PART I: MULTIPLE CHOICE QUESTIONS (MCQs) 20 MARKS
1. If you lose sight of the red reflex during the ophthalmoscopic exam:
a. the client has abnormally large sclera
b. the client will complain of pain
c. you have not focused the ophthalmoscope appropriately
d. you are no longer directing the light through the pupil
2. An enlarged lymph node is more likely to be attributable to infection if it is:
a. hard and discrete
b. non tender
c. tender and part of a group of enlarged nodes
d. asymmetrical
3. When describing findings on the retina, what should the examiner use for a landmark?
a. macula
b. arterio-venous crossings
c. optic disc
d. pupil
4. One of the questions a practitioner can ask to assess a client’s perception and knowledge about a healthy diet is:
a. How much vegetables, fruits, and fiber do you include in your diet?
b. Describe what you believe to be a healthy diet?
c. Tell how much of your diet comes from fat?
d. What are your favorite foods?
5. The practitioner is preparing to perform abdominal assessment on Mrs. Taylor. In what order should the assessment be performed?
a. Inspect, palpate, auscultate, and percuss
b. Percuss, inspect, palpate, auscultate
c. Inspect, percuss, auscultate, palpate
d. Inspect, auscultate, percuss, palpate
6. Which interview question will assess a client’s self perception and self concept in relationship with their integumentary system?
a. Is there a history of allergic disorders or skin problems in your family?
b. Do you have any skin pain, itching, burning, stinging, tingling, achiness, tenderness,/numbness?
c. Describe the appearance of your skin, hair, and nails?
d. Does your skin irritation seem to become worse when you experience an increase in stress?
7. A practitioner is preparing to examine a patient’s thyroid gland. While standing behind the patient, how should s/he palpate this gland?
a. Position her right palm over the upper third of the trachea
b. Lightly places her left fingertips over the middle of the trachea
c. Position her fingers on either side of the trachea below the thyroid cartilage
d. Places her right fingertips over the middle of the trachea
8. What auscultatory sound indicates normal bowel sounds?
a. High-pitched, tinkling
b. Rushing, distant
c. Tinkling, growling
d. Gurgling, clicking
9. A practitioner is assessing a client, who is experiencing fatigue, generalized edema, and decreased urination pattern. She notices accumulation of whitish crystals on his skin. How will she record this assessment finding?
a. Uremic crystals
b. Ascetic frost
c. Uremic frost
d. Urea crystallization
10. A practitioner is preparing to auscultate a patient’s renal arteries. In which position should he place the stethoscope?
a. Lower right and left abdominal quadrants
b. Upper right and left abdominal quadrants
c. Middle right and left abdominal quadrants
d. Both upper and lower abdominal quadrants on the right and left sides
11. A key question on activity and exercise to include in a health assessment interview focusing on the cardio-vascular system is:
a. How long do you rest at night and day time?
b. Have you had any leg pain when you walk or do passive exercises?
c. Have you experienced any difficulty in your thought process?
d. Have you had any change in your ability, energy level, and strength to perform activities of daily living?
12. The apex of the heart is normally found in which anatomic location?
a. Right midclavicular line, 2nd intercostal space
b. Left midclavicular line, 5th intercostal space
c. Subxyphoid space
d. Left sterna border, 2nd intercostal space
13. A practitioner is percussing Tony’s Chest. She hears a sound which is indicative of atelectasis or pleural effusion. What sound did the she hear upon percussion?
a. Solid sound
b. Flat sound
c. Dull sound
d. Resonance
14. To assess John’s facial muscle strength, the practitioner asks him to:
a. Close his eyes tightly
b. Hold her eyes open as the nurse tries to shut them
c. Grimace
d. Blow out his cheeks
15. During the health assessment interview, what question should a practitioner ask to determine the cognitive perceptual aspects of the musculoskeletal system?
a. Describe your normal activities for a 24-hour period
b. Describe any musculoskeletal problems that limit your activities of daily living
c. Describe any bone, joint, or muscle pain you are feeling
d. Have any of your family members had osteoporosis, arthritis, tuberculosis or gout?
16. The test that is conducted by placing a tuning fork on a client’s mastoid bone is called the:
a. Rinne test
b. Weber test
c. Whisper test
d. Tophi test
17. In what order should the assessment of the abdomen be performed?
a. Inspect, palpate, auscultate, and percuss
b. Percuss, inspect, palpate, auscultate
c. Inspect, auscultate, percuss, palpate
d. Inspect, percuss, auscultate, palpate
18. Health assessment data:
a. Focuses on objective client information
b. Is the basis for planning and implementing initial and ongoing interventions
c. Is most accurate when performed every 2 hours
d. Needs to be verified by the collaborative team
19. Which statement is true about nursing diagnoses?
a. Nurses can diagnose client health problems and provide interventional therapy based upon physician- directed orders
b. Nurses can client health problems and provide care outside of nursing’s scope of practice in an emergency situation if sound judgment is used
c. Nurses can diagnose health problems both real and potential that the nurse is capable and licensed to treat
d. Nurses can diagnose health problems and direct interventions based upon standing orders
20. Which of the following assessment findings indicates dysfunction of cranial nerve XI?
a. Inability to swallow
b. Horse voice
c. Inability to move the tongue from side to side
d. Inability to shrug shoulders
PART II: SHORT ANSWER QUESTIONS (SAQs) 40 MARKS
1. Why should a practitioner note and respond to non-verbal cues when conducting a health interview? (5 marks)
2. Explain what the findings of either increased or decreased fremitus would indicate (4 marks)
3. Describe the specific features a practitioner would be looking for during an otoscopic examination of the ear (8 marks)
4. Explain how you would perform any four (4) discrimination sensation tests during a neurologic examination of the sensory nervous system? (8 marks)
5. Explain the percussion sounds that can be noted in chest examination (5marks)
6. Explain the three (3) basic percussion techniques (6 marks)
7. State four abnormalities that can be noted on palpation of the integument(4 marks)
PART III: LONG ANSWER QUESTIONS (LAQs) 40 MARKS
1. Describe the classification of murmurs you expect to find upon auscultation of the chest to assess for heart function? (20 marks)
2. Nursing process is a process by which nurses deliver care to patients, supported by nursing models or philosophies. The process has five (5) main characteristics.
a. Describe the characteristics of the nursing process (10 marks)
b. Discuss the application of nursing models in the nursing process (10 marks)
