Question

Client reports pain in the right wrist with tingling in the fingers.

Answer 1

Correct Answers

Assess for psoas sign [ Non-essential ]
Perform the Lasègue test [ Non-essential ]
Perform McMurray test [ Non-essential ]
Assess for Rovsing sign [ Non-essential ]
Observe for the flick signal [ Indicated ]
Perform the Tinel sign test [ Indicated ]
Perform the Phalen test [ Indicated ]

Rationale :

✋Wrist pain, finger tingling, weakness, and dropping objects suggest carpal tunnel syndrome caused by median-nerve compression.

⚡A positive Tinel sign reproduces tingling when the median nerve is tapped at the wrist.

🙏The Phalen test reproduces symptoms when the wrists are flexed together, while the flick signal involves shaking the hand to relieve symptoms.

🦵The psoas, Lasègue, McMurray, and Rovsing tests assess abdominal, spinal, or knee conditions unrelated to carpal tunnel syndrome.

📌Core Message:

The flick signal, Tinel test, and Phalen test are appropriate assessments for suspected carpal tunnel syndrome.

Answer 2

Correct Answers:

Poor skin turgor
Thinning hair
Decreased elasticity

Rationale :

👵Aging reduces collagen, elastin, and subcutaneous tissue, causing decreased skin elasticity.

💧Older skin demonstrates poor turgor and can remain tented longer after being pinched.

💇Hair commonly becomes thinner because hair follicles decrease in number and activity.

🛡️These changes increase susceptibility to dryness, bruising, tearing, and pressure injuries.

📌Core Message:

Expected age-related findings include poor turgor, decreased elasticity, dryness, and thinning hair.

Answer 3

Correct Answers:

Client is walking with a tripod cane.
Client has a limp.
Client is alert and oriented x4.

Rationale :

👀Objective data consist of observable or measurable findings obtained during assessment.

🦯The nurse can directly observe the client walking with a tripod cane.

🚶A limp is also visible during gait assessment.

🧠Orientation can be objectively assessed by asking the client questions about person, place, time, and situation.

📌Core Message:

Objective findings are directly observed or measured, whereas pain and dizziness reported by the client are subjective.

Answer 4

Correct Answers:

The nurse advises the client that the lesion should be further evaluated as soon as possible and should initiate a referral.

Rationale :

⚠️A dark lesion with elevation and asymmetrical borders has concerning features of malignant melanoma.

🔍Suspicious lesions are evaluated using the ABCDE criteria: asymmetry, border irregularity, color variation, diameter, and evolution.

🩺Prompt dermatological examination and possible biopsy are necessary for diagnosis.

⏱️Early identification and treatment significantly improve melanoma outcomes.

📌Core Message:

An asymmetric, irregular, dark, and elevated lesion requires prompt referral for evaluation and possible biopsy.

Answer 5

Correct Answers:

Hold and gently pull the pinna of the ear downward and out.

Rationale :

👶In infants and children younger than approximately 3 years, the ear canal is shorter and angled differently than in adults.

👂Pulling the pinna downward and outward helps straighten the external auditory canal.

🔦The otoscope should be inserted gently while the examiner braces the hand against the infant’s head.

🛡️This technique improves visualization while reducing injury from sudden movement.

📌Core Message:

Straighten an infant’s ear canal by gently pulling the pinna downward and outward before otoscopic examination.

Answer 6

Correct Answers:

The client does not remember the details of the accident

Rationale :

🧠Amnesia following a motor vehicle accident can indicate a concussion or traumatic brain injury.

⚠️Changes in memory require immediate neurological assessment because intracranial injury can worsen rapidly.

👀The nurse should assess level of consciousness, pupils, orientation, motor responses, and other neurological changes.

🩻The client may require urgent neuroimaging and ongoing observation.

📌Core Message:

Memory loss after trauma is a neurological warning sign requiring immediate evaluation for traumatic brain injury.

Answer 7

Correct Answers:

Take the blood pressure several minutes after the client has entered the room.

Rationale :

⏱️The client should rest quietly for approximately 5 minutes before blood pressure measurement.

❤️Recent walking, anxiety, talking, caffeine, or exertion can temporarily elevate the reading.

🪑The client should sit with the back supported, feet flat, legs uncrossed, and arm supported at heart level.

📏Correct preparation and cuff sizing improve measurement accuracy.

📌Core Message:

Accurate blood-pressure measurement requires several minutes of rest, correct positioning, and an appropriately sized cuff.

Answer 8

Correct Answers:

Right upper quadrant

Rationale :

🫀Most of the liver lies beneath the right lower ribs in the right upper quadrant.

🥁Percussion moves from areas of lung resonance and intestinal tympany toward liver dullness.

📏The upper and lower borders of dullness can be used to estimate liver span.

⚠️Mononucleosis can cause hepatomegaly, so assessment should be performed gently.

📌Core Message:

Liver dullness is assessed primarily in the right upper quadrant along the right midclavicular line.

Answer 9

Correct Answers:

"Please call for assistance when getting out of bed."

Rationale :

📉The systolic blood pressure decreased by 20 mm Hg after standing, meeting the criterion for orthostatic hypotension.

💫Orthostatic hypotension can cause dizziness, syncope, and falls.

🛡️The immediate nursing priority is preventing injury by assisting the client with position changes and ambulation.

