strength is decreased.
Where is the disorder of the peripheral nervous system in this patient?
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A)
B)
C)
D)
Anterior horn cell
Spinal root and nerve
Peripheral polyneuropathy
Neuromuscular junction
Ans: C
Feedback: With peripheral polyneuropathy there will be distal extremity symptoms before proximal
symptoms. There will be weakness and atrophy and decreased sensory sensations. There is often the
classic glove-stocking distribution pattern of the lower legs and hands. Causes include diabetic
neuropathy, as in this case, alcoholism, and vitamin deficiencies.
8. A 21-year-old engineering student comes to your office, complaining of leg and back pain and of
tripping when he walks. He states this started 3 months ago with back and buttock pain but has since
progressed to feeling weak in his left leg. He denies any bowel or bladder symptoms. He can think of
no specific traumatic incidences but he was a defensive lineman in high school and junior college.
His past medical history is unremarkable. He denies tobacco use or alcohol or drug abuse. His
parents are both healthy. On examination he is tender over the lumbar spine and he has a positive
straight-leg raise on the left. His Achilles tendon deep reflex is decreased on the left. While watching
his gait you notice he has to pick his left foot up high in order not to trip.
What abnormality of gait does he most likely have?
A) Sensory ataxia
B) Parkinsonian gait
C) Steppage gait
D) Spastic hemiparesis
Ans: C
Feedback: This gait is associated with foot drop, usually secondary to a lower motor neuron disease.
This is often seen with a herniated disc, such as in this patient.
9. A 17-year-old high school student is brought in to your emergency room in a comatose state. His
friends have accompanied him and tell you that they have been shooting up heroin tonight and they
think their friend may have had too much. The patient is unconscious and cannot protect his airway,
so he is intubated. His heart rate is 60 and he is breathing through the ventilator. He is not posturing
and he does not respond to a sternal rub. Preparing to finish the neurologic examination, you get a
penlight.
What size pupils do you expect to see in this comatose patient?
A) Pinpoint pupils
B) Large pupils
C) Asymmetric pupils
D) Irregularly shaped pupils
Ans: A
Feedback: Narcotics and cholinergics cause very small (1 mm) pupils. Reactions to light can be
appreciated with a magnifying glass.
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10. A 37-year-old woman is brought into your emergency room comatose. The paramedics say her
husband found her unconscious in her home. Her past medical history consists of type 1 diabetes and
she is on insulin. In the ambulance the paramedics obtained a glucose check and her sugar was 15
(normal is 70 to 105). They began a dextrose saline infusion and intubated her to protect her airway.
Despite their efforts, she is posturing in the emergency room with her arms straight at her side and her
jaw clenched. Her legs are also straight and her feet are plantar flexed. What type of posturing is she
showing?
A) Decorticate rigidity
B) Decerebrate rigidity
C) Hemiplegia
D) Chorea
Ans: B
Feedback: In this type of rigidity the jaws are clenched and the neck is extended. The arms are
adducted and stiffly extended at the elbows with forearms pronated and wrists and fingers flexed. The
legs are stiffly extended at the knees with the feet plantar flexed. This posture occurs with lesions in the
diencephalon, midbrain, or pons. It can also be seen with severe metabolic disorder such as hypoxia or
hypoglycemia, as in this case.
11. A patient presents with a left-sided facial droop. On further testing, you note that he is
unable to wrinkle his forehead on the left and has decreased taste. Which of the following is true?
A)
B)
C)
D)
This represents a central lesion.
This represents a CN IV lesion.
This may be related to travel.
This most likely represents a stroke.
Ans: C
Feedback: Because the forehead is also involved, this represents a peripheral nerve lesion of CN VII
and does not represent a classic middle cerebral artery stroke. The latter would spare the upper face
but include speech difficulties as well as upper extremity weakness on the ipsilateral side. One cause
of this type of lesion is Lyme disease and relates to travel to endemic areas, so a careful travel history
should be sought.
12. Which is true of examination of the olfactory nerve?
A) It is not tested for laterality.
B) The smell must be identified to declare a normal response.
C) Abnormal responses may be seen in otherwise normal elderly.
D) Allergies are unrelated to testing of this nerve.
Ans: C
Feedback: Abnormal olfactory nerve examination findings may be seen in otherwise normal elderly
but may also be associated with other conditions such as Parkinson's disease. You should try to
determine if only one side is abnormal by occluding the contralateral nostril. The smell must only be
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detected, not identified by name, to indicate a normal examination. If nasal occlusion occurs for other
reasons, such a allergic rhinitis or anatomic abnormalities, the nerve cannot be tested and may seem to
be abnormal for unrelated reasons.
13. Steve has had a stroke and comes to you for follow-up today. On examination you find that he
has increased muscle tone, some involuntary movements, an abnormal gait, and a slowness of
response in movements. He most likely has involvement of which of the following?
A) The corticospinal tract
B) The cerebellum
C) The cerebrum
D) The basal ganglia
Ans: D
Feedback: These findings are typical of disease in the basal ganglia.
14. You are conducting a mental status examination and note impairment of speech and
judgement, but the rest of your examination is intact. Where is the most likely location of the
problem?
A) Cerebrum
B) Cerebellum
C) Brainstem
D) Basal ganglia
Ans: A
Feedback: The cerebrum is responsible for higher cognitive functions such as speech and judgement.
15. A patient presents with a daily headache which has worsened over the past several months. On
funduscopic examination, you notice that the disk edge is indistinct and the veins do not pulsate.
Which is most likely?
A) Migraine
B) Glaucoma
C) Visual acuity problem
D) Increased intracranial pressure
Ans: D
Feedback: This is a description of papilledema, which should make you think of increased
intracranial pressure. This can be a critical finding. This patient may have a brain tumor or benign
intracranial hypertension. These findings cannot be ignored and should be acted upon quickly.
16. A young woman comes in today, complaining of fatigue, irregular menses, and polyuria
which have gradually increased over the past few months. Which eye findings would be
consistent with her condition?
A) An upper quadrantanopsia
B) A lower quadrantanopsia
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C) A bitemporal hemianopsia
D) An increased cup-to-disc ratio
Ans: C
Feedback: These symptoms are consistent with a pituitary lesion. Enlargement of a tumor in this
area would compress the fibers responsible for the lateral visual fields. A quadrantanopsia
would usually be caused by a lesion in the optic radiations in the parietal lobe of the cerebrum.
Glaucoma would cause a narrowing of the entire visual field, not just the lateral aspects.
17. A patient with a history of seizure disorder and on several seizure medications says a friend
noted ―jumping eye movements.‖ The patient describes a sensation of movement at rest since his
medications were adjusted upward following a breakthrough seizure several weeks ago. On
examination you note that the eyes both slowly move to the right and then quickly jump to the left.
Which of the following is true?
A) This is called nystagmus to the left
B) This is called saccadic eye movement
C) This represents a subclinical seizure
D) This most likely has an ominous cause
Ans: A
Feedback: Nystagmus is named for the fast component, in this case, toward the left. Nystagmus is
common with several seizure medications and in this case is likely due to the recent increase in
medications rather than a more ominous cause. Saccadic eye movements are similar to nystagmus but
represent fixations on apparently moving objects, like watching roadside trees from a moving vehicle.
A subclinical seizure with bilateral findings and no effect on consciousness would be unusual.
18. You are testing the biceps strength in a young man following a spinal trauma from a motor
vehicle accident. He cannot lift his hand upward, but if the arm is abducted to 90 degrees, he can then
move his forearm side to side. This would represent which muscle strength grading?
A) I
B) II
C) III
D) IV
Ans: B
Feedback: The ability to move an extremity, but not against gravity, represents a strength of 2 out of
5. Zero represents no muscular contraction detected (not even a ―flicker‖); one represents a
contraction but no movement of the extremity; three means that the extremity can move against
gravity but not against resistance; four means perceived weakness but the patient can oppose some
resistance; and five is normal.
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19. You ask a patient to hold her arms up, with her palms up, and then to close her eyes. The right
arm begins to move downward after a few seconds and her thumb rotates upward. This is most
likely a problem with which part of the nervous system?
A) Corticospinal tract
B) Spinothalamic tract
C) Thalamus
D) Dorsal root ganglion
Ans: A
Feedback: This describes a pronator drift, which signifies decreased position sense involvement of the
corticospinal tract. This tract does not travel through the thalamus. This is commonly tested as an
early sign of stroke. This would not occur with a dorsal root ganglion problem.
20. You are examining a child with severe cerebral palsy. When you suddenly move his foot
dorsally, a sustained ―beating‖ of the foot against your hand ensues. What does this represent?
A) A focal seizure
B) Clonus
C) Extinction
D) Reinforcement
Ans: B
Feedback: Clonus is a sustained rhythmic ―beating‖ which correlates with CNS disease and
hyperreflexia. A focal seizure could be virtually ruled out by stopping the stimulus and watching the
phenomenon stop. Extinction is a term applied to sensory testing where one side of a simultaneous,
bilateral stimulus is not felt because of damage to the cortex. Reinforcement applies to enhancing
reflex examination by distracting the patient, for example, by pulling his hands against each other.
21. Jim is an HIV-positive patient who complains about back pain in addition to several other
problems. On percussion, there is slight tenderness over the T7 vertebrae, and when you flex his thigh
to 90 degrees and extend his lower legs, you meet strong resistance at about 45 degrees of extension.
What are likely causes of this constellation of symptoms?
A) Fractured vertebrae
B) Malingering
C) Infection
D) Medication side effect
Ans: C
Feedback: This represents Kernig's sign. When present bilaterally it often indicates meningeal
irritation. (Kernig was a physician in eastern Europe and treated many children with tuberculous
meningitis.) It is useful in cases when there has been chronic inflammation of the meninges, as seen in
TB and cryptococcal disease. There was no trauma reported, and these signs are too important to
ascribe them to malingering. Such localized physical findings are unlikely to be caused by medication
side effects.
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22. A patient with alcoholism is brought in with confusion. You ask him to ―stop traffic‖ with his
palms and notice that every few seconds his palms suddenly move toward the floor. What does this
indicate?
A) Stroke
B) Metabolic problems
C) Carpal tunnel syndrome
D) Severe fatigue and weakness
Ans: B
Feedback: This is asterixis and represents the inability to maintain a sustained contraction of the
muscles. It is usually due to various metabolic diseases. A variant of this is called ―milkmaid's grip‖
in which the patient is asked to grasp two fingers. A positive occurs if the patient is unable to sustain
the grip and it feels as if the patient is trying to milk a cow. Most would consider checking an
ammonia level in this patient. A stroke is less likely to produce bilateral symptoms. Carpal tunnel
represents a sensory loss in the median nerve distribution.
