Maryville University Nurs 612 Final Exam 4
Nursing (Chamberlain University)
1. Assessing orientation to person, place, and time helps determine
Answer: State of consciousness
2. Under most conditions, adult patients should be able to repeat a series of numbers.
Answer: five to eight
3. Recent memory may be tested by
Answer: showing the patient four items and asking him or her to list the items about 10
minutes later
4. Which condition is considered progressive rather than reversible?
Answer: Dementia
5. An older adult is administered the Set Test and scores a 14. The nurse interprets this score
as indicative of
Answer: dementia
6. Which of the following is usually related to structural diseases of the brain?
Answer: Dementia
7. A state of impaired cognition, consciousness, mood and behavioral dysfunction of acute
onset refers to
Answer: Delirium
8. The mini-mental state examination should be administered for a patient who
Answer: gets lost in her or his neighborhood
9. The mini-mental state examination
Answer: may be used to estimate cognitive changes quantitatively
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10. While interviewing a 70-year-old female clinic patient, she tells you that she takes ginkgo
biloba and St John's wort. You make a short note to check for results of the
Answer: Mini-mental state examination
11. For purpose of examination and communication of physical findings, the breast is divided
into
Answer: four quadrants plus a tail
12. When conducting a clinical breast examination, the examiner should
Answer: Inspect both breasts simultaneously
13. Which breast change is typical after menopause?
Answer: thickening of the inframammary ridge
14. In a woman complaining of a breast lump, it is most important to ask about
Answer: its relationship to menses
15. A 50 year old woman presents as a new patient. which finding in her personal and social
history would increase her risk profile for developing breast cancer?
Answer: nulliparity
16. To begin the clinical breast examination for a man, ask him to
Answer: sit with his arms hanging at his sides.
17. Inspection of the breasts usually begins with the patient in which position?
Answer: Sitting
18. Which finding, found on inspection, is related to fibrotic tissue changes that occur with
breast carcinoma?
Answer: Skin dimpling or retraction
19. Venous patterns on breasts are suggestive of pathology when they are
Answer: unilateral
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20. In a patient with breast cancer, pau d'orange skin is often first evident
Answer: on or around the nipple
21. Recent unilateral inversion of a previously everted nipple suggests
Answer: cancer
22. You are conducting a clinical breast exam for a 30 year old patient. Her breasts are
symmetrical with bilateral, multiple tender masses that are freely moveable with well-defined
borders. You recognize that these symptoms and assessment findings are consistent with
Answer: fibrocystic changes
23. When palpating breast tissue, the examiner should use the at each site.
Answer: finger pads
24. The largest amount of glandular breast tissue lies in the
Answer: upper outer quadrant
25. The tail of spence extends
Answer: into the axillae
26. When examining axillary lymph nodes, the patient's arm is
Answer: flexed at the elbow
27. Lymphatic flow of the breast primarily drains
Answer: radially
28. The greatest concern for breast cancer is when you palpate nodes
Answer: supraclavicular
29. You are performing a clinical breast examination for a 55-year-old woman. While
palpating the supraclavicular area, you suspect that you felt a node. To improve your hooked
technique, you should
Answer: ask the patient to turn her head toward that side
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30. What structures are located at the 5 and 7 o'clock positions of the vaginal orifice and open
onto the sides of the vestibule in the groove between the labia minora and the hymen?
Answer: Bartholin glands
31. Which factor is associated with an increased risk of cervical cancer?
Answer: Early parity
32. The risk of ovarian cancer is increased by a history of
Answer: nulliparity
33. During digital examination of the vagina, the cervix is noted to be positioned posteriorly.
Upon bimanual examination of this woman, you would expect to palpate a(n) uterus.
Answer: Anteverted
34. The presence of cervical motion tenderness may indicate
Answer: pelvic inflammatory disease
35. During a routine vaginal examination, you insert the speculum and visualize the cervix
the cervix projection into the vaginal vault is approximately 5 cm. Upon bimanual
examination, you would expect to find the uterus
Answer: Upon bimanual examination, you would expect to find the uterus to be anteverted
and approximately 8 cm in length.
