NUR 216 EXAM 3 QUESTIONS WITH
CORRECT ANSWERS
A cnurse cis cassessing ca cclient's ccranial cnerves. cWhich cof cthe cfollowing cclient cactions cis
can cindication cthat ccranial cnerve c1 cis cintact?
A. cThe cclient ccan cstick ctheir ctongue cout c
B. cThe cclient ccan csmile csymmetrically
C. cThe cclient ccan chear cwhispered cwords
D. cThe cclient ccan cidentify ca cminty cscent c- ccorrect canswers✔✔D. cThe cclient ccan
cidentify ca cminty cscent
Rationale- cCranial cnerve c1, cthe colfactory cnerve, ccontrols cthe csense cof csmell. cTo ctest
cthis cnerve's cfunction, cthe cnurse cshould cask cthe cclient cto cidentify ca cnonirritating caroma,
csuch cas cmint cor ccoffee
A cnurse cis cperforming ca crespiratory cassessment con ca cclient. cThe cnurse causcultates ca
cwet, cpopping csound cupon cinspiration cof cthe cclients cbreathing. cThe cnurse cshould
cidentify cthis cobservation cas cwhich cof cthe cfollowing cfindings?
A. cCrackles
B. cStridor
C. cWheezes
D. cFriction cRub c- ccorrect canswers✔✔A. cCrackles
Rationale- ccrackles, csometimes ccalled crales, care cwet, cpopping csounds ccreated cby cair
cmoving cthrough cliquid cor cby ccollapsed calveoli csnapping copen con cinspiration. cThey care
cmost ccommon cat cthe cend cof cinspiration cof cbreathing.
A cnurse cis cperforming ca ccardiovascular cassessment con ca cclient cwhich cof cthe cfollowing
cfindings cshould cthe cnurse cexpect?
A. cA ccontinuous csensation cof cvibration cfelt cover cthe csecond cand cthird cleft cintercostal
cspaces
B. cA chigh-pitched, cscraping csound cheard cin cthe cthird cintercostal cspace cto cthe cleft cof
cthe csternum
C. cA cbrief cthump cfelt cnear cthe cfourth cor cfifth cintercostal cspace cnear cthe cleft cmid
cclavicular cline
D. cA cwhooshing cor cswishing csound cover cthe csecond cintercostal cspace calong cthe cleft
carsenal cborder c- ccorrect canswers✔✔C. cA cbrief cthump cfelt cnear cthe cfourth cor cfifth
cintercostal cspace cnear cthe cleft cmid cclavicular cline
Rationale- cThis cis cwhere cyou cwould cinspect cand cpalpate cfor cthe cpoint cof cmaximal
cimpulse. cAlso ccalled can capical cpulse cstation, cit coccurs cas cthe cApex cof cthe cheart
cbumps cagainst cthe cchest cwall cwith ceach cheartbeat. cThe capical cimpulse cis cnot calways
cvisible cbut ccan cbe cfelt cas ca cbrief cthump. cThis cis can cexpected cfinding cand cshould cbe
cperformed cwhen cyou care cpreparing cto causcultate cthe capical cpulse.
,The cnurse cis cpreparing cto cperform ca ccomprehensive cphysical cassessment con ca cclient.
cWhich cof cthe cfollowing cactions cshould cthe cnurse cplan cto ctake cfirst?
A. cDocument caccurate cdata
B. cDevelop ca cplan cof ccare
C. cValidate cprevious cdata
D. cEvaluate coutcomes cof ccare c- ccorrect canswers✔✔B. cDevelop ca cplan cof ccare
Rationale- cThe cfirst caction cthe cnurse cshould ctake cusing cthe cnursing cprocess cis cto
cassess cthe cclient cand cdevelop ca cplan cof ccare. cThe cnursing cprocess cfollow cthe csteps
cof cassessment, canalysis, cplanning, cimplementation, cand cevaluation.
A cnurse cis cpalpating ca ctender carea cof ca cclients cabdomen. cThe cnurse cslowly capplies
cpressure cover cthe carea cwith ctheir cfingertips, cthen cquickly creleases cit. cThe cclient
creports cincreased cpain con cthe crelease cof cpressure. cWhich cof cthe cfindings cshould cthe
cnurse cdocument?