23. You examine a ―sleepy‖ patient. You note that she will open her eyes and look at you but
responds slowly and is confused. She does not appear interested in her surroundings. How would
you describe her level of consciousness?
A) Lethargic
B) Obtunded
C) Stuporous
D) Comatose
Ans: B
Chapter 21 Reproductive Systems
MULTIPLE CHOICE
1. The external male genital structures include the:
a.
b.
c.
d.
Testis.
Scrotum.
Epididymis.
Vas deferens.
ANS: B
The external male genital structures include the penis and scrotum. The testis, epididymis, and vas
deferens are internal structures.
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2. An accessory glandular structure for the male genital organs is the:
a.
b.
c.
d.
Testis.
Scrotum.
Prostate.
Vas deferens.
ANS: C
Glandular structures accessory to the male genital organs are the prostate, seminal vesicles, and
bulbourethral glands.
3. Which of these statements is true regarding the penis?
a.
b.
c.
d.
The urethral meatus is located on the ventral side of the penis.
The prepuce is the fold of foreskin covering the shaft of the penis.
The penis is made up of two cylindrical columns of erectile tissue.
The corpus spongiosum expands into a cone of erectile tissue called the glans.
ANS: D
At the distal end of the shaft, the corpus spongiosum expands into a cone of erectile tissue, the
glans. The penis is made up of three cylindrical columns of erectile tissue. The skin that covers the
glans of the penis is the prepuce. The urethral meatus forms at the tip of the glans.
4. When performing a genital examination on a 25-year-old man, the nurse notices deeply
pigmented, wrinkled scrotal skin with large sebaceous follicles. On the basis of this information, the
nurse would:
a.
b.
c.
d.
Squeeze the glans to check for the presence of discharge.
Consider this finding as normal, and proceed with the examination.
Assess the testicles for the presence of masses or painless lumps.
Obtain a more detailed history, focusing on any scrotal abnormalities the patient has
noticed.
ANS: B
After adolescence, the scrotal skin is deeply pigmented and has large sebaceous follicles and appears
corrugated.
5. Which statement concerning the testes is true?
a. The lymphatic vessels of the testes drain into the abdominal lymph nodes.
b. The vas deferens is located along the inferior portion of each testis.
c. The right testis is lower than the left because the right spermatic cord is longer.
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d. The cremaster muscle contracts in response to cold and draws the testicles closer to
the body.
ANS: D
When it is cold, the cremaster muscle contracts, which raises the scrotal sac and brings the testes
closer to the body to absorb heat necessary for sperm viability. The lymphatic vessels of the testes
drain into the inguinal lymph nodes. The vas deferens is located along the upper portion of each testis.
The left testis is lower than the right because the left spermatic cord is longer.
6. A male patient with possible fertility problems asks the nurse where sperm is produced. The
nurse knows that sperm production occurs in the:
a.
b.
c.
d.
Testes.
Prostate.
Epididymis.
Vas deferens.
ANS: A
Sperm production occurs in the testes, not in the other structures listed.
7. A 62-year-old man states that his physician told him that he has an inguinal hernia. He asks the
nurse to explain what a hernia is. The nurse should:
a. Tell him not to worry and that most men his age develop hernias.
b. Explain that a hernia is often the result of prenatal growth abnormalities.
c. Refer him to his physician for additional consultation because the physician made the
initial diagnosis.
d. Explain that a hernia is a loop of bowel protruding through a weak spot in the
abdominal muscles.
ANS: D
A hernia is a loop of bowel protruding through a weak spot in the musculature. The other options are
not correct responses to the patients question.
8. The mother of a 10-year-old boy asks the nurse to discuss the recognition of puberty. The
nurse should reply by saying:
a.
b.
c.
d.
Puberty usually begins around 15 years of age.
The first sign of puberty is an enlargement of the testes.
The penis size does not increase until about 16 years of age.
The development of pubic hair precedes testicular or penis enlargement.
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ANS: B
Puberty begins sometime between age 9 for African Americans and age 10 for Caucasians and
Hispanics. The first sign is an enlargement of the testes. Pubic hair appears next, and then penis size
increases.
9. During an examination of an aging man, the nurse recognizes that normal changes to expect
would be:
a.
b.
c.
d.
Enlarged scrotal sac.
Increased pubic hair.
Decreased penis size.
Increased rugae over the scrotum.
ANS: C
In the aging man, the amount of pubic hair decreases, the penis size decreases, and the rugae over the
scrotal sac decreases. The scrotal sac does not enlarge.
10. An older man is concerned about his sexual performance. The nurse knows that in the
absence of disease, a withdrawal from sexual activity later in life may be attributable to:
a.
b.
c.
d.
Side effects of medications.
Decreased libido with aging.
Decreased sperm production.
Decreased pleasure from sexual intercourse.
ANS: A
In the absence of disease, a withdrawal from sexual activity may be attributable to side effects of
medications such as antihypertensives, antidepressants, sedatives, psychotropics, antispasmotics,
tranquilizers or narcotics, and estrogens. The other options are not correct.
11. A 59-year-old patient has been diagnosed with prostatitis and is being seen at the clinic for
complaints of burning and pain during urination. He is experiencing:
a. Dysuria.
b. Nocturia.
c. Polyuria.
d. Hematuria.
ANS: A
Dysuria (burning with urination) is common with acute cystitis, prostatitis, and urethritis. Nocturia is
voiding during the night. Polyuria is voiding in excessive quantities. Hematuria is voiding with blood
in the urine.
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12. A 45-year-old mother of two children is seen at the clinic for complaints of losing my urine
when I sneeze. The nurse documents that she is experiencing:
a.
b.
c.
d.
Urinary frequency.
Enuresis.
Stress incontinence.
Urge incontinence.
ANS: C
Stress incontinence is involuntary urine loss with physical strain, sneezing, or coughing that occurs as
a result to weakness of the pelvic floor. Urinary frequency is urinating more times than usual (more
than five to six times per day). Enuresis is involuntary passage of urine at night after age 5 to 6 years
(bed wetting). Urge incontinence is involuntary urine loss from overactive detrusor muscle in the
bladder. It contracts, causing an urgent need to void.
13. When the nurse is conducting sexual history from a male adolescent, which statement would be
most appropriate to use at the beginning of the interview?
a.
b.
c.
d.
Do you use condoms?
You dont masturbate, do you?
Have you had sex in the last 6 months?
Often adolescents your age have questions about sexual activity.
ANS: D
The interview should begin with a permission statement, which conveys that it is normal and acceptable
to think or feel a certain way. Sounding judgmental should be avoided.
14. Which of these statements is most appropriate when the nurse is obtaining a genitourinary
history from an older man?
a.
b.
c.
d.
Do you need to get up at night to urinate?
Do you experience nocturnal emissions, or wet dreams?
Do you know how to perform a testicular self-examination?
Has anyone ever touched your genitals when you did not want them to?
ANS: A
The older male patient should be asked about the presence of nocturia. Awaking at night to urinate
may be attributable to a diuretic medication, fluid retention from mild heart failure or varicose veins,
or fluid ingestion 3 hours before bedtime, especially coffee and alcohol. The other questions are
more appropriate for younger men.
15. When the nurse is performing a genital examination on a male patient, the patient has an
erection. The nurses most appropriate action or response is to:
a. Ask the patient if he would like someone else to examine him.
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b. Continue with the examination as though nothing has happened.
c. Stop the examination, leave the room while stating that the examination will
resume at a later time.
d. Reassure the patient that this is a normal response and continue with the
examination.
ANS: D
When the male patient has an erection, the nurse should reassure the patient that this is a normal
physiologic response to touch and proceed with the rest of the examination. The other responses are
not correct and may be perceived as judgmental.
16. The nurse is examining the glans and knows which finding is normal for this area?
a.
b.
c.
d.
The meatus may have a slight discharge when the glans is compressed.
Hair is without pest inhabitants.
The skin is wrinkled and without lesions.
Smegma may be present under the foreskin of an uncircumcised male.
ANS: D
The glans looks smooth and without lesions and does not have hair. The meatus should not have any
discharge when the glans is compressed. Some cheesy smegma may have collected under the foreskin
of an uncircumcised male.
17. When performing a genitourinary assessment, the nurse notices that the urethral meatus is
ventrally positioned. This finding is:
a.
b.
c.
d.
Called hypospadias.
A result of phimosis.
Probably due to a stricture.
Often associated with aging.
ANS: A
Normally, the urethral meatus is positioned just about centrally. Hypospadias is the ventral location of
the urethral meatus. The position of the meatus does not change with aging. Phimosis is the inability
to retract the foreskin. A stricture is a narrow opening of the meatus.
18. The nurse is performing a genital examination on a male patient and notices urethral drainage.
When collecting urethral discharge for microscopic examination and culture, the nurse should:
a. Ask the patient to urinate into a sterile cup.
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b. Ask the patient to obtain a specimen of semen.
c. Insert a cotton-tipped applicator into the urethra.
d. Compress the glans between the examiners thumb and forefinger, and collect any
discharge.
ANS: D
If urethral discharge is noticed, then the examiner should collect a smear for microscopic examination
and culture by compressing the glans anteroposteriorly between the thumb and forefinger. The other
options are not correct actions.
19. When assessing the scrotum of a male patient, the nurse notices the presence of multiple firm,
nontender, yellow 1-cm nodules. The nurse knows that these nodules are most likely:
a.
b.
c.
d.
From urethritis.
Sebaceous cysts.
Subcutaneous plaques.
From an inflammation of the epididymis.
ANS: B
Sebaceous cysts are commonly found on the scrotum. These yellowish 1-cm nodules are firm,
nontender, and often multiple. The other options are not correct.
20. When performing a scrotal assessment, the nurse notices that the scrotal contents show a red glow
with transillumination. On the basis of this finding the nurse would:
a.
b.
c.
d.
Assess the patient for the presence of a hernia.
Suspect the presence of serous fluid in the scrotum.
Consider this finding normal, and proceed with the examination.
Refer the patient for evaluation of a mass in the scrotum.
ANS: B
Normal scrotal contents do not allow light to pass through the scrotum. However, serous fluid does
transilluminate and shows as a red glow. Neither a mass nor a hernia would transilluminate.
