NCLEX Mock Test: Basic Physical Assessment (100 Questions)
Question 1:
A nurse is preparing to assess the peripheral pulses of a client admitted with peripheral vascular disease. Which technique is most appropriate for palpating the dorsalis pedis pulse?
A) Place fingers firmly behind the medial malleolus.
B) Use the thumb to press deeply over the inguinal ligament.
C) Apply light pressure with the fingertips lateral to the extensor tendon of the great toe.
D) Press firmly with the heel of the hand over the popliteal fossa.
Question 2:
While assessing a client’s respiratory status, the nurse observes the client using accessory muscles (sternocleidomastoid and trapezius) to breathe. This finding typically indicates which condition?
A) Normal quiet breathing
B) Increased work of breathing
C) Deep sleep state
D) Effective airway clearance
Question 3:
A nurse is assessing a 70-year-old client’s skin turgor to evaluate hydration status. Which site provides the most reliable information in this age group?
A) Dorsum of the hand
B) Forearm
C) Skin over the sternum or clavicle
D) Lower abdomen
Question 4:
During an abdominal assessment, the nurse auscultates for bowel sounds. What is the correct sequence of assessment techniques for the abdomen?
A) Palpation, Percussion, Auscultation, Inspection
B) Inspection, Palpation, Percussion, Auscultation
C) Inspection, Auscultation, Percussion, Palpation
D)11 Auscultation, Inspection, Palpation, Percussion2
Question 5:
A client admitted with heart failure has gained 2 kg (4.4 lbs) in the past 24 hours. The nurse assesses the client’s lower extremities and presses firmly over the tibia for 5 seconds. An indentation of 6 mm remains after releasing pressure. How should the nurse document this finding?
A) 1+ pitting edema
B) 2+ pitting edema
C) 3+ pitting edema
D) 4+ pitting edema
Question 6:
A nurse is assessing the level of consciousness (LOC) of a client who sustained a head injury. The client opens their eyes only in response to painful stimuli, mumbles incomprehensible sounds, and withdraws from pain. Which Glasgow Coma Scale (GCS) score should the nurse assign?
A) 5
B) 7
C) 9
D) 11
Question 7:
When auscultating the lungs of a client with pneumonia, the nurse hears high-pitched, musical squeaking sounds, predominantly during expiration. How should the nurse document this finding?
A) Crackles (rales)
B) Wheezes
C) Rhonchi
D) Stridor
Question 8:
A nurse is assessing a client’s pupillary response to light. The nurse shines a penlight into the client’s right eye and observes that the right pupil constricts. What is this response called?
A) Consensual light reflex
B) Accommodation
C) Direct light reflex
D) Corneal reflex
Question 9:
During a cardiovascular assessment, the nurse palpates the apical pulse (Point of Maximal Impulse – PMI). Where is the PMI normally located in an adult client?
A) Second intercostal space, right sternal border
B) Fourth intercostal space, left sternal border
C) Fifth intercostal space, left midclavicular line
D) Third intercostal space, left midaxillary line
Question 10:
A nurse is assessing a client’s orientation. Which question best evaluates orientation to ‘place’?
A) “Can you tell me today’s date?”
B) “Do you know why you are here?”
C) “What is your full name?”
D) “Can you tell me where we are right now?”
Question 11:
While inspecting a client’s oral cavity, the nurse observes white, curd-like patches on the tongue and buccal mucosa that can be scraped off, revealing a reddened base. This finding is suggestive of which condition?
A) Leukoplakia
B) Oral candidiasis (thrush)
C) Aphthous ulcers (canker sores)
D) Geographic tongue
Question 12:
A nurse is assessing the capillary refill time on a middle-aged adult client. After pressing on the nail bed, the color returns in 4 seconds. What is the nurse’s interpretation of this finding?
A) Normal capillary refill
B) Brisk capillary refill, indicating hypertension
C) Sluggish capillary refill, potentially indicating decreased perfusion
D) Inconclusive finding, requires reassessment
Question 13:
When percussing the abdomen, the nurse expects to hear which sound predominantly over areas filled with air, such as the stomach and intestines?