A. cBorborygmi
B. cRebound cTenderness
C. cTympany c
D. cAbdominal cGuarding c- ccorrect canswers✔✔B. cRebound cTenderness
Rationale- cThe cnurse cshould cdocument cthat cthe cclient cis cexperiencing crebound
ctenderness, cwhich cis can cincrease cin cpain cwhen cdeep cpalpation cover ca ctender carea cis
creleased. cRebound ctenderness cis cin cthe cright clower cquadrant cat cMcBurney's cpoint
c(one-third cthe cdistance cfrom cthe canterior ciliac ccrest cto cthe cumbilicus) cis can cindication
cof cacute cappendicitis.
A cnurse cis cperforming ca cphysical cexamination cof cthe cspine cfor can colder cadult cclient.
cThe cnurse cshould cidentify cthat cwhich cof cthe cfollowing cfindings cis ccommon cwith caging?
A. cLordosis
B. cKyphosis c
C. cAnkylosis c
D. cScoliosis c- ccorrect canswers✔✔B. cKyphosis c
Rationale- ckyphosis, ca cpronounced c"hunchback" ccurvature cof cthe cspine, cis can
cabnormal cangulation cof cthe cposterior ccurve cof cthe cthoracic cspine, cusually ca cresult cof
costeoporosis. cIt cis cmost ccommon cin colder cadults cand ctends cto cincrease cwith caging.
cThis cpronounced cconvexity cof cthe cthoracic cspine cis calso ccommon cin colder cclients cwho
chave chad cvertebral cfractures.
Disorders cin cwhich cparts cof cthe cear cusually cresult cin cearaches?
A. cInner cand cmiddle cear
B. cInner cand cexternal cear
C. cMiddle cand cexternal cear
D. cTravis cand ceardrum c- ccorrect canswers✔✔B. cInner cand cexternal cear
Eye cdischarge cis cusually cassociated cwith:
A. cHypertension c(HTN)
B. cConjunctivitis c
C. cOtitis cexterna c
, D. cMeibomianitis c- ccorrect canswers✔✔B. cConjunctivitis
Which ctype cof chearing closs cresults cfrom cdisorders cof cthe cinner cear cor cof cthe ceighth
ccranial cnerve?
A. cConductive chearing closs
B. cSensorineural chearing closs
C. cMixed chearing closs
D. cFunctional chearing closs c- ccorrect canswers✔✔B. cSensorineural chearing closs
Which cterm cis cused cto ctest cfor ccorneal csensitivity?
A. cCotton-tipped capplicator
B. cGauze cpad
C. cTissue
D. cWisp cof ccotton c- ccorrect canswers✔✔D. cWisp cof ccotton
What cshould cyou cpalpate cbefore cinserting cthe cotoscope cinto cthe cpatient's cear?
A. cTragus c
B. cLymph cnodes
C. cHelix
D. cEarlobe c- ccorrect canswers✔✔A. cTragus
Which csymptom ccommonly caccompanies cthroat cpain?
A. cEye cpain
B. cEar cpain
C. cHeadache
D. cNasal ccongestion c- ccorrect canswers✔✔B. cEar cpain
If cyour cpatient cpresents cwith csevere cepistaxis, cwhat cis cimportant cfor cyou cto ccheck
cquickly?
A. cTheir chistory
B. cTheir cheight
C. cTheir cweight
D. cTheir cvital csigns c- ccorrect canswers✔✔D. cTheir cvital csigns
What cis cscoliosis? c- ccorrect canswers✔✔A cdeformity ccaused cby ca clateral ccurvature cof
cthe cthoracic cspine. cIt cis ctypically cdetected cin cadolescence. cMild cscoliosis cusually chas
clittle cconsequence, cbut cmore csevere ccurvature ccan crestrict clung cfunction.
What cis cankylosis? c- ccorrect canswers✔✔Immobility cand cconsolidation cof ca cjoint cdue cto
cdisease, cinjury, cor csurgical cprocedures. cThe cstiff cjoint cis coften ca cresult cof ca ccongenital
ccondition cor cscarring.
What cis ckyphosis? c- ccorrect canswers✔✔a cpronounced c"hunchback" ccurvature cof cthe
cspine, cis can cabnormal cangulation cof cthe cposterior ccurve cof cthe cthoracic cspine, cusually
ca cresult cof costeoporosis. cIt cis cmost ccommon cin colder cadults cand ctends cto cincrease
CORRECT ANSWERS
A cnurse cis cassessing ca cclient's ccranial cnerves. cWhich cof cthe cfollowing cclient cactions cis
can cindication cthat ccranial cnerve c1 cis cintact?
