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MCQ’s of Health Assessment –II

By; Zia Ud Din Zeb College of Nursing Timergara Dir Lower

Unit-1 Assessment of the Peripheral Vascular and Musculoskeletal Systems

1. All of the following are the pulses which are 5. A client has a 1+/0-4+ dorsalis pedis pulse
located in a arm EXCEPT? on the right. The lower leg is cool, pale, and
a) Brachial pulse painful. This description is most consistent
b) Radial pulse with:
c) Ulnar pulse a) Venous insufficiency
d) Popliteal b) Arterial insufficiency
c) Thrombophlebitis
2. Which of the following pulse is not located d) Lymphatic insufficiency
in legs?
a) Carotid 6. Evaluation of the texture, moisture, and
b) Popliteal temperature of the skin; hair distribution;
c) Dorsalis Pedis capillary refill; and auscultating for bruits
d) Posterior Tibialis are primarily related to which of the
following assessments?
3. When performing an assessment on a client a) Lymphatic
the nurse notes the presence of an enlarged b) Respiratory
epitrochlear lymph node. The nurse would c) Venous
anticipate finding which of the following on d) Arterial
the assessment?
a) The forearm and hand for infection or 7. The nurse performs Allen's test to assess
inflammation which of the following?
b) The lower legs for injury a) Patency of the radial and ulnar arteries
c) The equality of radial pulse b) Arterial circulation to the lower extremities
d) Capillary refill and temperature of the c) Varicose veins
extremities d) Edema

4. When performing an assessment on a client 8. A client is being evaluated for suspected

the nurse notes the presence of an enlarged thrombosis of a deep leg vein. Which of the
superficial inguinal nodes. The nurse would following is the nurse most likely to note
anticipate finding which of the following on during the assessment?
the assessment? a) Pain in the calf when dorsiflexing the foot
a) The forearm and hand for infection or b) A cool foot with diminished pulses
inflammation c) Increased pain with elevation of the
b) The lower legs for injury extremity
c) The equality of radial pulse d) Decreased hair distribution on the legs
d) Capillary refill and temperature of the
extremities 9. Pain in the calf when dorsiflexing the foot
the test is called which sign?
a) Trendelenburg Test
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b) Manual Compression Test b) Smoking &Diabetes

c) Positive Homan’s Sign c) Increasing age
d) Phalen Test d) all of these

10. Inspection of a person's right hand reveals a 16. Burger's test is used to assess the adequacy
red swollen area. To further assess for of the arterial supply to the __________
infection, you would palpate the: a) Lower limb
a) Inguinal node b) Upper limb
b) Cervical node c) Both a & b
c) Axillary node d) Body trunk
d) Epitrochlear node
17. The examiner wishes to assess for arterial
11. Very deep pitting, indentation last a long deficit in the lower extremities. After raising
time, leg is very swollen is consider grade--- the legs 12" off the table and then having
----- edema. the person sit up and dangle the leg, the
a) 1+ color should return in:
b) 2+ a) 5 seconds or less
c) 3+ b) 10 seconds or less
d) 4+ c) 15 seconds
d) 30 seconds
12. When assessing the characteristics of the
pulse, the nurse notes which of the 18. On inspection of a client's legs, the nurse
following? Select all that apply. has found varicose veins. Which test should
a) Rate the nurse next perform to determine the
b) Rhythm competence of the saphenous vein valves?
c) Symmetry a) Allen test
d) Amplitude b) Trendelenburg test
e) All of the above c) Position change test
d) Ankle-brachial pressure index (ABPI)
13. Positive Homan's sign indicate:
a) Pitting Edema 19. The nurse is reviewing an assessment of a
b) DVT patient's peripheral pulses and notices that
c) Aterial Insuffieciency the documentation states that the radial
d) Carpal Tunnel Syndrom pulses are "2+." The nurse recognizes that
this reading indicates what type of pulse?
14. Rope like, bulging, or contorted veins may a) Bounding
indicate ________ b) Normal
a) Atrophic vein c) Weak
b) Hypertrophic vein d) Absent
c) Varicose veins
d) None of the above 20. The nurse is assessing a patient's pedal
pulses. What anatomical location should be
15. which of the following factors that increase palpated?
your risk of developing peripheral artery a) Behind the knee
disease include ________ b) On the top of the foot
a) High blood pressure c) On the inner aspect of the ankle
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d) On the lateral aspect of the ankle 26. Back of hands together hold for 60 seconds
Tests for carpel tunnel syndrome is called:
21. For how long does a patient need to make a) Tinel's Tests
tight-clenching fist for modified allen's test? b) Phalen's Test
a) 30 seconds c) Ballottement Test
b) 20 seconds d) Allen Test
c) 10 seconds
d) 14 seconds 27. How many thoracic vertebrae are there in a
human body?
22. A nurse performs the Trendelenburg test a) 10
for a client with varicose veins. Which b) 12
action should the nurse take when c) 16
performing this test? d) 20
a) Ensure that the client's legs are over the 28. When nurse ask a patient to place the right
side of the bed arm behind the head ,the nurse is testing
b) Tourniquet should be put on before leg for which ROM?
elevation a) Flexion of elbow
c) Legs should be elevated for 15 seconds b) Internal rotation
d) Have the client stand upright after c) External rotation and abduction of
tourniquet removal shoulder
d) Hyperextension of shoulder
23. The capillary refill time in a healthy
individual adult is normally: 29. Fibrous bands running directly from one
a) 4-5 seconds bone to another that strengthen the joint
b) 7-11 second and help prevent movement in undesirable
c) More than 15 seconds directions are called:
d) Less than 3 seconds a) Bursa.
b) Tendons.
24. Ask the person to hold both hands back to
c) Cartilage.
back while flexing the wrists 90 degrees.
Acute flexion of the wrist for 60 seconds
d) Ligaments.
produces numbness and burning in a
30. The functional units of the musculoskeletal
person with in which disease
system are the:
a) Osteoarthritis
b) Muscle atrophy a) Joints.
c) Carpel Tunnel Syndrome b) Bones.
d) Scoliosis c) Muscles.
d) Tendons
25. There are about how many muscles in a
adult human body? 31. When reviewing the musculoskeletal
a) 302 system, the nurse recalls that
b) 206 hematopoiesis takes place in the:
c) 360 a) Liver.
d) 660 b) Spleen.
c) Kidneys.
d) Bone marrow.
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a) Flexion
32. When performing a musculoskeletal b) Abduction
assessment, the nurse knows that the c) Adduction
correct approach for the examination d) Extension
should be:
a) Proximal to distal. 38. The nurse is performing an assessment on
b) Distal to proximal. an older adult patient and observes the
c) Posterior to anterior. patient has an hunchback increased
d) Anterior to posterior. curvature of the thoracic spine What does
the nurse understand this common finding
33. Choose the muscle that is not a muscle of is known as?
mastication. a) Lordosis
a) Masseter b) Scoliosis
b) Temporalis c) Osteoporosis
c) Medial Pterygoid d) Kyphosis
d) Orbicularis Oculi
39. A woman who is 8 months pregnant
34. Choose the muscle that does not belong to comments that she has noticed a change in
the quadriceps femoris group of the her posture and is having lower back pain.
anterior thigh. The nurse tells her that during pregnancy,
a) Rectus femoris women have a posture shift to compensate
b) Vastus lateralis for the enlarging fetus. This shift in posture
c) Vastus medialis is known as:
d) Biceps femoris a) Lordosis.
b) Scoliosis.
35. Skeletal muscles are: c) Ankylosis.
a) Unsteriated d) Kyphosis.
b) Branched
c) Uninucleated 40. Tap on the medial nerve Positive: They will
d) Voluntary muscles get tingling feeling and pain:
a) Tinel's Tests
36. A patient tells the nurse that, All my life Ive b) Phalen's Test
been called knock knees. The nurse knows c) Ortolani Maneuver
that another term for knock knees is: d) Allis Test
a) Genu varum. 41. Ali, a transcriptionist, reports pain and
burning in her right hand. What assessment
b) Genu valgum.
procedures should you perform next?
c) Pes planus.
a) Trendelenburg and drawer signs
d) Metatarsus adductus.
b) McMurray and Thomas tests
37. A patient tells the nurse that she is having a c) Bulge test and ballottement
hard time bringing her hand to her mouth d) Phalen and Tinel tests
when she eats or tries to brush her teeth. 42. The nurse has completed the
The nurse knows that for her to move her musculoskeletal examination of a patients
hand to her mouth, she must perform knee and has found a positive bulge sign.
which movement? The nurse interprets this finding to indicate:
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a) Irregular bony margins. d) Genu varum