A) Dullness
B) Resonance
C) Tympany
D) Flatness
Question 14:
A client reports severe right flank pain radiating to the groin. During percussion over the costovertebral angle (CVA), the client experiences sharp pain. This finding (CVA tenderness) is most commonly associated with which condition?
A) Gastritis
B) Cholecystitis
C) Appendicitis
D) Pyelonephritis (kidney infection)
Question 15:
A nurse is preparing to assess a client’s hearing using the Rinne test. Which piece of equipment is required for this assessment?
A) Stethoscope
B) Tuning fork
C) Ophthalmoscope
D) Penlight
Question 16:
During inspection of a client’s spine, the nurse observes an exaggerated posterior curvature of the thoracic spine. How should this finding be documented?
A) Scoliosis
B) Lordosis
C) Kyphosis
D) Ankylosis
Question 17:
A nurse is assessing the range of motion (ROM) of a client’s shoulder joint. Asking the client to move their arm away from the midline of the body assesses which movement?
A) Flexion
B) Extension
C) Adduction
D) Abduction
Question 18:
While auscultating a client’s heart sounds, the nurse identifies the S1 sound (“lub”). Which cardiac event produces the S1 sound?
A) Closure of the aortic and pulmonic valves
B) Closure of the mitral and tricuspid valves
C) Opening of the mitral and tricuspid valves
D) Rapid ventricular filling
Question 19:
A nurse is assessing a client’s radial pulse and notes that the rhythm is irregular. What is the most appropriate next action?
A) Document the finding as normal for this client.
B) Auscultate the apical pulse for one full minute.
C) Immediately notify the healthcare provider.
D) Reassess the radial pulse using a Doppler device.
Question 20:
During a skin assessment of an immobile client, the nurse observes a localized area of non-blanchable erythema over the sacrum. The skin is intact. How should the nurse stage this pressure injury?
A) Stage 1
B) Stage 2
C) Deep Tissue Injury (DTI)
D) Unstageable
Question 21:
A nurse is using a Snellen chart to assess a client’s visual acuity. The client is standing 20 feet away and can read the line marked “40” with their right eye. How should the nurse document this finding?
A) OD 20/20
B) OS 20/40
C) OD 20/40
D) OU 40/20
Question 22:
When assessing a client’s thyroid gland, the nurse gently palpates the neck. Which finding would require further investigation?
A) Gland ascends with swallowing
B) Smooth, non-tender gland
C) Palpable thrill over the gland
D) Gland is symmetrical
Question 23:
A nurse is assessing the strength of a client’s lower extremities. The nurse asks the client to push their feet against the nurse’s hands (plantar flexion). Which muscle group is being tested?
A) Quadriceps
B) Hamstrings
C) Gastrocnemius and soleus
D) Tibialis anterior
Question 24:
While auscultating a client’s abdomen, the nurse hears loud, gurgling bowel sounds (borborygmi). The client reports having diarrhea. How should the nurse interpret these bowel sounds?
A) Hypoactive
B) Hyperactive
C) Absent
D) Normal
Question 25:
A nurse is assessing a client’s respiratory rate and notes it to be 26 breaths per minute, shallow, and regular. How should the nurse document the respiratory rate terminology?
A) Bradypnea
B) Tachypnea
C) Hyperpnea
D) Apnea
Question 26:
During palpation of a client’s lymph nodes in the neck, the nurse feels enlarged, tender, and mobile nodes. This finding is most suggestive of which condition?
A) Metastatic cancer
B) Chronic infection
C) Acute infection or inflammation
D) Normal finding in adults
Question 27:
A nurse assesses a client’s peripheral pulses and grades the radial pulse as “1+”. What does this grading indicate?
A) Bounding pulse
B) Normal pulse
C) Absent pulse
D) Weak, thready pulse
Question 28:
When assessing a client’s level of consciousness, the nurse notes the client is drowsy but awakens easily to voice and then falls back asleep. How should this level of consciousness be documented?