A. cThe cclient ccan cstick ctheir ctongue cout c
B. cThe cclient ccan csmile csymmetrically
C. cThe cclient ccan chear cwhispered cwords
D. cThe cclient ccan cidentify ca cminty cscent c- ccorrect canswers✔✔D. cThe cclient ccan
cidentify ca cminty cscent
Rationale- cCranial cnerve c1, cthe colfactory cnerve, ccontrols cthe csense cof csmell. cTo ctest
cthis cnerve's cfunction, cthe cnurse cshould cask cthe cclient cto cidentify ca cnonirritating caroma,
csuch cas cmint cor ccoffee
A cnurse cis cperforming ca crespiratory cassessment con ca cclient. cThe cnurse causcultates ca
cwet, cpopping csound cupon cinspiration cof cthe cclients cbreathing. cThe cnurse cshould
cidentify cthis cobservation cas cwhich cof cthe cfollowing cfindings?
A. cCrackles
B. cStridor
C. cWheezes
D. cFriction cRub c- ccorrect canswers✔✔A. cCrackles
Rationale- ccrackles, csometimes ccalled crales, care cwet, cpopping csounds ccreated cby cair
cmoving cthrough cliquid cor cby ccollapsed calveoli csnapping copen con cinspiration. cThey care
cmost ccommon cat cthe cend cof cinspiration cof cbreathing.
A cnurse cis cperforming ca ccardiovascular cassessment con ca cclient cwhich cof cthe cfollowing
cfindings cshould cthe cnurse cexpect?
A. cA ccontinuous csensation cof cvibration cfelt cover cthe csecond cand cthird cleft cintercostal
cspaces
B. cA chigh-pitched, cscraping csound cheard cin cthe cthird cintercostal cspace cto cthe cleft cof
cthe csternum
C. cA cbrief cthump cfelt cnear cthe cfourth cor cfifth cintercostal cspace cnear cthe cleft cmid
cclavicular cline
D. cA cwhooshing cor cswishing csound cover cthe csecond cintercostal cspace calong cthe cleft
carsenal cborder c- ccorrect canswers✔✔C. cA cbrief cthump cfelt cnear cthe cfourth cor cfifth
cintercostal cspace cnear cthe cleft cmid cclavicular cline
Rationale- cThis cis cwhere cyou cwould cinspect cand cpalpate cfor cthe cpoint cof cmaximal
cimpulse. cAlso ccalled can capical cpulse cstation, cit coccurs cas cthe cApex cof cthe cheart
cbumps cagainst cthe cchest cwall cwith ceach cheartbeat. cThe capical cimpulse cis cnot calways
cvisible cbut ccan cbe cfelt cas ca cbrief cthump. cThis cis can cexpected cfinding cand cshould cbe
cperformed cwhen cyou care cpreparing cto causcultate cthe capical cpulse.
,The cnurse cis cpreparing cto cperform ca ccomprehensive cphysical cassessment con ca cclient.
cWhich cof cthe cfollowing cactions cshould cthe cnurse cplan cto ctake cfirst?
A. cDocument caccurate cdata
B. cDevelop ca cplan cof ccare
C. cValidate cprevious cdata
D. cEvaluate coutcomes cof ccare c- ccorrect canswers✔✔B. cDevelop ca cplan cof ccare
Rationale- cThe cfirst caction cthe cnurse cshould ctake cusing cthe cnursing cprocess cis cto
cassess cthe cclient cand cdevelop ca cplan cof ccare. cThe cnursing cprocess cfollow cthe csteps
cof cassessment, canalysis, cplanning, cimplementation, cand cevaluation.
A cnurse cis cpalpating ca ctender carea cof ca cclients cabdomen. cThe cnurse cslowly capplies
cpressure cover cthe carea cwith ctheir cfingertips, cthen cquickly creleases cit. cThe cclient
creports cincreased cpain con cthe crelease cof cpressure. cWhich cof cthe cfindings cshould cthe
cnurse cdocument?