b) Soft-tissue swelling in the joint.
c) Swelling from fluid in the epicondyle. 48. The movement of the forearm to turn the
d) Swelling from fluid in the suprapatellar palm facing upward is called:
pouch. a) Pronation
b) Supination
43. When doing an assessment of the spine of c) Eversion
an older adult, you can expect to see which d) Inversion
variation?
a) Lordosis 49. A patient who has had rheumatoid arthritis
b) Torticollis for years comes to the clinic to ask about
changes in her fingers. The nurse will assess
c) Kyphosis
for signs of what problems?
d) Scoliosis
a) Heberden nodes
44. Which movement involves turning a body b) Bouchard nodules
part around its own axis? c) Swan-neck deformities
a) Flexion d) All of the above
b) Extension
c) Rotation 50. The nurse notices that a woman in an
d) Abduction exercise class is unable to jump rope. The
nurse is aware that to jump rope, ones
45. The patient's muscle tone is hypertonic so shoulder has to be capable of:
the muscles are stiff and the movements a) Inversion.
are awkward. The nurse documents these b) Supination.
findings as c) Protraction.
a) Atony d) Circumduction
b) Tremors
c) Spasticity 51. Which movement involves increasing the
d) Fasciculation angle between two bones?
46. During a neonatal examination, the nurse a) Flexion
notices that the newborn infant has six b) Extension
toes. This finding is documented as: c) Rotation
a) Unidactyly. d) Adduction
b) Syndactyly.
52. When assessing muscle strength, the nurse
c) Polydactyly.
observes that a patient has complete range
d) Multidactyly.
of motion against gravity with full
resistance. What grade of muscle strength
47. When assessing a newborn, you note that
should the nurse record using a 0- to 5-
one knee is lower than the other when the
point scale?
legs are flexed and the heels are together
on the bed. You should correctly document
a) 2
this finding as positive b) 3
a) Ballottement c) 4
b) Thomas Test d) 5
c) Allis sign
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53. To palpate the temporomandibular joint, 59. Which of the following describes the gait
the nurses fingers should be placed in the pattern seen in scissor gait?
depression __________ of the ear. a) Toe walking
a) Distal to the helix b) Crossed leg movements
b) Proximal to the helix c) Limping on one side
c) Anterior to the tragus d) Shuffling steps
d) Posterior to the tragus
60. The ankle joint is the articulation of the
54. Which joint allows for movements in only tibia, fibula, and:
one plane, like bending and straightening? a) Talus.
a) Hinge joint b) Cuboid.
b) Ball and socket joint c) Calcaneus.
c) Pivot joint d) Cuneiform bones.
d) Gliding joint
61. ---------is an abnormal crunching, grinding or
55. The movement of the foot to lift the toes grating sound when a joint with roughened
upward is called: articular surfaces moves.
a) Dorsiflexion a) Muscle cramping
b) Plantar flexion b) Bruits
c) Inversion c) Crepitus
d) Eversion d) Murmur

56. The nurse is checking the range of motion in 62. When assessing the lymphatic system of an
a patient knee and knows that the knee is adult client, the nurse notes that the
capable of which movement(s)? epitrochlear nodes are nonpalpable. What
a) Flexion and extension does this indicate?
b) Supination and pronation a) Lymphedenoma
c) Circumduction b) Atherosclerosis
d) Inversion and eversion c) Possible lymphoma
d) Normal finding
57. The movement of the ankle to turn the sole
of the foot outward is called: 63. On inspection of a client's legs, the nurse
a) Inversion has found varicose veins. Which test should
b) Eversion the nurse next perform to determine the
c) Plantar flexion competence of the saphenous vein valves?
d) Dorsiflexion a) Allen test
b) Trendelenburg test
58. With the arm straight out in front of the c) Position change test
body, drawing a circle in the air with the d) Ankle-brachial pressure index (ABPI)
forefinger represents which movement of
the arm? 64. Which assessment technique is used to
a) Rotation. assess for large amounts of fluid around the
b) Circumduction. patella?
c) Extension. a) Tinel sign
d) Inversion. b) Ballottement Test
c) Phalen test
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d) Berger test

65. "Bow leg" The measure distance between 68. Which assessment technique is used to
knees when ankles are together 2.5 cm assess arterial blood flow in the lower
space: extremities?
a) Genu varum a) Allen's test
b) Osteoporosis b) Homans' sign
c) Genu valgum c) Ankle-brachial index (ABI)
d) Osteoarthritis d) Trendelen burg test

66. . The nurse finds that a patient can flex the 69. During an inspection for checking the
arms when no resistance is applied but is balance gait when a person walk on heel to
unable to flex when the nurse applies light toe it's called ......type of walking?
resistance. The nurse should document the a) Walk on toe
patient's muscle strength as level b) Hopping
a) 0 , None , 0% c) Walk on heel
b) 1 , Trace , 10% d) Tandem walk
c) 2 , Poor , 25%
d) 3, Fair , 50 % 70. The Nurse asses the patient in supine
position, raise his legs to about 45° at the
67. Lateral curvature of the spine with an hip and hold for 2-3 minutes, after two
increase in convexity on the side that is minutes ask the patient to sit up and lower
curved, is seen in which of the following the leg by hanging it off the side of the bed,
abnormal spinal curvatures? this type of test is called?
a) Kyphosis a) Allen’s Test
b) Scoliosis b) Buerger’s Test
c) Lordosis c) Trendelenburg Test
d) Flattening of the lumbar curvature d) Romberg test
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UNIT-2 ASSESSMENT OF MENTAL STATUS & SENSORY NEURO SYSTEM