A) Alert
B) Lethargic
C) Stuporous
D) Comatose
Question 29:
A nurse is assessing a client’s deep tendon reflexes (DTRs) and taps the patellar tendon. The expected normal response is:
A) Plantar flexion of the foot
B) Extension of the lower leg
C) Flexion of the lower leg
D) No response
Question 30:
During inspection of a client’s chest, the nurse observes that the anteroposterior (AP) diameter is approximately equal to the transverse diameter, giving a “barrel chest” appearance. This finding is commonly associated with which chronic condition?
A) Asthma
B) Pneumonia
C) Chronic Obstructive Pulmonary Disease (COPD)
D) Pulmonary embolism
Question 31:
A nurse is assessing a postoperative client’s pain using the Numeric Rating Scale (0-10). The client rates their pain as 8/10. Which characteristic of pain assessment does this represent?
A) Quality
B) Location
C) Intensity
D) Duration
Question 32:
When assessing the Weber test using a tuning fork placed on the midline of the client’s forehead, the client reports hearing the sound equally in both ears. How should the nurse interpret this finding?
A) Conductive hearing loss in the right ear
B) Sensorineural hearing loss in the left ear
C) Normal finding or bilateral symmetrical hearing loss
D) Suggestive of otitis media
Question 33:
A nurse is assessing a dark-skinned client for cyanosis. Which areas should the nurse inspect for the most reliable indication?
A) Sclera and nail beds
B) Palms of hands and soles of feet
C) Oral mucosa and conjunctivae
D) Earlobes and tip of the nose
Question 34:
While auscultating a client’s lung fields, the nurse hears soft, low-pitched sounds primarily during inspiration, heard over most of the peripheral lung fields. How should this breath sound be documented?
A) Bronchial
B) Bronchovesicular
C) Vesicular
D) Tracheal
Question 35:
A nurse is preparing to measure a client’s blood pressure using a manual sphygmomanometer. To ensure accuracy, the cuff bladder width should be approximately what percentage of the circumference of the client’s arm?
A) 20%
B) 40%
C) 60%
D) 80%
Question 36:
During inspection of a client’s abdomen, the nurse observes visible, engorged veins around the umbilicus (caput medusae). This finding is often associated with which underlying condition?
A) Appendicitis
B) Bowel obstruction
C) Portal hypertension (severe liver disease)
D) Gastric ulcer
Question 37:
A nurse asks a client to stand with feet together, arms at the sides, and eyes closed. The nurse observes the client beginning to sway significantly. This assessment is known as the Romberg test and assesses which function?
A) Cerebellar function (coordination)
B) Proprioception (position sense)
C) Cranial nerve function
D) Muscle strength
Question 38:
When percussing over a solid organ, such as the liver, which sound does the nurse expect to hear?
A) Tympany
B) Resonance
C) Hyperresonance
D) Dullness
Question 39:
A nurse is assessing a client’s gait. The client walks with short, shuffling steps, a stooped posture, and minimal arm swing. This type of gait is characteristic of which neurological disorder?
A) Cerebellar ataxia
B) Parkinson’s disease
C) Hemiplegic gait (stroke)
D) Spastic gait (cerebral palsy)
Question 40:
While auscultating a client’s carotid arteries, the nurse hears a blowing or swishing sound. How should this finding be documented?
A) Thrill
B) Murmur
C) Bruit
D) Friction rub
Question 41:
A nurse is assessing a client’s peripheral vision using the confrontation test. What is the primary principle of this test?
A) Comparing the client’s visual acuity to the nurse’s.
B) Assessing the client’s ability to read fine print.
C) Comparing the client’s peripheral visual field to the nurse’s (assuming normal).
D) Testing the client’s pupillary reaction to distant objects.
Question 42:
During palpation of a client’s abdomen, the client experiences pain upon abrupt withdrawal of the nurse’s hand after deep palpation in the right lower quadrant (Blumberg’s sign). This finding suggests:
A) Hepatomegaly
B) Splenomegaly
C) Peritoneal inflammation (e.g., appendicitis)
D) Bowel obstruction
Question 43:
A nurse assesses a client’s temperature using a temporal artery scanner and obtains a reading of 39.0°C (102.2°F). What is the most appropriate initial interpretation of this finding?