A. cBorborygmi
B. cRebound cTenderness
C. cTympany c
D. cAbdominal cGuarding c- ccorrect canswers✔✔B. cRebound cTenderness
Rationale- cThe cnurse cshould cdocument cthat cthe cclient cis cexperiencing crebound
ctenderness, cwhich cis can cincrease cin cpain cwhen cdeep cpalpation cover ca ctender carea cis
creleased. cRebound ctenderness cis cin cthe cright clower cquadrant cat cMcBurney's cpoint
c(one-third cthe cdistance cfrom cthe canterior ciliac ccrest cto cthe cumbilicus) cis can cindication
cof cacute cappendicitis.
A cnurse cis cperforming ca cphysical cexamination cof cthe cspine cfor can colder cadult cclient.
cThe cnurse cshould cidentify cthat cwhich cof cthe cfollowing cfindings cis ccommon cwith caging?
A. cLordosis
B. cKyphosis c
C. cAnkylosis c
D. cScoliosis c- ccorrect canswers✔✔B. cKyphosis c
Rationale- ckyphosis, ca cpronounced c"hunchback" ccurvature cof cthe cspine, cis can
cabnormal cangulation cof cthe cposterior ccurve cof cthe cthoracic cspine, cusually ca cresult cof
costeoporosis. cIt cis cmost ccommon cin colder cadults cand ctends cto cincrease cwith caging.
cThis cpronounced cconvexity cof cthe cthoracic cspine cis calso ccommon cin colder cclients cwho
chave chad cvertebral cfractures.
Disorders cin cwhich cparts cof cthe cear cusually cresult cin cearaches?
A. cInner cand cmiddle cear
B. cInner cand cexternal cear
C. cMiddle cand cexternal cear
D. cTravis cand ceardrum c- ccorrect canswers✔✔B. cInner cand cexternal cear
Eye cdischarge cis cusually cassociated cwith:
A. cHypertension c(HTN)
B. cConjunctivitis c
C. cOtitis cexterna c
, D. cMeibomianitis c- ccorrect canswers✔✔B. cConjunctivitis
Which ctype cof chearing closs cresults cfrom cdisorders cof cthe cinner cear cor cof cthe ceighth
ccranial cnerve?
A. cConductive chearing closs
B. cSensorineural chearing closs
C. cMixed chearing closs
D. cFunctional chearing closs c- ccorrect canswers✔✔B. cSensorineural chearing closs
Which cterm cis cused cto ctest cfor ccorneal csensitivity?
A. cCotton-tipped capplicator
B. cGauze cpad
C. cTissue
D. cWisp cof ccotton c- ccorrect canswers✔✔D. cWisp cof ccotton
What cshould cyou cpalpate cbefore cinserting cthe cotoscope cinto cthe cpatient's cear?
A. cTragus c
B. cLymph cnodes
C. cHelix
D. cEarlobe c- ccorrect canswers✔✔A. cTragus
Which csymptom ccommonly caccompanies cthroat cpain?
A. cEye cpain
B. cEar cpain
C. cHeadache
D. cNasal ccongestion c- ccorrect canswers✔✔B. cEar cpain
If cyour cpatient cpresents cwith csevere cepistaxis, cwhat cis cimportant cfor cyou cto ccheck
cquickly?
A. cTheir chistory
B. cTheir cheight
C. cTheir cweight
D. cTheir cvital csigns c- ccorrect canswers✔✔D. cTheir cvital csigns
What cis cscoliosis? c- ccorrect canswers✔✔A cdeformity ccaused cby ca clateral ccurvature cof
cthe cthoracic cspine. cIt cis ctypically cdetected cin cadolescence. cMild cscoliosis cusually chas
clittle cconsequence, cbut cmore csevere ccurvature ccan crestrict clung cfunction.
What cis cankylosis? c- ccorrect canswers✔✔Immobility cand cconsolidation cof ca cjoint cdue cto
cdisease, cinjury, cor csurgical cprocedures. cThe cstiff cjoint cis coften ca cresult cof ca ccongenital
ccondition cor cscarring.
What cis ckyphosis? c- ccorrect canswers✔✔a cpronounced c"hunchback" ccurvature cof cthe
cspine, cis can cabnormal cangulation cof cthe cposterior ccurve cof cthe cthoracic cspine, cusually
ca cresult cof costeoporosis. cIt cis cmost ccommon cin colder cadults cand ctends cto cincrease