21. During a health history, a 22-year old woman asks, Can I get that vaccine for human papilloma
virus (HPV)? I have genital warts and Id like them to go away! What is the nurses best response?
a. The HPV vaccine is for girls and women ages 9 to 26 years, so we can start that
today.
b. This vaccine is only for girls who have not yet started to become sexually active.
c. Lets check with the physician to see if you are a candidate for this vaccine.
d. The vaccine cannot protect you if you already have an HPV infection.
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ANS: D
The HPV vaccine is appropriate for girls and women age 9 to 26 years and is administered to prevent
cervical cancer by preventing HPV infections before girls become sexually active.
However, it cannot protect the woman if an HPV infection is already present.
22. During an examination, the nurse observes a female patients vestibule and expects to see the:
a.
b.
c.
d.
Urethral meatus and vaginal orifice.
Vaginal orifice and vestibular (Bartholin) glands.
Urethral meatus and paraurethral (Skene) glands.
Paraurethral (Skene) and vestibular (Bartholin) glands.
ANS: A
The labial structures encircle a boat-shaped space, or cleft, termed the vestibule. Within the vestibule
are numerous openings. The urethral meatus and vaginal orifice are visible. The ducts of the
paraurethral (Skene) glands and the vestibular (Bartholin) glands are present but not visible.
23. During a speculum inspection of the vagina, the nurse would expect to see what at the end of the
vaginal canal?
a.
b.
c.
d.
Cervix
Uterus
Ovaries
Fallopian tubes
ANS: A
At the end of the canal, the uterine cervix projects into the vagina.
24. The uterus is usually positioned tilting forward and superior to the bladder. This position is
known as:
a.
b.
c.
d.
Anteverted and anteflexed.
Retroverted and anteflexed.
Retroverted and retroflexed.
Superiorverted and anteflexed.
ANS: A
The uterus is freely movable, not fixed, and usually tilts forward and superior to the bladder (a position
labeled as anteverted and anteflexed).
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25. An 11-year-old girl is in the clinic for a sports physical examination. The nurse notices that she
has begun to develop breasts, and during the conversation the girl reveals that she is worried about
her development. The nurse should use which of these techniques to best assist the young girl in
understanding the expected sequence for development? The nurse should:
a. Use the Tanner scale on the five stages of sexual development.
b. Describe her development and compare it with that of other girls her age.
c. Use the Jacobsen table on expected development on the basis of height and
weight data.
d. Reassure her that her development is within normal limits and tell her not to
worry about the next step.
ANS: A
The Tanner scale on the five stages of pubic hair development is helpful in teaching girls the expected
sequence of sexual development (see Table 26-1). The other responses are not appropriate.
26. A woman who is 8 weeks pregnant is in the clinic for a checkup. The nurse reads on her chart that
her cervix is softened and looks cyanotic. The nurse knows that the woman is exhibiting
sign and
sign.
a.
b.
c.
d.
Tanner; Hegar
Hegar; Goodell
Chadwick; Hegar
Goodell; Chadwick
ANS: D
Shortly after the first missed menstrual period, the female genitalia show signs of the growing fetus.
The cervix softens (Goodell sign) at 4 to 6 weeks, and the vaginal mucosa and cervix look cyanotic
(Chadwick sign) at 8 to 12 weeks. These changes occur because of increased vascularity and edema
of the cervix and hypertrophy and hyperplasia of the cervical glands.
Hegar sign occurs when the isthmus of the uterus softens at 6 to 8 weeks. Tanner sign is not a correct
response.
27. Generally, the changes normally associated with menopause occur because the cells in the
reproductive tract are:
a.
b.
c.
d.
Aging.
Becoming fibrous.
Estrogen dependent.
Able to respond to estrogen.
ANS: C
Because cells in the reproductive tract are estrogen dependent, decreased estrogen levels during
menopause bring dramatic physical changes. The other options are not correct.
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28. The nurse is reviewing the changes that occur with menopause. Which changes are
associated with menopause?
a.
b.
c.
d.
Uterine and ovarian atrophy, along with a thinning of the vaginal epithelium
Ovarian atrophy, increased vaginal secretions, and increasing clitoral size
Cervical hypertrophy, ovarian atrophy, and increased acidity of vaginal secretions
Vaginal mucosa fragility, increased acidity of vaginal secretions, and uterine
hypertrophy
ANS: A
The uterus shrinks because of its decreased myometrium. The ovaries atrophy to 1 to 2 cm and are not
palpable after menopause. The sacral ligaments relax, and the pelvic musculature weakens;
consequently, the uterus droops. The cervix shrinks and looks paler with a thick glistening epithelium.
The vaginal epithelium atrophies, becoming thinner, drier, and itchy. The vaginal pH becomes more
alkaline, and secretions are decreased, which results in a fragile mucosal surface that is at risk for
vaginitis.
29. A 54-year-old woman who has just completed menopause is in the clinic today for a yearly
physical examination. Which of these statements should the nurse include in patient education? A
postmenopausal woman:
a. Is not at any greater risk for heart disease than a younger woman.
b. Should be aware that she is at increased risk for dyspareunia because of decreased
vaginal secretions.
c. Has only stopped menstruating; there really are no other significant changes with
which she should be concerned.
d. Is likely to have difficulty with sexual pleasure as a result of drastic changes in the
female sexual response cycle.
ANS: B
Decreased vaginal secretions leave the vagina dry and at risk for irritation and pain with intercourse
(dyspareunia). The other statements are incorrect.
30. A woman is in the clinic for an annual gynecologic examination. The nurse should plan to
begin the interview with the:
a.
b.
c.
d.
Menstrual history, because it is generally nonthreatening.
Obstetric history, because it includes the most important information.
Urinary system history, because problems may develop in this area as well.
Sexual history, because discussing it first will build rapport.
ANS: A
Menstrual history is usually nonthreatening and therefore a good topic with which to begin the
interview. Obstetric, urinary, and sexual histories are also part of the interview but not necessarily
the best topics with which to start.
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31. A patient has had three pregnancies and two live births. The nurse would record this
information as grav
, para
, AB
.
a.
b.
c.
d.
2; 2; 1
3; 2; 0
3; 2; 1
3; 3; 1
ANS: C
Gravida (grav) is the number of pregnancies. Para is the number of births. Abortions are interrupted
pregnancies, including elective abortions and spontaneous miscarriages.
32. During the interview with a female patient, the nurse gathers data that indicate the patient is
perimenopausal. Which of these statements made by this patient leads to this conclusion?
a.
b.
c.
d.
I have noticed that my muscles ache at night when I go to bed.
I will be very happy when I can stop worrying about having a period.
I have been noticing that I sweat a lot more than I used to, especially at night.
I have only been pregnant twice, but both times I had breast tenderness as my first
symptom.
ANS: C
Hormone shifts occur during the perimenopausal period, and associated symptoms of menopause may
occur, such as hot flashes, night sweats, numbness and tingling, headache, palpitations, drenching
sweats, mood swings, vaginal dryness, and itching. The other responses are not correct.
33. A 50-year-old woman calls the clinic because she has noticed some changes in her body and
breasts and wonders if these changes could be attributable to the hormone replacement therapy
(HRT) she started 3 months earlier. The nurse should tell her:
a. HRT is at such a low dose that side effects are very unusual.
b. HRT has several side effects, including fluid retention, breast tenderness, and
vaginal bleeding.
c. Vaginal bleeding with HRT is very unusual; I suggest you come into the clinic
immediately to have this evaluated.
d. It sounds as if your dose of estrogen is too high; I think you may need to decrease the
amount you are taking and then call back in a week.
ANS: B
Side effects of HRT include fluid retention, breast pain, and vaginal bleeding. The other responses
are not correct.
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34. A 52-year-old patient states that when she sneezes or coughs she wets herself a little. She is very
concerned that something may be wrong with her. The nurse suspects that the problem is:
a.
b.
c.
d.
Dysuria.
Stress incontinence.
Hematuria.
Urge incontinence.
ANS: B
Stress incontinence is involuntary urine loss with physical strain, sneezing, or coughing. Dysuria is
pain or burning with urination. Hematuria is bleeding with urination. Urge incontinence is involuntary
urine loss that occurs as a result of an overactive detrusor muscle in the bladder that contracts and
causes an urgent need to void.
35. During the interview, a patient reveals that she has some vaginal discharge. She is worried that
it may be a sexually transmitted infection. The nurses most appropriate response to this would be:
a.
b.
c.
d.
Oh, dont worry. Some cyclic vaginal discharge is normal.
Have you been engaging in unprotected sexual intercourse?
Id like some information about the discharge. What color is it?
Have you had any urinary incontinence associated with the discharge?
ANS: C
Questions that help the patient reveal more information about her symptoms should be asked in a
nonthreatening manner. Asking about the amount, color, and odor of the vaginal discharge provides the
opportunity for further assessment. Normal vaginal discharge is small, clear or cloudy, and always
nonirritating.
36. A woman states that 2 weeks ago she had a urinary tract infection that was treated with an
antibiotic. As a part of the interview, the nurse should ask, Have you noticed any:
a.
b.
c.
d.
Changes in your urination patterns?
Excessive vaginal bleeding?
Unusual vaginal discharge or itching?
Changes in your desire for intercourse?
ANS: C
Several medications may increase the risk of vaginitis. Broad-spectrum antibiotics alter the balance of
normal flora, which may lead to the development of vaginitis. The other questions are not appropriate.
37. Which statement would be most appropriate when the nurse is introducing the topic of sexual
relationships during an interview?
a. Now, it is time to talk about your sexual history. When did you first have
intercourse?
b. Women often feel dissatisfied with their sexual relationships. Would it be okay to
discuss this now?
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c. Women often have questions about their sexual relationship and how it affects their
health. Do you have any questions?
d. Most women your age have had more than one sexual partner. How many would you
say you have had?
ANS: C
The nurse should begin with an open-ended question to assess individual needs. The nurse should
include appropriate questions as a routine part of the health history, because doing so communicates
that the nurse accepts the individuals sexual activity and believes it is important. The nurses comfort
with the discussion prompts the patients interest and, possibly, relief that the topic has been
introduced. The initial discussion establishes a database for comparison with any future sexual
activities and provides an opportunity to screen sexual problems.
Chapter 22 Putting it All Together
MULTIPLE CHOICE
1. An 85-year-old man has come in for a physical examination, and the nurse notices that he uses a
cane. When documenting general appearance, the nurse should document this information under the
section that covers:
a. Posture.
b. Mobility.
c. Mood and affect.
d. Physical deformity.