1. The patient has difficulty identifying

numbers written on his left hand. What is 5. When assessing "Insight" in mental status
this test called? examination, the examiner is evaluating the
A) Stereognosis patient's:
B) Agraphesthesia A) Awareness of current feelings
C) Astereognosis B) Awareness of the examiner's feelings
D) Graphesthesia C) Awareness of one's own illness or
condition
2. Which part of the central nervous system is D) Ability to plan for the future

responsible for coordinating voluntary

6. A person's "Orientation" in mental status
movements and maintaining balance and examination refers to:
posture A) Awareness of one's own thoughts
B) Awareness of time, place, and person
A) Cerebrum
C) Ability to concentrate and sustain
B) Cerebellum attention
C) Medulla Oblongata D) Memory of past experiences
D) Thalamus
7. The primary sensory relay station in the
3. A Nurse Touch the patient face with cotton brain that processes and directs sensory
swab on forehead, cheek, and chin and information to the appropriate areas of the
instruct the patient to clench your teeth.
cortex is the:
Nurse is assessing:
A) Motor function of trigeminal nerves A) Hippocampus
B) Sensory function of trigeminal nerves B) Hypothalamus
C) Both motor and sensory function of
C) Thalamus
trigeminal nerves
D) Amygdala
D) Motor function of facial nerves

8. Which part of the CNS plays a crucial role in

4. Stereognosis is the test always done with
regulating autonomic functions such as
the patient eyes close to assess the:
breathing, heart rate, and blood pressure?
A) Gate and posture
A) Cerebrum
B) Eye site
B) Medulla Oblongata
C) Ability to identify a familiar object by
C) Hypothalamus
touch
D) Pons
D) All of the above
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9. The largest part of the human brain

responsible for voluntary muscle 14. The fluid-filled spaces within the brain that
movement, sensory perception, and higher provide cushioning and support are called:
cognitive functions is the: A) Ventricles
A) Thalamus B) Meninges
B) Cerebellum C) Ganglia
C) Brainstem D) Synapses
D) Cerebrum
15. Which area of the brain is associated with
10. The protective layers that surround and emotions, particularly fear and pleasure
cushion the brain and spinal cord are called: responses?
A) Synapses A) Thalamus
B) Meninges B) Hypothalamus
C) Ventricles C) Amygdala
D) Ganglia D) Hippocampus

11. Which of the following best describes 16. The area of the brain that regulates body
"Cognition" in mental status examination? temperature, hunger, thirst, and other
A) Ability to express emotions homeostatic functions is the:
B) Ability to think abstractly and solve A) Thalamus
problems B) Hypothalamus
C) Motor coordination and balance C) Amygdala
D) Ability to perceive the environment D) Hippocampus
accurately
17. Which part of the CNS is responsible for
12. In mental status examination, the term reflexes and serves as a pathway for
"Perception" refers to: ascending and descending nerve tracts?
A) Recognition of familiar faces A) Cerebrum
B) Interpretation of sensory stimuli B) Spinal Cord
C) Ability to plan and execute tasks C) Brainstem
D) Ability to concentrate and sustain D) Cerebellum
attention
18. The area of the brainstem that plays a role
13. Which structure connects the two in sleep, arousal, and attention is the:
hemispheres of the cerebrum and facilitates A) Medulla Oblongata
communication between them? B) Pons
A) Corpus Callosum C) Midbrain
B) Medulla Oblongata D) Reticular Formation
C) Pons
D) Amygdala
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19. Which structure is responsible for D) Effector organs to CNS

producing cerebrospinal fluid (CSF) in the
central nervous system? 17. Which of the following parts of the brain
A) Corpus Callosum
controls the body temperature and urge of
B) Choroid Plexus
C) Cerebellum eating?
D) Thalamus
A) Thalamus

20. The region of the brain involved in the B) Cerebellum

formation of new memories and spatial
navigation is the: C) Pons
A) Hippocampus
B) Amygdala D) Hypothalamus
C) Hypothalamus
D) Pons 18. Which cranial nerve is responsible for
vision?
21. Which part of the CNS is responsible for
relaying motor and sensory signals between A) Cranial Nerve II (Optic)
the cerebral cortex and the peripheral B) Cranial Nerve V (Trigeminal)
nervous system? C) Cranial Nerve VII (Facial)
A) Spinal Cord D) Cranial Nerve X (Vagus)
B) Cerebellum
19. The cranial nerve responsible for taste
C) Medulla Oblongata
sensation on the anterior two-thirds of the
D) Pons
tongue is:

22. The region of the brainstem that helps A) Cranial Nerve V (Trigeminal)
control breathing and other autonomic B) Cranial Nerve VII (Facial)
functions is the: C) Cranial Nerve IX (Glossopharyngeal)
A) Pons D) Cranial Nerve XII (Hypoglossal)
B) Midbrain
C) Reticular Formation 20. Which cranial nerve is responsible for
D) Medulla Oblongata controlling the muscles of mastication
(chewing)?
23. Afferent neurons carry nerve impulses from
A) Cranial Nerve III (Oculomotor)
A) CNS to muscles B) Cranial Nerve V (Trigeminal)
C) Cranial Nerve IX (Glossopharyngeal)
B) CNS to receptors D) Cranial Nerve XI (Accessory)

C) Receptors to CNS 21. The cranial nerve that controls movements

of the eyeball and constriction of the pupil is:
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A) Cranial Nerve III (Oculomotor) D) Cranial Nerve VIII (Vestibulocochlear)

B) Cranial Nerve IV (Trochlear)
C) Cranial Nerve VI (Abducent) 27. The cranial nerve involved in the sensation
D) Cranial Nerve VIII (Vestibulocochlear) of the face and the motor functions for chewing
is:
22. Cranial Nerve responsible for the sense of
hearing and balance is: A) Cranial Nerve V (Trigeminal)
B) Cranial Nerve VII (Facial)
A) Cranial Nerve V (Trigeminal) C) Cranial Nerve IX (Glossopharyngeal)
B) Cranial Nerve VII (Facial) D) Cranial Nerve XI (Accessory)
C) Cranial Nerve VIII (Vestibulocochlear)
D) Cranial Nerve X (Vagus) 28. The cranial nerve responsible for controlling
the muscles of the soft palate and throat is:
23. Which cranial nerve is involved in
controlling the muscles of facial expression? A) Cranial Nerve IX (Glossopharyngeal)
B) Cranial Nerve X (Vagus)
A) Cranial Nerve VII (Facial) C) Cranial Nerve XI (Accessory)
B) Cranial Nerve IX (Glossopharyngeal) D) Cranial Nerve XII (Hypoglossal)
C) Cranial Nerve X (Vagus)
D) Cranial Nerve XII (Hypoglossal) 29. Which cranial nerve is responsible for
controlling the muscles that turn the head and
24. The cranial nerve responsible for controlling shrug the shoulders?
the muscles of the tongue is:
A) Cranial Nerve IX (Glossopharyngeal)
A) Cranial Nerve IX (Glossopharyngeal) B) Cranial Nerve X (Vagus)
B) Cranial Nerve X (Vagus) C) Cranial Nerve XI (Accessory)
C) Cranial Nerve XI (Accessory) D) Cranial Nerve XII (Hypoglossal)
D) Cranial Nerve XII (Hypoglossal)
30. The cranial nerve responsible for controlling
25. Which cranial nerve is involved in the sense the muscles that move the eyes downward and
of smell? inward is:

A) Cranial Nerve I (Olfactory) A) Cranial Nerve III (Oculomotor)

B) Cranial Nerve III (Oculomotor) B) Cranial Nerve IV (Trochlear)
C) Cranial Nerve V (Trigeminal) C) Cranial Nerve VI (Abducent)
D) Cranial Nerve VII (Facial) D) Cranial Nerve VIII (Vestibulocochlear)

26. The cranial nerve responsible for controlling 31. Cranial Nerve involved in the gag reflex and
the muscles that move the eyes is: swallowing is:

A) Cranial Nerve III (Oculomotor) A) Cranial Nerve IX (Glossopharyngeal)

B) Cranial Nerve IV (Trochlear) B) Cranial Nerve X (Vagus)
C) Cranial Nerve VI (Abducent) C) Cranial Nerve XI (Accessory)
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D) Cranial Nerve XII (Hypoglossal) 37. A mental status examination includes an

assessment of memory. Which type of memory
32. The cranial nerve responsible for controlling
is typically assessed by asking the patient to
the muscles that move the tongue is:
recall recent events?
A) Cranial Nerve IX (Glossopharyngeal)
A) Immediate memory
B) Cranial Nerve X (Vagus)
B) Short-term memory
C) Cranial Nerve XI (Accessory)
C) Long-term memory
D) Cranial Nerve XII (Hypoglossal)
D) Remote memory
33. Which component of mental status
38. When assessing "Judgment" in mental
examination assesses a person's general
status examination, the examiner is primarily
appearance, behavior, and cooperation?
interested in:
A) Affect
A) Ability to remember past events
B) Appearance
B) Ability to plan for the future
C) Thought Process
C) Ability to concentrate and sustain
D) Perception
attention
34. The term "Affect" in mental status D) Ability to express emotions
examination refers to:
39. Which term refers to an involuntary
A) Overall presentation repetition of thoughts, words, or phrases?
B) Mood and feelings A) Obsession
C) Thought content B) Compulsion
D) Thought process C) Circumstantiality
D) Palilalia
35. When assessing a person's thought process,
the examiner is primarily concerned with:
40. In mental status examination, the term
A) Content of thoughts "Circumstantiality" is associated with:
B) Flow and organization of thoughts A) Repetition of thoughts
C) Specific beliefs or ideas B) Repetition of words
D) Memories and perceptions C) Excessive detail and delay in reaching
the point
36. Which term refers to a false belief that is D) Lack of inhibition
firmly held despite clear evidence to the
contrary? 41. Which term describes a rapid shift of ideas
with only superficial connections between
A) Obsession
them?
B) Compulsion
A) Flight of ideas
C) Delusion
B) Poverty of thought
D) Phobia
C) Tangentiality
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D) Blocking C) Ability to identify a familiar object by

touch
42. When assessing "Insight" in mental status D) All of the above
examination, the examiner is evaluating the
47. A Nurse Touch the patient face with cotton
patient's:
swab on forehead, cheek, and chin and instruct
A) Awareness of current feelings
the patient to clench your teeth. Nurse is
B) Awareness of the examiner's feelings
assessing:
C) Awareness of one's own illness or
condition A) Motor function of trigeminal nerves
D) Ability to plan for the future B) Sensory function of trigeminal nerves
C) Both motor and sensory function of
43. The term "Echolalia" refers to: trigeminal nerves
D) Motor function of facial nerves
A) Repetition of one's own words
B) Repetition of others' words 48. During History taking nurse assess memory
C) Rapid speech with a pressured rhythm of a patient she ask a question, When you
celebrate your birthday? Nurse purpose is to
D) Paucity of speech
assess:
44. When assessing "Abstraction" in mental
A) Recent memory
status examination, the examiner is evaluating B) Remote memory
the patient's ability to: C) Immediate memory
D) All of the above
A) Recognize familiar objects
B) Think in concrete terms 49. Glasgow Coma Scale (GCS) is a measure of;
C) Think in abstract terms and understand A) Level of consciousness
proverbs B) Memory
D) Perceive sensory stimuli C) Intra cranial pressure
D) Fluid volume
45. While assessing vibration sense Nurse
should Place stem of tuning fork which of the 50. Nurse sohail asked the patient to repeat the
following part of patient body: series counting backwards from 100 by 3's he
performed which of the following;
A) On face
A) Memory test
B) Against bony prominences
B) Attention test
C) Directly on abdomen
C) Judgment test
D) Non of the above D) Insight test
46. Stereognosis is the test always done with 51. A patient is able to list five month's
the patient eyes close to assess the: backwards but unable to repeat five digits span
forward and backward which type of memory is
A) Gate and posture affected?
B) Eye site
A) Recent memory
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B) Remote memory C) Cognitive function

C) Immediate memory D) Coordination
D) Long term memory
57. When examining a patients general
52. The Digit Span test is part of which aspect
appearance and behavior—look at:
of a mental status examination?
A) Appearance and behavior A) Facial expressions and orientation to
B) Thought place
C) Cognition B) How they are sitting and facial
D) Mood and affect expressions
C) Grooming and orientation to time
53. Which of the following is not a component D) Facial expressions and object
of the cerebellar examination? identification
A) Coordination
B) Balance
58. Of the following, which one is not one of
C) Fine coordination
the functions assessed in the Glasgow Coma
D) Motor activity integration
Scale.
54. What is the function of the cerebellum? A) Eye opening
A) Body control and coordination B) Verbal response
B) Integration of voluntary movement: C) Motor response
posture, balance, coordination D) Pain response
C) Involuntary control of internal
environment 59. Pick the test that you could used on your
D) Comprehension of written words and patient when assessing cerebellar
symbols coordination.
A) Back bends
55. Which of the following is not a chief
B) Tandem walking
complaint for patients with neurological
C) Touching toes
disorders?
D) None
A) Seizures
B) Nausea
60. How do you facilitate a Romberg’s test?
C) Pain
A) Client touches finger to nose, finger-
D) Weakness or paresthesia
finger
B) Client stands on one foot, puts arms
56. Which of the following is the most sensitive
above head, and does one knee bend
indicator of changes in the neurological
C) Client stands with feet together,
status of patients with neurological
hands at sides and eyes closed
disorders?
D) Client sits on chair and then tries to
A) LOC
stand back up
B) Orientation
15