A) Hypothermia
B) Normal temperature
C) Fever (pyrexia)
D) Technical error, requires re-measurement
Question 44:
When inspecting the external ear canal of an adult client using an otoscope, how should the nurse manipulate the auricle (pinna)?
A) Pull it down and back
B) Pull it straight back
C) Pull it up and forward
D) Pull it up and back
Question 45:
A nurse is assessing a client’s cranial nerve function. Asking the client to smile, frown, puff out cheeks, and raise eyebrows tests which cranial nerve?
A) CN V (Trigeminal)
B) CN VII (Facial)
C) CN IX (Glossopharyngeal)
D) CN XII (Hypoglossal)
Question 46:
While assessing a client’s respiratory pattern, the nurse observes periods of progressively deeper, faster breathing followed by periods of apnea. This pattern is known as:
A) Kussmaul respirations
B) Biot’s respirations
C) Cheyne-Stokes respirations
D) Tachypnea
Question 47:
A nurse is performing a skin assessment on an older adult client and notes multiple small, flat, brown macules on the dorsum of the hands. The client states they have been there for years. These are likely:
A) Actinic keratoses
B) Senile lentigines (liver spots)
C) Cherry angiomas
D) Skin tags
Question 48:
When assessing a client’s peripheral edema, the nurse notes swelling that is bilateral, soft, and leaves no indentation after pressure. How should this be documented?
A) Pitting edema
B) Brawny edema
C) Lymphedema
D) Non-pitting edema
Question 49:
A nurse is auscultating the heart sounds of a client and hears the S2 sound (“dub”). Which anatomical location is best for hearing the S2 sound most clearly?
A) Apex of the heart
B) Base of the heart (aortic and pulmonic areas)
C) Left lateral sternal border
D) Tricuspid area
Question 50:
A nurse is assessing a client’s pain and asks, “Can you describe what your pain feels like? Is it sharp, dull, aching, burning?” Which characteristic of pain is the nurse assessing?
A) Intensity
B) Location
C) Quality
D) Timing
Question 51:
During inspection of a client’s fingernails, the nurse observes that the angle between the nail base and the skin is greater than 180 degrees, and the nail base feels spongy. This finding is known as clubbing and is associated with:
A) Iron deficiency anemia
B) Chronic hypoxia
C) Acute infection
D) Raynaud’s phenomenon
Question 52:
A nurse is assessing a client’s ability to identify a familiar object placed in their hand with their eyes closed (e.g., a key, coin). This test assesses which sensory function?
A) Graphesthesia
B) Stereognosis
C) Two-point discrimination
D) Proprioception
Question 53:
When auscultating the lungs, the nurse hears discontinuous, high-pitched, short, popping sounds during inspiration that are not cleared by coughing. These sounds are described as:
A) Wheezes
B) Fine crackles (rales)
C) Coarse crackles (rales)
D) Pleural friction rub
Question 54:
A nurse is preparing to take an adult client’s rectal temperature. Which action is essential for client safety and comfort?
A) Insert the thermometer 3 inches into the rectum.
B) Position the client in the prone position.
C) Use a water-soluble lubricant on the thermometer probe.
D) Instruct the client to hold their breath during insertion.
Question 55:
During assessment of a client’s visual fields, the nurse notes bilateral loss of peripheral vision (tunnel vision). This finding can be associated with which condition?
A) Cataracts
B) Macular degeneration
C) Glaucoma
D) Retinal detachment
Question 56:
A nurse palpates a client’s abdomen and notes a firm, rigid, board-like abdomen. This finding is a classic sign of:
A) Constipation
B) Gastric distention
C) Peritonitis
D) Ascites
Question 57:
When assessing a client’s pupillary accommodation, the nurse asks the client to focus on a distant object and then shift focus to an object held close to their nose. What is the expected normal response?
A) Pupils dilate when focusing near.
B) Pupils constrict and eyes converge when focusing near.