ANS: B
Use of assistive devices would be documented under the mobility section. The other responses are all
other categories of the general appearance section of the health history.
2. The nurse is performing a vision examination. Which of these charts is most widely used for
vision examinations?
a.
b.
c.
d.
Snellen
Shetllen
Smoollen
Schwellon
ANS: A
The Snellen eye chart is most widely used for vision examinations. The other options are not tests for
vision examinations.
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3. After the health history has been obtained and before beginning the physical examination, the
nurse should first ask the patient to:
a.
b.
c.
d.
Empty the bladder.
Completely disrobe.
Lie on the examination table.
Walk around the room.
ANS: A
Before beginning the examination, the nurse should ask the person to empty the bladder (save the
specimen if needed), disrobe except for underpants, put on a gown, and sit with the legs dangling off
side of the bed or table.
4. During a complete health assessment, how would the nurse test the patients hearing?
a.
b.
c.
d.
Observing how the patient participates in normal conversation
Using the whispered voice test
Using the Weber and Rinne tests
Testing with an audiometer
ANS: B
During the complete health assessment, the nurse should test hearing with the whispered voice test.
The other options are not correct.
5. A patient states, Whenever I open my mouth real wide, I feel this popping sensation in front of my
ears. To further examine this, the nurse would:
a. Place the stethoscope over the temporomandibular joint, and listen for bruits.
b. Place the hands over his ears, and ask him to open his mouth really wide.
c. Place one hand on his forehead and the other on his jaw, and ask him to try to open
his mouth.
d. Place a finger on his temporomandibular joint, and ask him to open and close his
mouth.
ANS: D
The nurse should palpate the temporomandibular joint by placing his or her fingers over the joint as
the person opens and closes the mouth.
6. The nurse has just completed an examination of a patients extraocular muscles. When
documenting the findings, the nurse should document the assessment of which cranial nerves?
a.
b.
c.
d.
II, III, and VI
II, IV, and V
III, IV, and V
III, IV, and VI
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ANS: D
Extraocular muscles are innervated by cranial nerves III, IV, and VI.
7. A patients uvula raises midline when she says ahh, and she has a positive gag reflex. The
nurse has just tested which cranial nerves?
a.
b.
c.
d.
IX and X
IX and XII
X and XII
XI and XII
ANS: A
Cranial nerves IX and X are being tested by having the patient say ahh, noting the mobility of the
uvula, and when assessing the patients gag reflex.
8. During an examination, the nurse notices that a patient is unable to stick out his tongue. Which
cranial nerve is involved with the successful performance of this action?
a.
b.
c.
d.
I
V
XI
XII
ANS: D
Cranial nerve XII enables the person to stick out his or her tongue.
9. A patient is unable to shrug her shoulders against the nurses resistant hands. What cranial
nerve is involved with successful shoulder shrugging?
a. VII
b. IX
c. XI
d. XII
ANS: C
Cranial nerve XI enables the patient to shrug her shoulders against resistance.
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10. During an examination, a patient has just successfully completed the finger-to-nose and the rapidalternating-movements tests and is able to run each heel down the opposite shin. The nurse will
conclude that the patients
function is intact.
a.
b.
c.
d.
Occipital
Cerebral
Temporal
Cerebellar
ANS: D
The nurse should test cerebellar function of the upper extremities by using the finger-to-nose test or
rapid-alternating-movements test. The nurse should test cerebellar function of the lower extremities
by asking the person to run each heel down the opposite shin.
11. When the nurse performs the confrontation test, the nurse has assessed:
a.
b.
c.
d.
Extraocular eye muscles (EOMs).
Pupils (pupils equal, round, reactive to light, and accommodation [PERRLA]).
Near vision.
Visual fields.
ANS: D
The confrontation test assesses visual fields. The other options are not tested with the confrontation
test.
12. Which statement is true regarding the complete physical assessment?
a. The male genitalia should be examined in the supine position.
b. The patient should be in the sitting position for examination of the head and neck.
c. The vital signs, height, and weight should be obtained at the end of the
examination.
d. To promote consistency between patients, the examiner should not vary the order of
the assessment.
ANS: B
The head and neck should be examined in the sitting position to best palpate the thyroid and lymph
nodes. The male patient should stand during an examination of the genitalia. Vital signs are measured
early in the assessment. The sequence of the assessment may need to vary according to different
patient situations.
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13. Which of these is included in an assessment of general appearance?
a.
b.
c.
d.
Height
Weight
Skin color
Vital signs
ANS: C
General appearance includes items such as level of consciousness, skin color, nutritional status, posture,
mobility, facial expression, mood and affect, speech, hearing, and personal hygiene.
Height, weight, and vital signs are considered measurements.
14. The nurse should wear gloves for which of these examinations?
a.
b.
c.
d.
Measuring vital signs
Palpation of the sinuses
Palpation of the mouth and tongue
Inspection of the eye with an ophthalmoscope
ANS: C
Gloves should be worn when the examiner is exposed to the patients body fluids.
15. The nurse should use which location for eliciting deep tendon reflexes?
a.
b.
c.
d.
Achilles
Femoral
Scapular
Abdominal
ANS: A
Deep tendon reflexes are elicited in the biceps, triceps, brachioradialis, patella, and Achilles heel.
16. During an inspection of a patients face, the nurse notices that the facial features are
symmetric. This finding indicates which cranial nerve is intact?
a.
b.
c.
d.
VII
IX
XI
XII
ANS: A
Cranial nerve VII is responsible for facial symmetry.
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17. During inspection of the posterior chest, the nurse should assess for:
a.
b.
c.
d.
Symmetric expansion.
Symmetry of shoulders and muscles.
Tactile fremitus.
Diaphragmatic excursion.
ANS: B
During an inspection of the posterior chest, the nurse should inspect for symmetry of shoulders and
muscles, configuration of the thoracic cage, and skin characteristics. Symmetric expansion and
tactile fremitus are assessed with palpation; diaphragmatic excursion is assessed with percussion.
18. During an examination, the patient tells the nurse that she sometimes feels as if objects are
spinning around her. The nurse would document that she occasionally experiences:
a.
b.
c.
d.
Vertigo.
Tinnitus.
Syncope.
Dizziness.
ANS: A
Vertigo is the sensation of a person moving around in space (subjective) or of the person sensing
objects moving around him or her (objective) and is a result of a disturbance of equilibratory apparatus
19. A patient tells the nurse, Sometimes I wake up at night and I have real trouble breathing. I have
to sit up in bed to get a good breath. When documenting this information, the nurse would note:
a.
b.
c.
d.
Orthopnea.
Acute emphysema.
Paroxysmal nocturnal dyspnea.
Acute shortness of breath episode.
ANS: C
Paroxysmal nocturnal dyspnea occurs when the patient awakens from sleep with shortness of breath
and needs to be upright to achieve comfort
20. During the examination of a patient, the nurse notices that the patient has several small, flat
macules on the posterior portion of her thorax. These macules are less than 1 cm wide. Another
name for these macules is:
a.
b.
c.
d.
Warts.
Bullae.
Freckles.
Papules.
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ANS: C
A macule is solely a lesion with color change, flat and circumscribed, less than 1 cm. Macules are
also known as freckles
21. During an examination, the nurse notices that a patients legs turn white when they are raised
above the patients head. The nurse should suspect:
a.
b.
c.
d.
Lymphedema.
Raynaud disease.
Chronic arterial insufficiency.
Chronic venous insufficiency.
ANS: C
Elevational pallor (striking) indicates arterial insufficiency
22. The nurse documents that a patient has coarse, thickened skin and brown discoloration over the
lower legs. Pulses are present. This finding is probably the result of:
a.
b.
c.
d.
Lymphedema.
Raynaud disease.
Chronic arterial insufficiency.
Chronic venous insufficiency.
ANS: D
Chronic venous insufficiency would exhibit firm brawny edema, coarse thickened skin, normal pulses,
and brown discoloration
23. The nurse notices that a patient has ulcerations on the tips of the toes and on the lateral aspect of
the ankles. This finding indicates:
a.
b.
c.
d.
Lymphedema.
Raynaud disease.
Arterial insufficiency.
Venous insufficiency.
ANS: C
Ulcerations on the tips of the toes and lateral aspect of the ankles are indicative of arterial insufficiency
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24. The nurse has just recorded a positive iliopsoas test on a patient who has abdominal pain. This
test is used to confirm a(n):
a.
b.
c.
d.
Inflamed liver.
Perforated spleen.
Perforated appendix.
Enlarged gallbladder.
ANS: C
An inflamed or perforated appendix irritates the iliopsoas muscle, producing pain in the RLQ.
25. The nurse will measure a patients near vision with which tool?
a. Snellen eye chart with letters
b. Snellen E chart
c. Jaeger card
d. Ophthalmoscope
ANS: C
The Jaeger card is used to measure near vision
26. If the nurse records the results to the Hirschberg test, the nurse has:
a.
b.
c.
d.
Tested the patellar reflex.
Assessed for appendicitis.
Tested the corneal light reflex.
Assessed for thrombophlebitis.
ANS: C
The Hirschberg test assesses the corneal light reflex
27. During the examination of a patients mouth, the nurse observes a nodular bony ridge down the
middle of the hard palate. The nurse would chart this finding as:
a.
b.
c.
d.
Cheilosis.
Leukoplakia.
Ankyloglossia.
Torus palatinus.
ANS: D
A normal variation of the hard palate is a nodular bony ridge down the middle of the hard palate; this
variation is termed torus palatinus
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28. During examination, the nurse finds that a patient is unable to distinguish objects placed in his
hand. The nurse would document:
a.
b.
c.
d.
Stereognosis.
Astereognosis.
Graphesthesia.
Agraphesthesia.
ANS: B
Astereognosis is the inability to identify correctly an object placed in the hand
29. After the examination of an infant, the nurse documents opisthotonos. The nurse recognizes that
this finding often occurs with:
a.
b.
c.
d.
Cerebral palsy.
Meningeal irritation.
Lower motor neuron lesion.
Upper motor neuron lesion.
ANS: B
Opisthotonos is a form of spasm in which the head is arched back, and a stiffness of the neck and an
extension of the arms and legs are observed. Opisthotonus occurs with meningeal or brainstem
irritation
30. After assessing a female patient, the nurse notices flesh-colored, soft, pointed, moist, papules in a
cauliflower-like patch around her introitus. This finding is most likely:
a.
b.
c.
d.