36. Small, pale yellow, raised, rounded areas are visualized on the surface of the cervix. You
should
Answer: chart this as nabothian cysts
37. The assessment of which structure is not part of the bimanual examination?
Answer: Bladder
38. When a woman is not sexually active, cervical cancer screening should begin
Answer: by age 21 years
39. During a pelvic examination for a postmenopausal woman, you would expect to assess
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Answer: absence of vaginal wall rugation
40. Which of the following is a risk factor for testicular cancer?
Answer: cryptorchidism
41. The most common cancer in young men age 15-30 years is
Answer: testicular
42. Self-examination of the male genitalia
Answer: should be performed while bathing
43. Mr. L has an unusually thick scrotum with edema and pitting. He has a history of cardiac
problems. The appearance of his scrotum is more likely a(n)
Answer: indication of general fluid retention
44. An enlarged, painless testicle in an adolescent or adult may indicate
Answer: a tumor
45. You palpate a soft, slightly tender mass in the right scrotum of a man. You attempt to
reduce the size of the mass, and there is no change in the mass size. Your next assessment
maneuver is to
Answer: transilluminate the mass
46. An adolescent male is being seen for acute onset of left testicular pain. The pain started 3
hours ago. He complains of nausea and denies dysuria and fever. Your prioritized assessment
should be to
Answer: establish absent cremasteric reflex
47. A 12 year old boy says that his left scrotum has a soft swollen mass. The scrotum is not
painful upon palpation. the left inguinal canal is without masses. The mass does
transilluminate with a penlight. This collection of symptoms is consistent with
Answer: hydrocele
48. A cremateric reflex should result in
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Answer: testicle and scrotal rise on the stroked side
49. Which technique is appropriate to detect an inguinal hernia?
Answer: Move your finger upward along the vas deferens
50. Which type of hernia lies within the inguinal canal?
Answer: indirect
51. What structure of the male genitalia travels through the inguinal canal and unites with the
seminal vesicle to form the ejaculatory duct?
Answer: vas deferens
52. A normal vas deferens should feel
Answer: smooth
53. An adolescent male is being seen for acute onset of left testicular pain. The pain started 3
hours ago. He complains of nausea and denies dysuria and fever. Your prioritized assessment
should be to
Answer: establish absent cremasteric reflex
54. The most emergent cause of testicular pain in a young male is
Answer: testicular torsion
55. The most common type of hernia occurring in young males is
Answer: indirect inguinal
56. Percussion of the abdomen begins with establishing
Answer: overall dullness and tympany in all quadrants
57. Before performing an abdominal examination, the examiner should
Answer: have the patient empty his or her bladder
58. When examining a patient with tense abdominal musculature, a helpful technique is to
have the patient
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Answer: flex his or her knees
59. After thorough inspection of the abdomen, the next assessment step is to
Answer: auscultate
60. How long do you auscultate for bowel sounds?
Answer: 5 minutes
61. To assess for liver enlargement in an obese person, you should
Answer: auscultate using the scratch technique
62. Percussion at the right midclavicular line, below the umbilicus, and continuing upward is
the correct technique for locating the
Answer: lower liver border
63. When palpating the abdomen, you should note whether the liver is enlarged in the
Answer: right upper quadrant
64. An examiner can recognize a friction rub in the liver by a sound that is
Answer: high pitched and associated with respirations
65. CVA tenderness might be a sign of
Answer: pyelonephritis
66. The autonomic nervous system coordinates which of the following?
Answer: internal organs of the body
67. The major function of the sympathetic nervous system is to
Answer: orchestrate the stress response
68. The parasympathetic nervous system maintains the day-to-day function of
Answer: digestion
69. The motor cortex of the brain is in the
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Answer: frontal lobe
70. The thalamus is the major integration center for perception of
Answer: pain
71. Which area of the brain is responsible for perceiving sounds and for determining their
source?
Answer: temporal lobe
72. Nerves that arise from the brain rather than the spinal cord are called
Answer: cranial
73. If a patient cannot shrug shoulders against resistance, which cranial nerve requires further
revaluation?