61. True of false a + Romberg’s test is 65. Which of the following is not a risk factor
pathological? for acquiring stroke/ CVA
A) True A) HTN
B) False B) Hyperlipidemia
C) Contraceptive use
62. Which of the following is a major role of the D) Being over 55
central nervous system?
A) Involuntary control of internal 66. When should cranial nerves be assessed in
environment the physical examination?
B) Personality and strength A) Peripheral vascular
C) Body control and coordination B) Musculoskeletal
D) Fight or flight C) Head and Neck
D) Integumentary
63. Which of the following gait disturbances
does not match with their clinical 67. The parasympathetic system is a fight or
manifestations? flight response.
A) Spastic hemiparesis: arm flexed, close A) True
to side B) False
B) Parkinsons’: stooped, hips, knees
flexed; short shuffling steps 68. The largest part of the human brain is;
C) Cerebellar ataxia: staggering, unsteady, A) Medulla oblongata
wide based B) Cerebrum
D) Scissor gait: paralysis of the lower foot C) Cerebellum
E) Steppage gait: feet lifted high, slapped D) Pons
down
69. Total number of cranial nerves are;
64. Which test is the most effective when A) 31
testing arousability? B) 12
A) Testing the patients orientation to C) 11
person, place, and time D) 7
B) Pouring ice cold water into the patients
ear 70. Afferent neurons carry nerve impulses
C) Screaming into the patients left ear for from;
six seconds A) CNS to muscles
D) Applying a painful (noxious) stimulus B) CNS to receptors
to the nail bed C) Receptors to CNS
D) Effector organs to CNS
16

UNIT-3 ASSESSMENT OF CVS

1. Where is the tricuspid valve best heard? d) Tricuspid and aortic valves
a) Second intercostal space, right sternal
border 6. What is the cause of the splitting of S2
b) Fourth intercostal space, left sternal heart sound?
border a) Aortic stenosis
c) Fifth intercostal space, midclavicular b) Pulmonary stenosis
line c) Atrial septal defect
d) Apex, fifth intercostal space, left d) Mitral regurgitation
midclavicular line
7. Where is the aortic valve best heard?
2. Which valve closure is associated with the a) Fifth intercostal space, midclavicular
"lub" sound in the heart? line
a) Aortic valve closure b) Second intercostal space, right sternal
b) Pulmonary valve closure border
c) Mitral valve opening c) Fourth intercostal space, left sternal
d) Tricuspid valve closure border
d) Apex, fifth intercostal space, left
3. The "dub" sound in the heart is associated midclavicular line
with the closure of which valve?
a) Aortic valve 8. A fixed split S2 heart sound is characteristic
b) Mitral valve of:
c) Tricuspid valve a) Atrial septal defect
d) None b) Pulmonary stenosis
c) Mitral regurgitation
4. The S1 heart sound is best heard at the: d) Aortic regurgitation
a) Apex
b) Second intercostal space, right sternal 9. Which of the following conditions is
border associated with a mid-systolic click?
c) Base a) Mitral stenosis
d) Third intercostal space, left sternal b) Aortic stenosis
border c) Mitral regurgitation
d) Mitral valve prolapsed
5. The S2 heart sound corresponds to the
closure of which valves? 10. The diastolic rumble is a characteristic
a) Mitral and tricuspid valves finding in:
b) Aortic and pulmonary valves a) Aortic regurgitation
c) Pulmonary and mitral valves b) Mitral stenosis
17

c) Pulmonary stenosis b) Digestion

d) Atrial septal defect c) Circulation
d) Excretion
11. The pericardial friction rub is best heard:
a) During systole 17. Which chamber of the heart pumps
b) During diastole oxygenated blood to the rest of the body?
c) Throughout the cardiac cycle a) Left atrium
d) With the patient holding their breath b) Right atrium
c) Left ventricle
12. A harsh, blowing holosystolic murmur is d) Right ventricle
indicative of:
a) Aortic stenosis 18. The "lub-dub" sound of the heartbeat
b) Mitral regurgitation corresponds to which cardiac events,
c) Pulmonary stenosis respectively?
d) Tricuspid regurgitation a) Closure of semilunar valves; closure of
atrioventricular valves
13. The best position to hear a mitral stenosis b) Closure of atrioventricular valves;
murmur is: closure of semilunar valves
a) Supine c) Contraction of atria; contraction of
b) Left lateral decubitus ventricles
c) Sitting forward d) Contraction of ventricles; relaxation of
d) Standing ventricles

14. The murmur of aortic regurgitation is best 19. Which vessel carries deoxygenated blood
heard: from the body to the right atrium?
a) At the apex a) Pulmonary artery
b) At the left sternal border b) Pulmonary vein
c) At the base c) Aorta
d) At the right sternal border d) Superior vena cava

15. Which valvular lesion is associated with a 20. What is the normal range for blood
blowing, decrescendo diastolic murmur? pressure in adults?
a) Aortic stenosis a) 80/40 mmHg
b) Mitral regurgitation b) 120/80 mmHg
c) Pulmonary stenosis c) 160/100 mmHg
d) Tricuspid regurgitation d) 200/120 mmHg

16. What is the primary function of the 21. Which condition is characterized by a rapid
cardiovascular system? heartbeat?
a) Respiration a) Bradycardia
18

b) Tachycardia a) Left atrium

c) Arrhythmia b) Right atrium
d) Hypertension c) Left ventricle
d) Right ventricle
22. What is the term for the accumulation of
fatty deposits on arterial walls? 28. The heart's Primary pacemaker is located in
a) Atherosclerosis which part of the heart?
b) Thrombosis a) Aorta
c) Embolism b) Left ventricle
d) Ischemia c) Right atrium
d) AV node
23. Which of the following is a modifiable risk
factor for cardiovascular disease? 29. What is the purpose of heart valves?
a) Age a) Regulate blood pressure
b) Gender b) Prevent backflow of blood
c) Smoking c) Produce red blood cells
d) Genetics d) Control heart rate

24. What is the purpose of an 30. Which blood vessels carry oxygenated
electrocardiogram (ECG or EKG)? blood away from the heart?
a) Measure blood pressure a) Arteries
b) Assess cholesterol levels b) Veins
c) Record electrical activity of the heart c) Capillaries
d) Monitor respiratory rate d) Venules

25. Which of the following is a symptom of 31. What is the name of the largest artery in
angina pectoris? the body?
a) Chest pain or discomfort a) Pulmonary artery
b) Persistent cough b) Aorta
c) Joint pain c) Coronary artery
d) Blurred vision d) Brachial artery