Urethral caruncle.
Syphilitic chancre.
Herpes simplex virus.
Human papillomavirus.
ANS: D
Human papillomavirus appears in a flesh-colored, soft, moist, cauliflower-like patch of pupils
31. While recording in a patients medical record, the nurse notices that a patients Hematest
results are positive. This finding means that there is(are):
a.
b.
c.
d.
Crystals in his urine.
Parasites in his stool.
Occult blood in his stool.
Bacteria in his sputum.
ANS: C
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If a stool is Hematest positive, then it indicates the presence of occult blood
32. While examining a 48-year-old patients eyes, the nurse notices that he had to move the
handheld vision screener farther away from his face. The nurse would suspect:
a.
b.
c.
d.
Myopia.
Omniopia.
Hyperopia.
Presbyopia.
ANS: D
Presbyopia, the decrease in power of accommodation with aging, is suggested when the handheld
vision screener card is moved farther away
33. A 5-year-old child is in the clinic for a checkup. The nurse would expect him to:
a.
b.
c.
d.
Need to be held on his mothers lap.
Be able to sit on the examination table.
Be able to stand on the floor for the examination.
Be able to remain alone in the examination room.
ANS: B
At 4 or 5 years old, a child usually feels comfortable on the examination table. Older infants and young
children aged 6 months to 2 or 3 years should be positioned in the parents lap.
34. Which statement is true regarding the recording of data from the history and physical
examination?
a. Use long, descriptive sentences to document findings.
b. Record the data as soon as possible after the interview and physical examination.
c. If the information is not documented, then it can be assumed that it was done as a
standard of care.
d. The examiner should avoid taking any notes during the history and examination
because of the possibility of decreasing the rapport with the patient.
ANS: B
The data from the history and physical examination should be recorded as soon after the event as
possible. From a legal perspective, if it is not documented, then it was not done. Brief notes should be
taken during the examination. When documenting, the nurse should use short, clear phrases and avoid
redundant phrases and descriptions.
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35. When assessing the neonate, the nurse should test for hip stability with which method?
a.
b.
c.
d.
Eliciting the Moro reflex
Performing the Romberg test
Checking for the Ortolani sign
Assessing the stepping reflex
ANS: C
The nurse should test for hip stability in the neonate by testing for the Ortolani sign. The other tests
are not appropriate for testing hip stability.
36. A female patient tells the nurse that she has four children and has had three pregnancies. How
should the nurse document this?
a.
b.
c.
d.
Gravida 3, para 4
Gravida 4, para 3
This information cannot be documented using the terms gravida and para.
The patient seems to be confused about how many times she has been pregnant.
ANS: A
Gravida refers to the number of pregnancies, and para refers to the number of
37. The nurse is documenting the assessment of an infant. During the abdominal assessment, the
nurse noticed a very loud splash auscultated over the upper abdomen when the nurse rocked her from
side to side. This finding would indicate:
a.
b.
c.
d.
Epigastric hernia.
Pyloric obstruction.
Hypoactive bowel sounds.
Hyperactive bowel sounds.
ANS: D
A succussion splash, which is unrelated to peristalsis, is a very loud splash auscultated over the
upper abdomen when the infant is rocked side to side. It indicates increased air and fluid in the
stomach as observed with pyloric obstruction or large hiatus hernia
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38. Which of these actions is most appropriate to perform on a 9-month-old infant at a well-child
checkup?
a.
b.
c.
d.
Testing for Ortolani sign
Assessment for stereognosis
Blood pressure measurement
Assessment for the presence of the startle reflex
ANS: A
Until the age of 12 months, the infant should be assessed for Ortolani sign. If Ortolani sign is present,
then it could indicate the presence of a dislocated hip. The other tests are not appropriate for a 9-monthold child.
Chapter 23 Assessing Children: Infancy Through Adolescence
Multiple Choice
1. During the delivery of a male infant, you are there to assess the Apgar score. He was born through
an intact pelvis and had no complications during labor or delivery. At 1 minute he is pink all over and
grimaces. He is flexing his arms and legs occasionally. He is breathing well and his heart rate is 110.
At 5 minutes he is still pink all over but now is crying vigorously, with active movement. His
respiratory effort is good and his heart rate is 130.
What is his Apgar score?
A) 8 at 1 minute, 10 at 5 minutes
B) 7 at 1 minute, 9 at 5 minutes
C) 9 at 1 minute, 10 at 5 minutes
D) 8 at 1 minute, 9 at 5 minutes
Ans: A
Feedback: In checking the Apgar, five things are looked at during the 1-minute and 5-minute marks.
The color, reflex irritability, muscle tone, respiratory effort, and heart rate are evaluated. In this case,
at 1 minute he received 2 points for being pink all over, 1 point for grimacing, 1 point for flexion of
the arms and legs, 2 points for strong respiratory effort, and 2 points for a heart rate over 100. This
gives a 1-minute total of 8. At 5 minutes he was given 2 points for being pink all over, 2 points for
vigorous crying, 2 points for active movement, 2 points for strong breathing, and 2 points for a heart
rate over 100. This gives a 5-minute total of 10. These are normal, healthy Apgar scores.
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2. A 24-year-old mother who is a smoker and cocaine addict gave birth at 39 weeks to a 2,000gram female infant who is in the neonatal intensive care unit. Using the Intrauterine Growth Curve
chart, you determine whether the infant's weight is appropriate for her gestational age.
In which category does the infant best fit?
A) Large for gestational age
B) Normal for gestational age
C) Small for gestational age
Ans: C
Feedback: For a 39-week infant, any weight less than 2,500 grams would be considered small.
Intrauterine growth retardation and low birth weight would be expected in a smoker who also abuses
cocaine.
3. A mother brings her 16-month-old son in for an evaluation. She is afraid he is not meeting his
developmental milestones and wants to know if he should be sent to therapy. He was the product of an
uneventful pregnancy and a spontaneous vaginal delivery. His Apgar scores were 7 and 9. Until
reaching a year old the mother believes he was hitting his milestones appropriately. You decide to
administer the Denver Developmental Screening Test. You find that he is using a spoon to eat with
and can take off his own shoes and shirt. He can build a tower of two cubes and dump raisins. His
vocabulary consists of at least 10 words. He can stand alone and stoop and recover, but he is unable to
walk without holding onto someone's hand.
What type of developmental delay does he have?
A) Personal/social
B) Fine motor
C) Language
D) Gross motor
Ans: D
Feedback: By 16 months a child should be able to walk unaided and even walk backwards and run.
This child was referred to physical therapy and did well.
4. A foster mother brings a 4-year-old child to see you for an evaluation. She has had custody of the
girl for 2 weeks. She knows that the child was born in your state and that her maternal grandmother
had custody for 6 months. She received good medical care during that time, but after her biologic
mother obtained custody the child was abused and has had no further medical care. She says the child
has had many behavioral problems and seems to be very behind on her developmental tasks. When
you examine the child you notice short palpebral fissures, a wide nasal philtrum, and thin lips. Her
cardiac, pulmonary, musculoskeletal, and abdominal examinations are normal. Her Denver
Developmental Screening Test shows most of her milestones have occurred only through the 24th
month.
What form of congenital retardation is she most likely to have?
A) Fetal alcohol syndrome
B) Congenital hypothyroidism
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C) Down syndrome
Ans: A
Feedback: The facial appearance in fetal alcohol syndrome shows short palpebral fissures, a wide
and flattened philtrum, and thin lips. These children often have mild retardation even with good care,
but with abuse they may have more profound retardation. This condition may occur with only
modest alcohol consumption.
5. A young Hispanic mother brings in her 2-month-old son. She is upset because her neighbors have
threatened to call the Child Protective Agency because they think his birthmark is a bruise. Her son
was the product of an uneventful pregnancy and spontaneous vaginal delivery. On examination you
see a large, smooth-bordered bluish mark on his buttock and lower back. Otherwise his examination
is unremarkable.
What form of birthmark is this likely to be?
A) Café-au-lait spot
B) Salmon patch
C) Mongolian spot
Ans: C
Feedback: Mongolian spots are large, smooth-bordered birthmarks found on the back and/or
buttocks. They are found more often in darker-pigmented infants such as in the Hispanic or Asian
population. They are commonly mistaken for bruises.
6. A 32-year-old white female presents to labor and delivery fully effaced and delivers a 5.8-lb
(2,500-gram) infant female with Apgar scores of 6 and 8. The mother has had no prenatal care and in
the nursery you perform the newborn examination. With the Ballard scoring system, the
neuromuscular examination score is 15. Looking at physical maturity, you see superficial peeling and
few veins on the skin. The lanugo hair has bald areas and the plantar surface of the foot has creases on
two thirds of it. The areola is stippled with a 2-mm bud. The pinna is well curved, is firm, and has
instant recoil. The labia majora and minora are equally prominent.
Add the score of the neuromuscular components to your score of physical maturity to determine weeks
of gestation. How many weeks of gestation has this child had?
A) 34 weeks
B) 36 weeks
C) 40 weeks
Ans: B
Feedback: Superficial peeling with few veins gives a score of 2 points; lanugo with balding areas
gives a score of 3 points; the plantar surface being covered by two thirds gives a score of 3 points; the
stippled areola with a 2-mm bud gives a score of 2 points; the well-formed pinna with instant recoil
gives a score of 3 points. The equal labia majora and labia minora give a score of 2 points. Adding
these numbers up gives a score of 15 points for physical maturity. Adding that to the 15 points for
neuromuscular maturity gives a point total of 30, which correlates to a gestational age of 36 weeks.
This would be expected with a birth weight of 2,500 grams.
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7. A mother brings in her 3-year-old son for a well-child check-up. She is concerned that he seems
different in size from all of the other preschool boys. He was the product of an uneventful pregnancy
and vaginal delivery. He has hit all of his developmental milestones on time. On examination he is 26
lbs (11.8 kg) and is 35 inches (89 cm) tall. Otherwise his examination is unremarkable. You give the
correct education for his age and then discuss his size.
For his age, what are his growth chart percentiles?
A) Tall and heavy for his age (>95%)
B) Average height and weight for his age (5 to 95%)
C) Small and light for his age (<5%)
Ans: C
Feedback: According to the growth charts, this child is less than the fifth percentile for both height
and weight, indicating that he is small and light for his age. This can be from a growth hormone
deficiency but is usually due to genetic factors (such as short, light parents). It is most important to
follow the trend of growth. It is more significant if this child was previously at the 50th percentile
for height and weight than if he has always been about the same percentile and following a line
parallel to expected growth lines.