🩺The nurse should also reassess symptoms, review medications, evaluate hydration, and notify the provider as appropriate.

📌Core Message:

A 20-mm Hg postural drop in systolic pressure indicates orthostatic hypotension and requires fall precautions.

Answer 10

Correct Answers:

"Does anything make the pain worse?"

Rationale :

⚡Provocation identifies activities, positions, movements, or factors that worsen pain.

🗣️Asking what makes the pain worse directly assesses this element of the PQRST pain framework.

🔎The nurse should also ask what relieves the pain.

📋The remaining PQRST components include quality, region or radiation, severity, and timing.

📌Core Message:

Pain provocation is assessed by asking what activities, movements, or circumstances make the pain worse.

Assessment test	Indicated	Non-essential
Assess for psoas sign
Perform the Lasègue test
Perform McMurray test
Assess for Rovsing sign
Observe for the flick signal
Perform the Tinel sign test
Perform the Phalen test

1 :
Client reports pain in the right wrist with tingling in the fingers.

4/9 1045

Correct Answers

2 :
A nurse assesses the skin integrity of an older adult. Which finding will the nurse document as an expected finding? Select all that apply.

3 :
The nurse performs an intake interview for a new client. The client is alert and oriented to time, person, and place, has a limp, walks with a tripod cane, and complains of feeling dizzy and having an earache for two days. Which would the nurse identify as objective data? Select all that apply.

4 :
On examining the skin of a 30-year-old lifeguard, the nurse notes a dark black lesion that is elevated and has asymmetrical borders. Which is the nurse's priority action?

5 :
The nurse examines the ear of a 1-month-old infant with an otoscope. What technique should the nurse use?

6 :
30-year-old client was in a motor vehicle accident and is admitted to the emergency department. Which assessment finding is most concerning?

7 :
The nurse prepares to take a blood pressure reading on a client who just arrived at the clinic. What action will the nurse take to obtain the most accurate blood pressure reading?

8 :
During a physical assessment, the nurse percusses the abdomen of a client with Mononucleosis for liver dullness. Where should the nurse percuss?

9 :
The nurse takes an older adult client's vital signs and obtains a blood pressure reading of 130/70 mmHg while the client is in the supine position and 110/65 mmHg when the client is standing. Which response by the nurse is most appropriate?

10 :
A client arrives at the emergency department, gripping their lower leg. Which question is a priority for the nurse to ask to assess pain provocation?

1 : Client reports pain in the right wrist with tingling in the fingers.

4/9 1045

Correct Answers

2 : A nurse assesses the skin integrity of an older adult. Which finding will the nurse document as an expected finding? Select all that apply.

3 : The nurse performs an intake interview for a new client. The client is alert and oriented to time, person, and place, has a limp, walks with a tripod cane, and complains of feeling dizzy and having an earache for two days. Which would the nurse identify as objective data? Select all that apply.

4 : On examining the skin of a 30-year-old lifeguard, the nurse notes a dark black lesion that is elevated and has asymmetrical borders. Which is the nurse's priority action?

5 : The nurse examines the ear of a 1-month-old infant with an otoscope. What technique should the nurse use?

6 : 30-year-old client was in a motor vehicle accident and is admitted to the emergency department. Which assessment finding is most concerning?

7 : The nurse prepares to take a blood pressure reading on a client who just arrived at the clinic. What action will the nurse take to obtain the most accurate blood pressure reading?

8 : During a physical assessment, the nurse percusses the abdomen of a client with Mononucleosis for liver dullness. Where should the nurse percuss?

9 : The nurse takes an older adult client's vital signs and obtains a blood pressure reading of 130/70 mmHg while the client is in the supine position and 110/65 mmHg when the client is standing. Which response by the nurse is most appropriate?

10 : A client arrives at the emergency department, gripping their lower leg. Which question is a priority for the nurse to ask to assess pain provocation?

1 :
Client reports pain in the right wrist with tingling in the fingers.

2 :
A nurse assesses the skin integrity of an older adult. Which finding will the nurse document as an expected finding? Select all that apply.

3 :
The nurse performs an intake interview for a new client. The client is alert and oriented to time, person, and place, has a limp, walks with a tripod cane, and complains of feeling dizzy and having an earache for two days. Which would the nurse identify as objective data? Select all that apply.

4 :
On examining the skin of a 30-year-old lifeguard, the nurse notes a dark black lesion that is elevated and has asymmetrical borders. Which is the nurse's priority action?

5 :
The nurse examines the ear of a 1-month-old infant with an otoscope. What technique should the nurse use?

6 :
30-year-old client was in a motor vehicle accident and is admitted to the emergency department. Which assessment finding is most concerning?

7 :
The nurse prepares to take a blood pressure reading on a client who just arrived at the clinic. What action will the nurse take to obtain the most accurate blood pressure reading?

8 :
During a physical assessment, the nurse percusses the abdomen of a client with Mononucleosis for liver dullness. Where should the nurse percuss?

9 :
The nurse takes an older adult client's vital signs and obtains a blood pressure reading of 130/70 mmHg while the client is in the supine position and 110/65 mmHg when the client is standing. Which response by the nurse is most appropriate?

10 :
A client arrives at the emergency department, gripping their lower leg. Which question is a priority for the nurse to ask to assess pain provocation?