26. What is the primary function of the heart? 32. Which of the following is responsible for the
a) Pumping blood lub-dub sound of the heart?
b) Digesting food a) Atrioventricular valves
c) Filtering toxins b) Pulmonary artery
d) Storing nutrients c) Papillary muscles
d) Chordae tendineae
27. Which chamber of the heart receives
oxygenated blood from the lungs? 33. Where is the tricuspid valve located?
19

a) Between the left atrium and left

ventricle 39. Stenosis of the bicuspid valve may initially
b) Between the right atrium and right cause an increase of pressure in the:
ventricle a) Superior and inferior vana cava
c) Between the aorta and the left ventricle b) Left ventricle
d) Between the pulmonary artery and the c) Right ventricle
right ventricle d) Pulmonary circuit
e) Cronary circuit
34. Which coronary vessel supplies blood to the
front part of the heart? 40. While assessing CVS, assess pulse for all of
a) Left anterior descending artery the following except?
b) Circumflex artery a) Rate
c) Right coronary artery b) Rhythm
d) Posterior descending artery c) Color
d) Quality
35. What is the term for the period of
relaxation when the heart fills with blood? 41. Most appropriate site for taking pulse less
a) Systole than one year is;
b) Diastole a) Radial
c) Contraction b) Apical
d) Ejection c) Femoral
d) Popliteal
36. What is a modifiable cardiac risk factor?
a) Age 42. Bradycardia is most common in which of
b) Gender the following sge group;
c) Family history a) Pediatric
d) Diet b) Teenage
c) Middle Age
37. On a normal ECG ventricular depolarization d) Geriatric
occurs during the;
a) P wave 43. Refer to pulse scale “0 to 4+” Nurse Sobia
b) QRS Complex documented a pulse quality of “2+” which
c) P-Q interval means?
d) S-T segment a) Thready pulse
b) Normal pulse
38. S3 is also Called: c) Bounding pulse
a) Murmur d) Weak pulse
b) Ventricular gallop
c) Opening snap
d) Ejection click
20

44. ------- measures the electrical impulse that d) Midclavicular line,4th intercostals space
causes atrial depolarization and mechanical
contraction. 48. Which one of the following heart sound is
a) P- Wave pathologic?
b) QRS-Complex a) Ejection click
c) T-Wave b) Whoop
d) ST-Segment c) S3
d) Both a & b
45. All of the following are the characteristics of
arterial insufficiency except? 49. ----- is a Creaking sound heard with
a) Skin cool, shiny, thin pericardial inflammation and louder with
b) Pain and cold inspiration.
c) Distal pulse weak or absent a) Murmur
d) Increase hair growth in the area b) S3
46. Which one of the following is true regarding c) Whoop
normal heart rate of infant? d) Friction Rub
a) 60-100
b) 60-110 50. Which of the following is true regarding
c) 30-70 heart murmur?
d) 80-160 a) Diastolic murmurs almost always
indicate pathology.
47. Nurse Hefsah is assessing CVS of a 50 years b) A systolic murmur is present between
old male patient, she understand that the S1 and S2
most accurate site for auscultation of c) A diastolic murmur is present between
pulmonary valve is? S2 and S1
a) Right sternal border,2nd intercostal d) A continuous murmur is present in
space systole and diastole
b) Left sternal border,2nd intercostals e) All of the above
space
c) Left sternal border, 5th intercostals
space
21

UNIT-4 ASSESSMENT OF THORAX & LUNGS

C. Epiglottis
1. There are how many pairs of ribs total? D. Corniculate
A. 7
B. 3 7. The maximum amount of the air a person can
C. 2 exhale after taking the deepest breath possible
D. 12 is called _____.
A. Total lung capacity
2. The trachea splits at the ___ to form the B. Inspiratory reserve volume
____. C. Vital capacity
A. Cricoid cartilage, secondary bronchi D. Expiratory reserve volume
B. Thyroid cartilage, primary bronchi
C. Carina, primary bronchi 8. Difficulty in breathing is termed as:
D. Hilum, secondary bronchi A. Dyspnea
B. Apnea
3. Which of the following is not part of the C. Insomnia
upper respiratory system? D. Hypoxia
A. Nose
B. Oral cavity 9. A deficiency of oxygen at the tissue level is
C. Pharynx called:
D. Trachea A. Hypoxia
B. Hypocapnia
4. Which of the following describes a correct C. Myxodema
order of structures in the respiratory passage D. Bradycardia
way?
A. Pharynx, trachea, larynx, bronchi, 10. The sternum the breast bone has 3 parts
bronchioles A. Intercostal, manubrium, the body, and
B. Larynx, pharynx, trachea, bronchioles, the xiphoid process
bronchi B. Manubrium, the body, and the xiphoid
C. Trachea, pharynx, larynx, bronchi, process
bronchioles C. Manubrium, body, clavicle
D. Pharynx, larynx, trachea, bronchi, D. The scalenun, body, xiphoid
bronchioles
11. Which of the following terms refers to
5. Which of the following is a common difficulty breathing in supine or recumbent
passageway for air, food and water? position?
A. Pharynx A. Central Apnea
B. Larynx B. Dyspnea
C. Esophagus C. Orthopnea
D. Trachea D. Dyspnea nocturia

6. The _____ cartilage(s) mark(s) the lowermost 12. The nurse is percussing over the lungs of a
portion of the larynx. patient with pneumonia. The nurse knows that
A. Cricoid percussion over an area of atelectasis in the
B. Thyroid lungs will reveal:
22

A. Tympany B. Fine Crackles

B. Resonance C. Wheezes
C. Crackles D. Sonorous
D. Dullness
18. Mr. Abid has classic barrel chest secondary
13. Mrs. Zeshan a 78 year old client is admitted to COPD. What would his AP:Lateral ratio?
with the diagnosis of mild chronic heart failure. A. 1:1
The nurse expects to hear when listening to B. 1:2
client’s lungs indicative of chronic heart failure C. 1:3
would be: D. 2:1
A. Stridor
B. Crackles 19. A breath sound that is low pitched, soft in
C. Wheezes intensity, and has an inspiratory component
D. Friction rubs that is longer than its expiratory component is
called:
14. Ahmad was scheduled for a physical A. Bronchial
assessment. When percussing the client’s chest, B. Tracheal
the nurse would expect to find which C. Bronchovesicular
assessment data as a normal sign over his D. Vesicular
lungs?
A. Dullness 20. The vertical line drawn from the midpoint of
B. Resonance the sternum is called:
C. Hyperresonance A. Anterior axillary line
D. Tympany B. Midsternal line
C. Scapular line
15. The primary muscles of respiration include D. Vertebral line
which of the following?
A. Diaphragm and external intercostals 21. When examining for tactile fremitus, it is
B. Sternomastoid and scaleni important to:
C. Trapezii and rectus abdominis A. Have the patient breathe quietly
D. External obliques and pectoralis major B. Ask the patient to cough
C. Palpate the chest symmetrically
16. In which location the diaphragmatic D. Use the bell of the stethoscope
excursion is checked for movements of the
diaphragm. Percuss from lung resonance to 22. During an examination of the anterior
dullness over the diaphragm during both thorax, the nurse is aware that the trachea
inhalation and exhalation. bifurcates anteriorly at the:
A. T 6, & T 4 A. Costal angle
B. T 8, & T 6 B. Sternal angle
C. T 10, & T 8 C. Xiphoid process
D. T 12, & T 10 D. Suprasternal notch