C) Only one pupil constricts when focusing near.
D) Eyes diverge when focusing near.
Question 58:
A nurse is assessing a client admitted with dehydration. Which finding would support this diagnosis?
A) Bounding peripheral pulses
B) Distended neck veins
C) Decreased skin turgor
D) Moist mucous membranes
Question 59:
During auscultation of a client’s heart, the nurse hears an extra sound occurring shortly after S2 (“lub-dub-dee”). This sound is best heard at the apex with the bell of the stethoscope and is known as an S3 gallop. In an older adult, this finding often indicates:
A) Normal aging change
B) Athletic heart syndrome
C) Heart failure or fluid overload
D) Aortic stenosis
Question 60:
A nurse is assessing a client’s strength against resistance and grades it as 3/5. What does this grade signify?
A) No muscle contraction detected.
B) Active movement against gravity only.
C) Active movement against gravity and some resistance.
D) Active movement against full resistance (normal).
Question 61:
While inspecting a client’s posterior chest, the nurse asks the client to say “ninety-nine” repeatedly. The nurse feels for vibrations transmitted through the chest wall. This assessment technique is called:
A) Chest excursion
B) Tactile fremitus
C) Egophony
D) Percussion
Question 62:
A nurse is assessing a client’s pedal pulses and is unable to palpate them bilaterally. What is the most appropriate initial action?
A) Document the pulses as absent.
B) Notify the healthcare provider immediately.
C) Use a Doppler ultrasound device to attempt to locate the pulses.
D) Elevate the client’s legs and reassess in 15 minutes.
Question 63:
During percussion of the chest wall over an area of lung consolidation (e.g., pneumonia), which sound would the nurse expect to hear?
A) Resonance
B) Hyperresonance
C) Tympany
D) Dullness
Question 64:
A nurse is assessing a client’s deep tendon reflexes and obtains a hyperactive response with clonus. How would this reflex be graded on a 0-4+ scale?
A) 1+
B) 2+
C) 3+
D) 4+
Question 65:
When assessing a client’s skin temperature, which part of the hand should the nurse use for the most accurate assessment?
A) Fingertips
B) Palm of the hand
C) Dorsal surface (back) of the hand
D) Ulnar surface of the hand
Question 66:
A nurse is assessing a client’s response to pain stimuli. The client stiffens, extends their arms and legs rigidly, and arches their back. This posturing is known as:
A) Flaccid paralysis
B) Decorticate posturing
C) Decerebrate posturing
D) Opisthotonos
Question 67:
While auscultating lung sounds, the nurse asks the client to whisper “one-two-three” repeatedly. The nurse hears the whispered voice clearly and distinctly through the stethoscope over an area of consolidation. This finding is termed:
A) Bronchophony
B) Egophony
C) Whispered pectoriloquy
D) Tactile fremitus
Question 68:
A nurse is assessing a client’s peripheral vascular system. Which finding is most characteristic of chronic arterial insufficiency in the lower extremities?
A) Warm skin, prominent superficial veins
B) Pitting edema, brownish discoloration
C) Thin, shiny skin with hair loss
D) Strong, bounding pedal pulses
Question 69:
During inspection of a client’s gait, the nurse observes that the client’s toes drag with each step, requiring them to lift the leg high (steppage gait). This pattern is often associated with weakness of which muscle group?
A) Quadriceps
B) Hamstrings
C) Gastrocnemius
D) Dorsiflexors (e.g., tibialis anterior)
Question 70:
A nurse is assessing a client’s breath sounds and hears loud, high-pitched, hollow sounds primarily over the trachea and larynx. These are identified as which type of breath sound?
A) Vesicular
B) Bronchovesicular
C) Bronchial (or Tracheal)
D) Adventitious
Question 71:
A nurse is assessing a client’s abdomen and notes a bluish discoloration around the umbilicus (Cullen’s sign). This finding may indicate which serious condition?