Answer: CN XI spinal accessory
74. Normal changes of the aging brain include
Answer: diminished perception of touch
75. The area of body surface innervated by a particular spinal nerve is called a
Answer: dermatome
76. A neurologic past medical history should include data about
Answer: circulatory problems
77. When assessing superficial pain, touch, vibration, and position perception, you are testing
Answer: sensory function
78. You are examining a patient in the emergency department who has recently sustained
head trauma. To initially assess this patient's neurologic status, you would
Answer: test the six cardinal points of gaze
79. You are initially evaluating the equilibrium of Ms. Q. You ask her to stand with her feet
together and arms at her sides. She loses her balance. Ms. Q has a positive
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Answer: Romberg sign
80. The finger to nose test allows assessment of
Answer: coordination and fine motor function
81. You are performing a two-point discrimination test as part of a well physical examination.
The area with the ability to discern two points in the shortest distance is the
Answer: fingertips
82. As Mr. B enters the room, you observe that his gait is wide based and he staggers from
side to side while swaying his trunk. You would document Mr. B's patterns as
Answer: cerebellar ataxia
83. Deep pressure tests are used mostly for patients who are experiencing
Answer: absent superficial pain sensation
84. To assess a cremasteric reflex, the examiner strokes
Answer: inner thigh and observes whether the testicle and scrotum rise on the stroked side
85. You have asked a patient to close his eyes and identify an object placed in his hand. You
are evaluating
Answer: stereognosis
86. The ability to recognize a number traced on the skin is called
Answer: graphesthesia
87. To assess spinal levels L2 L3 L4 which deep tendon reflex should be tested
Answer: patellar
88. It is especially important to test for ankle clonus if
Answer: deep tendon reflexes are hyperactive
89. Which sign is associated with meningitis and intracranial hemorrhage?
Answer: Nuchal rigidity
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90. When assessing a 17 year old patient for nuchal rigidity, you gently raise his head off the
examination table. He involuntarily flexes his hips and knees. To confirm your suspicions
associated with this positive test result, you would also perform a test for the sign.
Answer: Kernig
91. On a scale of 0-4+ which deep tendon reflex score is appropriate for a finding of clonus in
a patient?
Answer: 4+
92. Cranial nerve XII may be assess in an infant by
Answer: observing the infant suck and swallow
93. A positive Babinski sign is normal until what age?
Answer: 16-24 months
94. Which of the following is a concern rather than an expected finding, in older adults?
Answer: Bilateral pillrolling of the fingers
95. Ipsilateral Horner syndrome indicates a cerebrovascular accident (CVA) occurring in the
Answer: posterior inferior cerebellar artery
96. An acute polyneuropathy the commonly follows a nonspecific infection occurring 10-14
days earlier and that primarily affects the motor and autonomic peripheral nerves in an
ascending pattern is
Answer: Guillain-Barre syndrome
97. The immune system attacks the synaptic junction between the nerve and muscle fibers
blocking acetylcholine receptor sites it
Answer: myasthenia gravis
98. Diabetic peripheral neuropathy will likely produce
Answer: diminished pain sensation
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99. Persons with Parkinson disease have an altered gait that is characterized by
Answer: short shuffling steps
100. A clinical syndrome of intracranial hypertension that mimics brain tumors is
Answer: psudotumor cerebri
101. Classic carpal tunnel syndrome would result in
Answer: reduced abduction of the thumb
102. You note that a child has a positive Gower sign. You know that this indicates generalized
Answer: muscle weakness
103. A tingling sensation radiating from the wrist to the hand on striking the median nerve is a
positive ______ sign.
Answer: Tinel
104. Thrombosis of a leg vein should be suspected if the patient feels calf pain
Answer: on dorsiflexion of the foot
105. Your patient presents with symptoms that lead you to suspect acute appendicitis. Which
assessment finding is least likely to be associated with this condition?
Answer: consistent right lower quadrant pain
106. A patient presents with symptoms that lead you to suspect acute appendicitis. which
assessment finding is least likely to be associated with this condition early in its course?
Answer: Obturator muscle test
107. Your patient is a 48 year old woman with complaints of serve cramping pain in the
abdomen and right flank. Her past medical history includes a history of bladder calculi. You
diagnose her with renal calculi at this time. Which of the following symptoms would you
expect with her diagnosis?
Answer: Abdominal pain on palpation, CVA tenderness, fever, hematuria
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108. A 45 year old laborer presents with low back pain, stating that he pain comes from the
right buttock and shoots down and across the right anterior thigh, down the shin to the ankle.
Which examination finding is considered more indicative of nerve root compression
Answer: Contralateral straight leg raise result
109. A positive straight leg raise test usually indicates
Answer: lumbar nerve root irritation
110. The Thomas test is used to detect
Answer: Flexion contractures of the hip
111. When performing the drawer test, the examiner would place the patient in a supine
position and flex the knee 45-90 degrees, placing the foot flat on the table, and then
Answer: grasp the lower leg with both hands and draw the tibia forward and then backward
112. Which one of the following techniques is used to detect a torn meniscus?
Answer: McMurray test
113. During a football game, a player was struck on the lateral side of the left leg while his
feet were firmly planted. He is complaining of left knee pain. To examine the left knee, you
should initially perform the test.
Answer: valgus stress
114. Anterior cruciate ligament integrity is assessed via the test
Answer: Lachman