17. The nurse auscultate the patient lungs: high 23. The nurse is observing the auscultation
pitch sound heard at the end of inspiration and technique of another nurse. The correct
do not change on coughing is called? method to use when progressing from one
A. Coarse Crackles
23

auscultatory site on the thorax to another is ___ A. Pneumonia

comparison. B. Pleural effusion
A. Side-to-side C. Asthma
B. Top-to-bottom D. Pulmonary embolism
C. Posterior-to-anterior
D. Interspace-by-interspace 30. What is the primary cause of stridor?
A. Bronchospasm
24. In a healthy adult, the expected B. Narrowing of the upper airway
measurement of expansion of the diaphragm is: C. Alveolar collapse
A. 1 to 2 cm D. Excessive fluid in the alveoli
B. 3 to 5 cm
C. 7 to 8 cm 31. Which condition is likely to cause absent
D. 10 to 12 cm breath sounds?
A. Pneumothorax
25. The nurse is listening to the breath sounds B. Pulmonary fibrosis
of a patient with severe asthma. Air passing C. Pleurisy
through narrowed bronchioles would produce D. Pulmonary edema
which of these adventitious sounds?
A. Wheezes 32. What type of breath sounds are typically
B. Bronchial sounds heard over consolidated lung tissue?
C. Whispered pectoriloquy A. Wheezing
D. Bronchophony B. Bronchial
C. Vesicular
26. Which of the following conditions is D. Crackles
characterized by the collapse of lung tissue?
A. Pneumothorax 33. Which of the following best describes
B. Pleural effusion pleural friction rub?
C. Pulmonary embolism A. Continuous, high-pitched squeaking
D. Atelectasis sound
B. Fine, discontinuous crackling sound
27. Which of the following best describes C. Low-pitched, rumbling sound
crackles? D. Absence of breath sounds
A. High-pitched, musical sounds
B. Low-pitched, rumbling sounds 34. What is the primary cause of diminished
C. Fine, discontinuous sounds breath sounds?
D. Coarse, continuous sounds A. Airway obstruction
B. Inflammation of the pleura
28. What is the characteristic sound of C. Bronchospasm
bronchial breath sounds? D. Decreased lung volume
A. Soft, rustling sound
B. High-pitched, musical sound 35. Which condition is associated with
C. Low-pitched, hollow sound decreased tactile fremitus and dull percussion
D. Whispering, indistinct sound notes?
A. Pneumonia
29. Which condition is typically associated with B. Asthma
wheezing breath sounds? C. Pulmonary embolism
24

D. Pleural effusion D. Over the lower lobes, posterior side

36. What is the primary cause of increased 41. During percussion, the nurse knows that a
resonance on percussion and decreased breath dull percussion note elicited over a lung lobe
sounds over hyperinflated lungs? most likely results from:
A. Bronchospasm A. Shallow breathing.
B. Alveolar consolidation B. Normal lung tissue.
C. Air trapping C. Decreased adipose tissue.
D. Pleural effusion D. Increased density of lung tissue.

37. When performing a respiratory assessment 42. When auscultating the lungs of an adult
on a patient, the nurse notices a costal angle of patient, the nurse notes that over the posterior
approximately 90 degrees. This characteristic is: lower lobes low-pitched, soft breath sounds are
A. Seen in patients with kyphosis. heard, with inspiration being longer than
B. Indicative of pectus excavatum. expiration. The nurse interprets that these are:
C. A normal finding in a healthy adult. A. Sounds normally auscultated over the
D. An expected finding in a patient with a trachea.
barrel chest. B. Bronchial breath sounds and are normal
in that location.
38. When assessing a patient's lungs, the nurse C. Vesicular breath sounds and are normal
recalls that the left lung: in that location.
A. Consists of two lobes. D. Bronchovesicular breath sounds and are
B. Is divided by the horizontal fissure. normal in that location.
C. Consists primarily of an upper lobe on the
posterior chest. 43. When inspecting the anterior chest of an
D. Is shorter than the right lung because of adult, the nurse should include which
the underlying stomach assessment?
A. Diaphragmatic excursion
39. During an assessment, the nurse knows that B. Symmetric chest expansion
expected assessment findings in the normal C. The presence of breath sounds
adult lung include the presence of: D. The shape and configuration of the chest
A. Adventitious sounds and limited chest wall
expansion.
B. Increased tactile fremitus and dull 44. The nurse knows that auscultation of fine
percussion tones. crackles would most likely be noticed in:
C. Muffled voice sounds and symmetrical A. A healthy 5-year-old child.
tactile fremitus. B. A pregnant woman.
D. Absent voice sounds and hyperresonant C. The immediate newborn period.
percussion tones. D. Association with a pneumothorax.

40. When assessing tactile fremitus, the nurse 45. During an assessment of an adult, the nurse
recalls that it is normal to feel tactile fremitus has noted unequal chest expansion and
most intensely over which location? recognizes that this occurs in which situation?
A. Between the scapulae A. An obese patient
B. Third intercostal space, MCL B. When part of the lung is obstructed or
C. Fifth intercostal space, MAL collapsed
25

C. When bulging of the intercostal spaces is had a fever as high as 103 F for the last 3 days
present and has a cough productive of green sputum.
D. When accessory muscles are used to On physical examination, you hear crackles in
augment respiratory effort
her lungs. A chest x-ray reveals consolidation in
46. The nurse is reviewing the characteristics of the left lower lobe with a diagnosis of lobar
breath sounds. Which statement about pneumonia.
bronchovesicular breath sounds is true? They When you perform the test for egophony on
are: this patient, you would expect to hear:
A. Musical in quality.
B. Usually pathological. A. "E to A Changes"
C. Expected near the major airways. B. "AAY"
D. Similar to bronchial sounds except that C. Whispered pectoriloquy
they are shorter in duration. D. "OOO"

47. During palpation of the anterior chest wall, 51. You are assessing a client who has
the nurse notices a coarse, crackling sensation emphysema, when percussing the lung fields,
over the skin surface. On the basis of these what sound would you expect to hear at the
findings, the nurse suspects: bases?
A. Tactile fremitus. A. Resonance
B. Crepitus. B. Tympany
C. Friction rub. C. Hyper-resonance
D. Adventitious sounds. D. Dullness