8. A mother brings her 4-year-old daughter to your office because of fever and decreased eating and
drinking. When you ask the little girl what is wrong, she says her mouth and throat hurt. On
examination her temperature is 101 degrees. Her ears and nose examinations are unremarkable. Her
mouth has ulcerations on the buccal mucosa and the tongue. She also has cervical lymphadenopathy.
Her cardiac and pulmonary examinations are normal. She is up to date on her childhood vaccinations.
What mouth abnormality does she most likely have?
A) Strep throat
B) Herpetic stomatitis
C) Oral candidiasis (thrush)
D) Diphtheria
Ans: B
Feedback: With herpetic stomatitis there is often a low-grade fever with small ulcers covering the
mucosa of the mouth. The pain from the ulcers leads to decreased oral intake and even dehydration.
9. A mother brings her 15-month-old daughter to your office for evaluation of a rash and fever. She
says the rash started one day and the fever developed the next day. Her daughter has had all of her
vaccinations up to 10 months. The mother sheepishly admits that she hasn't had time to bring her
daughter in since her 10-month check-up. On examination you see a mildly sick- appearing toddler
with a 102-degree temperature. Looking at her skin you see at least 100 of a variety of papules,
vesicles, and ulcers in different stages of development.
What illness prevented by proper vaccination does this toddler have?
A) Varicella (chickenpox)
B) Measles
C) Smallpox
Ans: A
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Feedback: Normally the first vaccine for varicella is given at 12 to 15 months. The characteristic rash
in waves of lesions is in a pattern of papules, vesicles, ulcers, and scabs. Because of the number of
persons who still get shingles (an outbreak of varicella in one dermatome following the original
infection by years), there is still enough virus in the United States to easily get chickenpox without
vaccination. This child is regarded as contagious to others until all of the lesions are ―scabbed over.‖
Smallpox would appear different in that all of the lesions would be in the same stage of development.
10. An adolescent male comes to your clinic with a note from his mother stating it is okay for him to
be seen today without her presence. He has come in for his annual sports physical required to play
football. For his age his physical examination is unremarkable and you sign his school's physical
examination form. You decide to take this opportunity to do some health education with him. He
admits to wondering a lot lately if he is normal. Although he is in football he really enjoys science
and computers more. He is worried that all his buddies will think he is a geek. He is convinced he
also won't get a date for the Sadie Hawkins dance next week because the girls all think he is boring,
too. He denies any experimentation with tobacco or alcohol, and he blushes when you mention sex.
After hitting all the pertinent age-appropriate education points you give him his sports physical form
and he leaves.
The patient's concerns during the visit most resemble what developmental stage of adolescence?
A) Early adolescence (10 to 14 years old)
B) Middle adolescence (15 to 16 years old)
C) Late adolescence (17 to 20 years old)
Ans: A
Feedback: His concern with whether he is normal or not is often seen in the development of social
identity in early adolescence. He is also concerned with the present (Sadie Hawkins dance) and not the
distant future, as is seen with late adolescence. He also denies the experimentation often seen in
middle adolescence.
11. A 38-week gestation, 2500-gram infant is placed on your service. How would she be
described?
A) Term, normal birth weight
B) Term, low birth weight
C) Preterm, normal birth weight
D) Preterm, low birth weight
Ans: A
Feedback: Preterm is defined as less than 37 weeks; term, 37–42 weeks; and post-term, over 42
weeks of gestation. Birth weights have similar limits: extremely low birth weight, less than 1000
grams; very low birth weight, less than 1500 grams; low birth weight, less than 2500 grams; and
normal birth weight, equal to or more than 2500 grams. These have prognostic implications and
impact on how closely to watch and how aggressively to treat these infants.
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12. You are observing an infant who is able to pull to a stand, uses ―mama‖ and ―dada‖
specifically, and indicates his wants by vocalization and pointing. Where would you place this
child's developmental age?
A) 12 months
B) 10 months
C) 8 months
D) 6 months
Ans: C
Feedback: Assessing developmental milestones is of major importance during the first year and
beyond. These accomplishments in the physical, cognitive/language, and social domains are normal
for an 8-month-old infant.
13. Which of the following will help to optimize yield from a pediatric examination?
A) Doing the examination out of order if necessary to take advantage of quiet periods for
auscultation, etc.
B) Being very orderly, so as not to miss a portion of the examination
C) Using firmness as needed to make it through your examination
D) Making sure to place the infant on the table during the examination while mom watches
close by
Ans: A
Feedback: While order and routine are comforting to the examiner, children should be examined in an
order which allows maximum yield. Many prefer to listen to the heart and lungs first while the child
is quiet, in a parent's arms. Likewise, you may gain advantage to examining the mouth while the baby
is crying. Most view the ENT examination as the most invasive for a child (especially the otoscopic
examination), so many leave this for last.
14. A 6-month-old infant is brought in for a well check. It is noted his head circumference is off the
chart and at a much higher percentile than was previously measured. What should you do next?
A) Recommend a neurology consult.
B) Order a CT of the head.
C) Remeasure the circumference.
D) Admit the child to the hospital for further workup.
Ans: C
Feedback: It is difficult to obtain accurate measurements of a squirming infant. The first step would be
to remeasure. Some recommend starting with three measurements and averaging or picking the middle
measurement. Height is technically not measured until a child is standing, so infants' measurements are
recorded as length.
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15. You are examining an infant in the nursery and notice a soft bump over the posterior right side
of the skull. It is not evident on the left. What does this represent?
A) Caput succedaneum
B) Plagiocephaly
C) Craniosynostosis
D) Cephalohematoma
Ans: D
Feedback: Cephalohematoma represents bleeding under the periosteum, which is why this lesion does
not cross the midline. The blood can contribute to neonatal jaundice as it breaks down.
Caput succedaneum is commonly seen as a spongy mass over the vertex, particularly when vacuum
extraction is used. Craniosynostosis describes a premature closure of bony skull sutures, and
plagiocephaly is a flattening of the parieto-occipital region on one side of the skull, which is frequently
thought to be positional.
16. You are assessing an infant and notice that his nares flare, he has a soft grunt with each breath,
and the skin between his ribs is pulled inward with inhalation. What is the significance of these
findings?
A) These are indicative of a CNS process.
B) These are indicative of respiratory distress.
C) These are indicative of muscular dystrophy.
D) These are frequently accompanied by stridor.
Ans: B
Feedback: It is critical to notice these findings of respiratory distress. Muscular dystrophy may not
allow the appearance of these signs because they are caused by muscular effort. It is hard to find a
cause for these signs in the CNS. Stridor is usually inspiratory, so while nasal flaring and retractions
may occur, grunting is unusual because exhalation is unimpeded.
17. A mother brings her infant to you because of a ―rattle‖ in his chest with breathing. Which of the
following would you hear if there were a problem in the upper airway?
A) Different sounds from the nose and chest
B) Asymmetric sounds
C) Inspiratory sounds
D) Sounds louder in the lower chest
Ans: C
Feedback: It is important to distinguish upper airway sounds from lower because many benign
conditions cause upper airway noise, such as viral upper respiratory infections. It is reassuring to hear
the same noises at the nose as at the chest. Lower respiratory conditions also are generally symmetric,
and sounds are louder at the upper chest versus the lower chest. They are usually very harsh and
loud, which concerns parents.
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18. An infant presents with a heart rate of 180, a respiratory rate of 68, and an enlarged liver.
What diagnosis does this suggest?
A) Pneumonia
B) Heart failure
C) Sepsis
D) Necrotizing enterocolitis
Ans: B
Feedback: Heart failure presents differently in infants than in adults. This triad should suggest this
diagnosis. Pneumonia, necrotizing enterocolitis, and sepsis should not necessarily cause
hepatomegaly. Observe closely for central cyanosis of the lips and tongue. Peripheral cyanosis alone
does not mean much in infants. Perform a careful cardiac examination in as quiet a setting as possible,
perhaps while the infant is in the mother's arms, to look for evidence of valvular disease.
19. You have been unable to hear normal S2 splitting in children up to this point. What
technique will maximize your chances of hearing this phenomenon?
A) Listen with the diaphragm over the left lower sternal border.
B) Listen with the bell over the 2nd left intercostal space.
C) Listen with the bell over the apex.
D) Listen with the diaphragm in the axilla.
Ans: B
Feedback: S2 is made of aortic and pulmonic components. Of these, the pulmonic component is much
softer and heard best over the pulmonic area. Even in the proper location, the pulmonic component
may be difficult to hear with the diaphragm because it is a soft, low-pitched sound.
For this reason, the bell should be used to listen for S2 splitting over the pulmonic area during
inspiration, when splitting should be maximized. Breathing also changes heart rate more rapidly in
children. One may think an arrhythmia is present until she notices that this rate change is related to
the respiratory cycle.
20. A mother is upset because she was told by another provider that her child has a worrisome
murmur. You listen near the clavicle and notice both a systolic and diastolic sound. You remember
that diastolic murmurs are usually indicative of bad pathology. What would you do next?
A) Cardiology referral
B) Echocardiogram
C) Supine examination
D) Reassure the mother
Ans: C
Feedback: The next step would be to examine the patient in the supine position. If this is a venous
hum, this murmur will resolve almost completely in the supine position. This is a very common
phenomenon in school-aged children, particularly over the clavicle, but can also occur outside this
range. Reassurance cannot be given without further examination, especially with a diastolic murmur.
Cardiology referral and echocardiography are unnecessary if examination in the supine position
reveals no murmur.
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21. A toddler is able to jump in place and balance on one foot as well. She can also speak in full
sentences and feed herself. What is the approximate developmental age of this child?
A) 2 years
B) 3 years
C) 4 years
D) 5 years
Ans: B
Feedback: These milestones are consistent with a physical, cognitive/language, and social and
emotional developmental age of 3 years.
22. You are having trouble examining the abdomen of a school-aged child due to ticklishness.
What should you do?
A) Have the child press on your hand.
B) Have the parent insist that the child allow you to examine her.
C) Ask the parent to leave the room.
D) Make the child realize that this is part of the examination and must be done.
Ans: A
Feedback: By having the child participate in the examination and pressing on your hand, it will
eliminate the ticklishness. Resistance to examination at this age is normal. The last three options
only make the situation worse. The key is to have the child participate in the examination in a fun
way.