A) Bowel obstruction
B) Intra-abdominal bleeding (e.g., pancreatitis, ectopic pregnancy)
C) Ascites
D) Gastric ulcer perforation
Question 72:
When assessing a client’s pulse oximetry, the nurse obtains a reading of 93% on room air. The client appears comfortable with no respiratory distress. What is the nurse’s most appropriate initial action?
A) Apply supplemental oxygen immediately.
B) Document the finding as within normal limits.
C) Encourage the client to take deep breaths and cough, then reassess.
D) Notify the healthcare provider urgently.
Question 73:
A nurse is performing the Allen test before obtaining an arterial blood gas sample from the radial artery. What is the purpose of this test?
A) To assess for nerve damage in the wrist.
B) To measure the pressure in the radial artery.
C) To evaluate the patency of the ulnar artery and collateral circulation.
D) To determine the depth of the radial artery.
Question 74:
During inspection of a client’s mouth, the nurse observes that the uvula deviates to the left side when the client says “Ahh.” This finding suggests potential dysfunction of which cranial nerve?
A) CN V (Trigeminal)
B) CN VII (Facial)
C) CN IX (Glossopharyngeal) or CN X (Vagus)
D) CN XII (Hypoglossal)
Question 75:
A nurse is assessing a client’s respiratory effort and notes that the chest wall sinks in between the ribs during inspiration (intercostal retractions). This finding indicates:
A) Effective gas exchange
B) Relaxed breathing pattern
C) Increased respiratory effort/distress
D) Pleural inflammation
Question 76:
When palpating the thyroid gland from a posterior approach, the nurse asks the client to perform which action to facilitate palpation?
A) Hold their breath
B) Turn their head sharply to the side
C) Swallow sips of water
D) Flex their neck forward
Question 77:
A nurse is assessing a client’s skin and notes a yellowish discoloration of the sclera and skin. How should this finding be documented?
A) Cyanosis
B) Pallor
C) Erythema
D) Jaundice
Question 78:
While auscultating a client’s bowel sounds, the nurse hears no sounds after listening for 2 minutes in the right lower quadrant. What is the nurse’s next appropriate action?
A) Document bowel sounds as absent.
B) Palpate the abdomen firmly to stimulate peristalsis.
C) Listen for a full 5 minutes in each of the four quadrants.
D) Administer a laxative as ordered.
Question 79:
A nurse is assessing a client’s level of orientation. The client correctly states their name and the current year but is unsure of the month or where they are. How should the nurse document this finding?
A) Alert and Oriented x 4 (A&Ox4)
B) Alert and Oriented x 3 (A&Ox3)
C) Alert and Oriented x 2 (A&Ox2)
D) Alert and Oriented x 1 (A&Ox1)
Question 80:
During inspection of a client’s posture, the nurse observes an increased inward curvature of the lumbar spine (swayback). This finding is known as:
A) Kyphosis
B) Scoliosis
C) Lordosis
D) Stenosis
Question 81:
A nurse is assessing a client’s pain using the PQRST method. The client describes the pain as “a constant, dull ache.” This description corresponds to which element of the assessment?
A) P (Provocation/Palliation)
B) Q (Quality)
C) R (Region/Radiation)
D) S (Severity)
Question 82:
When assessing chest expansion (excursion) posteriorly, where should the nurse place their hands?
A) Over the clavicles anteriorly
B) Along the costal margins anteriorly
C) At the level of T9 or T10, pinching a small fold of skin
D) Over the scapulae bilaterally
Question 83:
A nurse assesses a client’s apical pulse rate at 110 beats per minute and the radial pulse rate at 98 beats per minute. What is the client’s pulse deficit?
A) 98 bpm
B) 110 bpm
C) 12 bpm
D) 208 bpm
Question 84:
During palpation of the carotid arteries, what is a crucial precaution the nurse must take?
A) Palpate both arteries simultaneously to compare strength.
B) Apply firm pressure to occlude the artery briefly.
C) Auscultate for bruits before palpating.
D) Palpate only one artery at a time.
Question 85:
A nurse is assessing a client’s range of motion in the hip joint. Asking the client to move their straightened leg backward assesses which movement?