23. You are examining a 5-year-old before he begins school. You notice a systolic, grade II/VI
vibratory murmur over the LLSB and apex with normal S2 splitting. He has normal pulses as well.
Which of the following is most likely?
A) Tricuspid stenosis
B) Mitral stenosis
C) Still's murmur
D) Venous hum
Ans: C
Feedback: This description is consistent with Still's murmur, a very common and benign murmur of
childhood. Tricuspid and mitral stenosis would be diastolic murmurs and the venous hum is usually
not heard in this area. Further evaluation is usually not necessary.
24. You are going to obtain a social history on an early adolescent boy. How should you
proceed to obtain the best information?
A) Ask his mother to leave the room.
B) Ask if he would prefer his mother to leave the room.
C) Ask your questions with his mother in the room.
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D) Ask his mother how she would like to proceed.
Ans: B
Feedback: It is best to ask the patient what he or she would prefer. Because the examination should
include a genitalia examination, some children in early adolescence are more comfortable with their
parents in the room. Some examiners will provide ―confidential time‖ to both the adolescent and the
parent, so that parental concerns can also be adequately addressed. Leaving the parent in the room
without asking the adolescent is usually not a good idea and can limit optimal history gathering and
examination.
25. You are assessing Tanner staging of the breast in a young woman. You notice projection of the
areola and nipple to form a secondary mound above the level of the breast. Which Tanner stage
would this be?
A) I
B) II
C) III
D) IV
Ans: C
Feedback: This would be a Tanner stage III because there is elevation of the nipple and areola above
the level of the surrounding breast tissue and because the areola has not receded to the general contour
of the breast.
26. A quiet 3-year-old is brought in for a routine check-up when you notice a fresh bruise in the
axilla and bilateral bruises over the upper back that appear slightly older. There are brown bruises
over his shins as well. His mother said this happened when he fell off of a couch. What diagnosis
should be considered?
A) Von Willebrand's disease
B) Normal childhood bruises from activity
C) Abuse
D) Seizure disorder
Ans: C
Feedback: No one wants to think that a child could be abused. In this case the bruises on the shins are
very normal for this age group with normal activity. The presence of bruises in other areas which do
not correlate with the given history are important to notice and should make you consider this
diagnosis. A very thorough examination must be conducted to search for other lesions that might be
consistent with the use of implements such as an electrical cord, clothes iron, cigarette, etc. A social
services consult and/or formal abuse evaluation should be considered. Unfortunately, emotional and
sexual abuse do not frequently leave outward signs. It is important to keep an open mind to the
presence of these other types of abuse as well.
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27. A 15-month-old is brought to you for a fever of 38.6 degrees Celsius and fussiness. The ear
examination is as follows: external ear, normal appearance and no tenderness with manipulation;
canal, normal diameter without evidence of inflammation; tympanic membrane, bulging,
erythematous, and opaque. Insufflation is deferred due to pain. What is your diagnosis?
A) Otitis externa
B) Cholesteatoma
C) Ruptured tympanic membrane
D) Otitis media
Ans: D
Feedback: There is no inflammation of the outer ear, including the canal, thus excluding otitis externa.
Cholesteatoma is a painless white lesion behind the TM. There is no drainage from the TM; thus,
rupture is unlikely. This is a classic description of otitis media. Many examiners will forego
insufflation if the diagnosis is clear, because this can cause discomfort in an already uncomfortable ear.
Chapter 24 Assessing Older Adults
Multiple Choice
1. Which of the following changes are expected in vision as part of the normal aging process?
A) Cataracts
B) Glaucoma
C) Macular degeneration
D) Blurring of near vision
Ans: D
Feedback: The lens loses its elasticity over time as part of the normal aging process, and the eye is
less able to accommodate and focus on near objects; therefore, the patient will be expected to have
blurring of near vision.
2. A 72-year-old retired truck driver comes to the clinic with his wife for evaluation of hearing loss.
He has noticed some decreased ability to hear what his wife and grandchildren are saying to him. He
admits to lip-reading more. He has a history of noise exposure in his young adult years: He worked as
a sound engineer at a local arena and had to attend a lot of concerts. Based on this information, what
is the most likely finding regarding his hearing acuity?
A) Loss of acuity for middle-range sounds
B) Increase of acuity for low-range sounds
C) Loss of acuity for high-range sounds
D) Increase of acuity for high-range sounds
Ans: A
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Feedback: Human speech is considered to be a middle-range sound. During the aging process there is a
loss of acuity, starting with high-pitched sounds but extending to the middle range and then into the low
range.
3. A 79-year-old retired banker comes to your office for evaluation of difficulty with urination; he
gets up five to six times per night to urinate and has to go at least that often in the daytime. He does
not feel as if his bladder empties completely; the strength of the urinary stream is diminished. He
denies dysuria or hematuria. This problem has been present for several years but has worsened over
the last 8 months. You palpate his prostate. What is your expected physical examination finding,
based on this description?
A) Normal size, smooth
B) Normal size, boggy
C) Enlarged size, smooth
D) Enlarged size, boggy
Ans: C
Feedback: This is the expected physical examination finding in benign prostatic hyperplasia (BPH).
4. A 70-year-old retired auto mechanic comes to your office because his neighbor is concerned about
his memory. The patient himself admits to misplacing his keys more often and forgets what he is
supposed to buy from the grocery store and where he has parked the car. He denies getting lost in
familiar places. Upon further questioning, he states that his wife of 40 years died 8 months ago; his
three children live in three different states; and he has limited his activities because the people he
interacted with were ―his wife's friends, not his.‖ He drinks a six-pack of beer daily; he does not
smoke or use illicit drugs. You perform a mini-mental state examination and obtain a total score of 24
out of 28. Based on this information, what is your most likely diagnosis?
A) Benign forgetfulness
B) Dementia
C) Meningitis
D) Depression
Ans: D
Feedback: The patient has symptoms of depression: His wife died, he has no real social support
system, and he has isolated himself from his usual activities. He also drinks a considerable amount
of alcohol on a daily basis, which can further depress his mood. Depression can masquerade as
dementia in the elderly and must be considered in a patient with memory loss.
5. An 85-year-old retired teacher comes to your office for evaluation of weakness. You obtain a
complete history, perform a thorough physical examination, and order laboratory tests. You diagnose
her with hyperthyroidism. Based on her age, which of the atypical symptoms of hyperthyroidism is
more likely to be seen?
A) Fatigue
B) Weight loss
C) Tachycardia
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D) Anorexia
Ans: D
Feedback: This is an atypical symptom of hyperthyroidism that is more likely to be seen in the older
patient.
6. A 78-year-old retired seamstress comes to the office for a routine check-up. You obtain an ECG
(electrocardiogram) because of her history of hypertension. You diagnose a previous myocardial
infarction and ask her if she had any symptoms related to this. Which of the following symptoms
would be more common in this patient's age group for an acute myocardial infarction?
A) Chest pain
B) Syncope
C) Pain radiating into the left arm
D) Pain radiating into the jaw
Ans: B
Feedback: This is an atypical symptom and more likely to be seen in this patient's age group.
7. An 88-year-old retired piano teacher comes for evaluation of fatigue. You notice that her clothes
are hanging loosely off her frame and that she has lost 15 pounds. She is unaware of this. Her husband
of 63 years died a few months ago. You ask the patient to complete a Rapid Screen for Dietary
Intake. Which of the following statements is considered to be part of this rapid screen?
A) I eat more than two meals per day.
B) I drink one glass of alcohol every day.
C) Without wanting to, I have lost or gained 10 pounds in the last 6 months.
D) I eat with at least one other person most of the time.
Ans: C
Feedback: This is part of the Rapid Screen for Dietary Intake.
8. An 89-year-old retired school principal comes for an annual check-up. She would like to know
whether or not she should undergo a screening colonoscopy. She has never done this before.
Which of the following factors should not be considered when discussing whether she should go
for this screening test?
A) Life expectancy
B) Time interval until benefit from screening accrues
C) Patient preference
D) Current age of patient
Ans: D
Feedback: The current age of the patient is not as important as her actual life expectancy and current
health status.
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9. Which of the following booster immunizations is recommended in the older adult population?
A) Tetanus
B) Diphtheria
C) Measles
D) Mumps
Ans: A
Feedback: Older adults who have received the primary series of three tetanus immunizations should
receive the single booster dose of tetanus immunization every 10 years.
10. You are asked to perform a home safety assessment for an 87-year-old retired farmer who lives
by himself. Which of the following is not considered to be an increased risk for falls?
A) Loose electrical cords
B) Slippery or irregular surfaces
C) Chairs at awkward angles
D) Bright lighting
Ans: D
Feedback: Bright lighting is a recommendation to improve an older person's ability to see all possible
things that could result in a fall.
11. A 73-year-old retired accountant comes to your office for her annual examination. She has
incontinence of urine when she coughs or sneezes. She takes several medications for control of
hypertension and diabetes. You use the DIAPERS mnemonic to assess the cause of her
incontinence. All of the following are items represented by the mnemonic except for:
A) Atrophic vaginitis
B) Depression
C) Pharmaceuticals
D) Restricted mobility
Ans: B
Feedback: Depression is not a risk factor for incontinence. The D in the mnemonic stands for delirium.
12. Which of the following brief screening measures is useful in assessing memory?
A) Three-item recall
B) Serial 7s
C) Spelling ―world‖ backward
D) Copying intersecting pentagrams
Ans: A
Feedback: If the patient is unable to remember three items after 1 minute has passed, then this is a
positive screening test and indicates a need for further testing. This is part of the ―10-Minute
Geriatric Screener.‖
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13. Which of the following questions is part of the screening for physical disability?
A) Are you able to go shopping for groceries or clothes?
B) Are you able to walk one block?
C) Are you able to pass the driver's license test?
D) Are you able to perform light dusting and pick up after yourself around the house?
Ans: A
Feedback: This is part of the Physical Disability screening portion of the 10-Minute Geriatric
Screener.
14. It is summer and an 82-year-old woman is brought to you from her home after seeing her primary
care doctor 2 days ago. She was started on an antibiotic at that time. Today, she comes to the
emergency room not knowing where she is or what year it is. What could be a likely cause of this?
A) Alzheimer's dementia
B) Stroke
C) Delirium
D) Meningitis
Ans: C
Feedback: These are not signs of normal aging and seem to be of acute onset. This makes
Alzheimer's less likely. Stroke and meningitis could cause these symptoms as well, but the
combination of the heat and a recent infection make delirium much more likely. Though she was
prescribed an antibiotic, she may not have improved because of bacterial resistance or because of
noncompliance due to cost, depression, or even an underlying mild dementia. Dementia should not
result in an acute mental status change, although illness may cause a worsening of dementia.
15. Blood pressure abnormalities found more commonly in Western elderly include which of the
following?
A) Isolated elevation of the diastolic BP
B) Narrow pulse pressure
C) Elevation of the systolic BP
D) Elevation of the BP with standing
Ans: C
Feedback: Isolated systolic hypertension is common in the elderly because of stiffening of the large
arteries. This is often accompanied by widening of the pulse pressure. Orthostatic BP changes are
often seen with postural changes and can account for falls as well.
16. Which of the following represents age-related changes in the lungs?
A) Decrease in chest wall compliance
B) Speed of expiration increases
C) Increase in respiratory muscle strength
D) Increased elastic recoil of lung tissue
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Ans: A
Feedback: The lungs age along with the rest of the body. These changes include decreased lung and
chest wall compliance, increased expiratory time, decreased muscle strength and cough, and
decreased elastic recoil.
17. Mrs. Stanton is a 79-year-old widow who presents to your office for a routine BP visit. You note
a new pulsatile mass in the right neck at the carotid artery. Which of the following is the most likely
cause for this?
A) Anxiety
B) Carotid artery aneurysm
C) Kinking of the artery
D) Tortuous aorta
Ans: C
Feedback: While a carotid artery aneurysm is a possibility, it is more likely due to kinking of the
carotid artery in this patient with HTN. A tortuous aorta will sometimes cause elevation of the left
jugular vein by impairing drainage within the thorax.
18. Mr. Chin is an 82-year-old man who comes to your office for a routine check. On examination,
you notice a somewhat high-pitched murmur in the second right intercostal space during systole. It
does not radiate and the rest of his examination is normal for his age. Which is true of the most likely
cause of this murmur?
A) It often decreases carotid upstroke.
B) It carries with it increased risk for cardiovascular disease.
C) It is usually accompanied by an S3 gallop.
D) It is found in 10% of otherwise normal elderly patients.
Ans: B
Feedback: This murmur most likely represents aortic sclerosis, a common murmur affecting about
one third of those near 60 years of age. It is caused by calcification of the valve and is associated
with cardiovascular risk. Aortic sclerosis does not usually cause obstruction to normal flow, so
carotid upstroke should be normal, and it is not associated with an S3 gallop.
19. Mrs. Buckley is a 75-year-old widow who wants you to look at her teeth because over the past
2 weeks she has had right-sided jaw pain when eating. It does not occur otherwise. She also has
had a headache. Which of the following should be considered?
A) Palpation of her temples
B) Dental referral
C) Ultrasound of the gallbladder
D) Inquiry about anosmia
Ans: A
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Feedback: This story can be consistent with temporal arteritis, which can cause blindness in 15% of
those affected. Early recognition is crucial. Most of these patients will have tenderness over one or
both of the temporal arteries, and some have diminished temporal pulses as well.
Early treatment with corticosteroids is indicated. It can also be associated with polymyalgia
rheumatic, a condition which causes pain in the shoulder girdles and pelvis.
20. Which of the following is commonly seen in aging men?
A) Erectile dysfunction in 20% of all men
B) Testicles ride higher within the scrotum
C) Strong response to visual erotic cues
D) Persistent sexual interest
Ans: D
Feedback: Erectile dysfunction affects about half of elderly men but sexual interest generally remains
intact. A decrease in sexual interest may indicate other problems such as depression. Visual cues
become less important and tactile stimulation more important. The testicles are positioned lower in the
scrotum.
21. Which of the following accompanies decreased ovarian function?
A) Increased sleep
B) Diminution of sexual interest
C) Enlargement of the clitoris
D) Decrease in vaginal secretions
Ans: D
Feedback: Menopause, or the cessation of menses for 1 year, commonly occurs in the late 40s to early
50s. Many experience hot flashes, sweating, chills, anxiety, decreased sleep, and urge incontinence.
Dyspareunia is common secondary to decreased vaginal secretions. Sexual interest does not normally
decrease. The clitoris and length of the vaginal vault decrease in response to decreased estrogen.
22. You are examining an elderly man and notice the following: decreased vibration sense in the feet
and ankles, diminished gag reflex, right patellar reflex less than the left, and diminished abdominal
reflexes. Which of these is abnormal?
A) Decreased vibration sense
B) Diminished gag reflex
C) Diminished right patellar reflex compared to the left
D) Diminished abdominal reflexes
Ans: C
Feedback: Asymmetry on any examination is usually reason for concern. The other changes are
commonly associated with aging. You may consider looking for other neurologic signs on the right,
although occasionally you may mistake an abnormally brisk reflex to be normal when
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compared to the other side. It is usually a good idea to question whether the opposite side is actually
the abnormal one when you find asymmetry on examination.
23. Mrs. Glynn is 90 years old and lives alone. She is able to bathe, dress, prepare her food, and
transfer from bed to chair independently. She has children in the area who help her with her
medications and transportation needs. Which of the following is considered an instrumental activity
of daily living?
A) Bathing
B) Dressing
C) Preparing food
D) Transferring from bed to chair
Ans: C
Feedback: Instrumental activities of daily living involve higher thought processes such as preparing
food, whereas bathing, dressing, and transferring are considered physical activities of daily living.
24. Mr. Kelly comes to you today for a burning pain in his lower abdomen. This has gone on for 2
months. He has received radiation for prostatic cancer for the past quarter. What assumptions
could you draw from this?
A) This represents persistent pain.
B) His pain reporting is likely to be unreliable.
C) There are ―red flags‖ present.
D) He is depressed.
Ans: C
Feedback: This scenario is consistent with acute pain, although this may become persistent if it lasts
beyond 3 months. The burning quality to the pain should be a red flag, along with descriptions of
pain as ―discomfort‖ or ―soreness.‖ Depressed affect or changes in posture or gait are also red flags.
Studies have found that pain reporting in the elderly is accurate.
Although depression may be present, we have no indications of it in this scenario.
25. Mr. White's son brings him in today because he notes that Mr. White has not been himself
lately. He seems forgetful and has not taken care of himself as he normally does. He has reported
falling twice at home to his son and has telephoned late at night because of insomnia. His blood
pressure and diabetes have been difficult to control and his warfarin dosing has become more
difficult. Which of the following should you suspect?
A)
B)
C)
D)
Alzheimer's dementia
Alcohol use
Urinary tract infection
Stroke
Ans: B
Feedback: All of these answers are common diseases of the elderly and many have atypical
presentations in this age group. The fact that his hypertension has become more difficult to control
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and his warfarin dosing is challenging to manage should lead you to consider that there is alcohol use.
Further questioning, quantifying his use of alcohol, and application of the CAGE questionnaire may
be useful.
26. Claire's daughter brings her in today after Claire fell at her home. Which assessments are
indicated at this time?
A) Orthostatic vital signs
B) Review of her medications
C) Assessment of gait and balance
D) All of the above
Ans: D
Feedback: Falls are common in the elderly and can often result in serious injuries. When assessing
the cause of falls, gait and balance should be checked first. Medication, particularly use of more than
three, is associated with falls. Vision problems, lower-limb joint problems, and cardiovascular
problems such as arrhythmias may be reasonable to search for. Orthostatic vital sign changes should
be sought.
27. Mrs. Geller is somewhat quiet today. She has several bruises of different colors on the ulnar
aspects of her forearms and on her abdomen. She otherwise has no complaints and her diabetes and
hypertension are well managed. Her son from out of state accompanies her today and has recently
moved in to help her. What should you suspect?
A) Overuse of aspirin
B) Frequent falls
C) Elder abuse
D) Depression
Ans: C
Feedback: The different colors of the bruising indicate that they have occurred at different times and
are unlikely to have resulted from a single fall. The location of the bruising on the ulnar aspects of the
forearms potentially indicates that she was trying to defend herself and are not typical areas to be
bruised by a fall. Depression may be evident, but this is more likely to be a result rather than a cause of
her situation today. While nothing is proven, it would be wise to interview her without her son in the
room. If in doubt, a social worker consult may be helpful to determine if elder abuse is occurring.
28. A patient comes to you for the appearance of red patches on his forearms that have been
present for several months. They remain for several weeks. He denies a history of trauma.
Which of the following is likely?
A) Actinic keratoses
B) Pseudoscars
C) Actinic purpura
D) Cherry angiomas
Ans: C
lOMoARcPSD| 21661070
Feedback: Actinic purpura is a common benign skin condition of the elderly, frequently involving the
forearms. Pseudoscars are white patches and cherry angiomas are bright-red raised lesions usually
found on the torso. Actinic keratoses are lesions resembling nevi, often with features which would be
concerning if considering melanoma (review the ABCDEs of melanoma), but they produce a slightly
greasy scale when scratched with a nail.
29. On routine screening you notice that the cup-to-disc ratio of the patient's right eye is 1:2.
What ocular condition should you suspect?
A) Macular degeneration
B) Diabetic retinopathy
C) Hypertensive retinopathy
D) Glaucoma
Ans: D
Feedback: This cup-to-disc ratio means that the cup takes up 50% of the disc, which is abnormally
large. This is usually an indication of glaucoma, which is a common cause of visual loss in the
elderly. The cup-to-disc changes are not seen in diabetes, hypertension, or macular degeneration.
Many elderly do not have regular eye examinations and are not screened for glaucoma.
30. Which of the following is true of assessment of the vascular system in the elderly?
A) Fewer than one third of patients with peripheral vascular disease have symptoms of
claudication.
B) An aortic width of 2.5 cm is abnormal.
C) Bruits are commonly benign findings.
D) Orthostatic blood pressure and pulse are not useful in this population.
Ans: A
Feedback: It is the minority of patients with peripheral vascular disease who experience claudication;
therefore, ankle–brachial ratios should be performed more frequently. The aorta should be 3 cm or
less. Bruits usually indicate pathology, and even when there is not a significant blockage, the risk of
vascular disease throughout the body is increased. Orthostatic vital signs are very useful in this
population. Remember to observe the pulse as well, as failure of the heart to increase its rate is a
common cause of orthostatic hypotension. This can occur as a result of autonomic neuropathy or
medications such as beta-blockers, among other causes.