A) Flexion
B) Abduction
C) Internal rotation
D) Hyperextension
Question 86:
While inspecting a client’s skin, the nurse notes a flat, non-palpable change in skin color that is less than 1 cm in diameter (e.g., a freckle). This lesion is termed a:
A) Papule
B) Macule
C) Vesicle
D) Nodule
Question 87:
A nurse is assessing a client’s mental status. Asking the client to interpret a common proverb (e.g., “People in glass houses shouldn’t throw stones”) primarily assesses which cognitive function?
A) Orientation
B) Memory
C) Abstract reasoning
D) Attention span
Question 88:
When auscultating the abdomen, the nurse should begin listening in which quadrant?
A) Right upper quadrant (RUQ)
B) Left upper quadrant (LUQ)
C) Right lower quadrant (RLQ)
D) Left lower quadrant (LLQ)
Question 89:
A nurse is assessing a client’s cranial nerve I (olfactory). Which method is most appropriate for this assessment?
A) Testing the client’s ability to identify different tastes.
B) Observing the client’s ability to follow a moving object with their eyes.
C) Asking the client to identify familiar smells with their eyes closed.
D) Assessing the client’s gag reflex.
Question 90:
A client reports a new onset of a painful, swollen, and red calf. The nurse should immediately assess for which potential complication?
A) Peripheral neuropathy
B) Deep vein thrombosis (DVT)
C) Arterial insufficiency
D) Superficial thrombophlebitis
Question 91:
During a lung assessment, the nurse percusses the anterior chest and notes hyperresonance in the upper lobes bilaterally. This finding is most consistent with which condition?
A) Pneumonia
B) Pleural effusion
C) Emphysema
D) Atelectasis
Question 92:
A nurse is assessing a client’s spine for scoliosis. Which position is best for the nurse to observe the client’s back?
A) Supine with knees flexed
B) Prone with arms at the sides
C) Standing, facing away from the nurse, then bending forward at the waist
D) Sitting upright on the edge of the examination table
Question 93:
When assessing a client’s triceps reflex, where should the nurse strike the tendon?
A) Just below the patella
B) At the wrist
C) Just above the olecranon process
D) In the antecubital fossa
Question 94:
A nurse is assessing a client with heart failure for jugular venous distension (JVD). The nurse should position the client in which way for this assessment?
A) Supine with the head flat
B) Prone with a pillow under the abdomen
C) Semi-Fowler’s (head of bed elevated 30-45 degrees)
D) High-Fowler’s (head of bed elevated 60-90 degrees)
Question 95:
During a skin assessment, the nurse observes multiple small, raised, red lesions with irregular borders. These lesions are itchy. How should the nurse document this finding?
A) Papules
B) Plaques
C) Wheals (urticaria)
D) Vesicles
Question 96:
A nurse is assessing a client’s gait and observes a wide-based, staggering walk. This type of gait is most likely associated with dysfunction of which part of the brain?
A) Frontal lobe
B) Parietal lobe
C) Cerebellum
D) Temporal lobe
Question 97:
When auscultating a client’s lungs, the nurse hears a continuous, low-pitched, snoring sound primarily during expiration. This adventitious breath sound is known as:
A) Wheeze
B) Crackle (rale)
C) Rhonchus
D) Pleural friction rub
Question 98:
A nurse is preparing to assess the Babinski reflex. Which technique is correct for eliciting this reflex?
A) Gently tapping the patellar tendon.
B) Stroking the lateral aspect of the sole of the foot from the heel to the ball, then across the ball of the foot to the great toe.
C) Lightly stroking the skin of the upper abdomen diagonally.
D) Briefly and gently touching the cornea with a wisp of cotton.
Question 99:
A nurse is assessing a client’s nutritional status and observes significant muscle wasting in the extremities. This finding is known as:
A) Cachexia
B) Edema
C) Ascites
D) Jaundice
Question 100:
During a mental status examination, the nurse asks the client to repeat a series of numbers forward and backward. This assesses which cognitive function?
A) Immediate recall and working memory
B) Long-term memory
C) Calculation ability
D) Language comprehension