48. In assessing a client, the sternum is 52. In auscultating the lungs, you hear
observed to be displaced anterior, increasing adventitious sounds that are continuous. You
anteroposterior diameter. The costal cartilage describe the sounds as low-pitched snoring or
adjacent to the protruding sternum are moaning heard primarily during expiration.
depressed. This is known as: A. Pleural friction rub
A. Pectus carinatum B. Sibilant wheeze
B. Pectus excavatum C. Sonorous wheeze
C. Scoliosis D. Coarse crackles
D. Kyphosis
53. Respiratory rate of new borne is--------------
49. Which finding may indicate abnormal breath/minute.
thoracic expansion? A. 12-20
B. 16-20
A. A 4-cm diaphragmatic excursion C. 18-30
B. A 1:2 ratio anteroposterior to lateral D. 30-60
diameter
C. An "S" shaped curvature of the spine 54. Rapid, deep breathing without pauses; in
D. A costal angle of 85 degrees adults, more than 20 breaths/minute; breathing
usually sounds labored with deep breaths that
resemble sighs
50. A 42-year-old waitress presents to the clinic A. Cheyne-Stokes
for evaluation of shortness of breath. She has B. Kussmaul’s Respirations
26

C. Hyperapnea C. Rhonchal
D. Tachypnea D. Diminished

55. Pectus Carinatum also called 59. Chest wall increased anterior-posterior;
A. Barrel chest normal in children; typical of hyperinflation
B. Pigeon chest seen in COPD is called
C. Funnel chest A. Barrel chest
D. Pectus Excavatum B. Elliptical chest
C. Kyphosis
56. Symmetric chest expansion can be measure D. Pectus Carinatum
on -------------side.
A. Anterior 60. During auscultation of the lungs of an adult
B. Posterior patient, the nurse notices the presence of
C. Axillary bronchophony. The nurse should assess for
D. Both a & b
signs of which condition
57. What level should the examiner's thumbs be
A. Airway obstruction
placed while assessing symmetric expansion?
B. Emphysema
A. C7-T3
C. Pulmonary consolidation
B. T8 T9
D. Asthma
C. T9 T10
D. T11-T12

58. Which of the following fremitus occurs with

compression or consolidation of lung tissue like
lobar pmeumonia.
A. Decreased
B. Increased
27

Unit-5 Assessment of Eyes & Ears

1. Which of the following is the transparent, c) Incus, stapes, cochlea

front part of the eye that covers the iris, pupil, d) Malleus, incus, cochlea
and anterior chamber? 6. The part of the ear that contains the cochlea,
a) Retina responsible for hearing, is the:
b) Cornea a) External ear
c) Lens b) Middle ear
d) Sclera c) Inner ear
2. The colored part of the eye that regulates the d) Tympanic membrane
amount of light entering the eye is called the: 7. The snail-shaped, fluid-filled structure in the
a) Pupil inner ear that converts sound vibrations into
b) Iris neural signals is the:
c) Retina a) Semicircular canals
d) Cornea b) Oval window
3. The structure in the eye that changes shape c) Cochlea
to help focus light onto the retina is the: d) Auditory nerve
a) Cornea 8. Which of the following structures is
b) Sclera responsible for maintaining balance and
c) Lens equilibrium?
d) Retina a) Semicircular canals
4. Which of the following is not a part of the b) Cochlea
middle ear? c) Auditory nerve
a) Cochlea d) Oval window
b) Tympanic membrane 9. The thin membrane that separates the
c) Ossicles external ear from the middle ear is called the:
d) Eustachian tube a) Tympanic membrane
5. The auditory ossicles in the middle ear are: b) Oval window
a) Malleus, incus, stapes c) Eustachian tube
b) Malleus, stapes, cochlea d) Cochlea
28

10. Which cranial nerve is responsible for d) It is cranial nerve XII.

transmitting sensory information from the eye 15. The part of the eye where the optic nerve
to the brain? exits and blood vessels enter and leave is called
a) Cranial nerve II (Optic nerve) the:
b) Cranial nerve V (Trigeminal nerve) a) Macula
c) Cranial nerve VII (Facial nerve) b) Optic disc
d) Cranial nerve X (Vagus nerve) c) Fovea
11. The space filled with fluid behind the d) Retina
eardrum is called the: 16. The vestibular system is primarily
a) Cochlea responsible for:
b) Oval window a) Hearing
c) Middle ear b) Vision
d) Tympanic cavity c) Balance and spatial orientation
12. Which of the following is not one of the d) Taste perception
three tiny bones in the middle ear? 17. The aqueous humor is found in which part
a) Malleus of the eye?
b) Incus a) Anterior chamber
c) Stapes b) Posterior chamber
d) Tympanum c) Vitreous chamber
13. The tiny hair cells within the cochlea are d) Retina
responsible for: 18. What is the function of the Eustachian tube?
a) Balance a) Equalize air pressure between the
b) Equilibrium middle ear and the atmosphere
c) Hearing b) Transmit sound waves to the cochlea
d) Proprioception c) Control the amount of light entering the
14. Which of the following statements about eye
the optic nerve is true? d) Produce tears to keep the eye moist
a) It connects the eye to the brainstem. 19. The macula, responsible for central vision
b) It is responsible for taste sensation. and visual acuity, is located in which part of the
c) It carries motor signals from the brain to eye?
the eye muscles. a) Iris
29

b) Cornea b) Saccule
c) Retina c) Semicircular canals
d) Lens d) All of the above
20. The part of the ear that amplifies sound 25. Light rays enter the eye through
vibrations and transmits them to the inner ear a) Iris
is the: b) Cornea
a) Pinna c) Pupil
b) Eardrum d) Sclera
c) Ossicles 26. The innermost lining of the eye is
d) Cochlea a) Choroid
21. Which of the following part of the ear b) Retina
separates middle ear from outer ear c) Sclera
a) Oval window d) Cornea
b) Round window 27. Which of the following photoreceptor cells
c) Malleous work in dim light
d) Tympanic membrane a) Rods
22. Oval window of the ear is attached to which b) Cones
of the following bone? c) Both a and b
a) Malleous d) None of the above
b) Stapes 28. Increase in intraocular pressure causes
c) Incus a) Cataract
d) None of the above b) Myopia
23. Membranous labyrinth of inner ear is filled c) Glaucoma
with fluid called d) Presbyopia
a) Perilymph 29. A condition in which lens loses its elasticity
b) Endolymph and stiffens with age is called
c) Both perilymph and endolymph a) Myopia
d) None of the above b) Hyperopia
24. Which of the following part of the ear c) Presbyopia
maintains balance or equilibrium? d) None of the above
a) Utricle 30. Colour perception is perceived by
30

a) Cones a) Normal vision

b) Rods b) Below average vision
c) Reduced vision
c) Both a and b
d) Legal blindness
d) None of the above
31. The muscle responsible for the change of 37. The Snellen chart is used to assess:
the shape of the lens is the a) Color vision
a) Ciliary muscle. b) Peripheral vision
b) Orbicularis oculi. c) Near vision
c) Orbicularis oris d) Distance vision
d) Superior rectus muscle.
38. Which of the following is NOT a component
32. The layer that contains photoreceptors is of the extraocular movements test?
the a) Convergence
a) Cornea
b) Accommodation
b) Iris.
c) Optic disc c) Saccades
d) Retina d) Smooth pursuit
e) Sclera
39. Cover-uncover test is performed to assess:
33. The area containing the highest a) Visual field defects
concentration of cones is the
b) Binocular vision and eye alignment
a) Fovea centralis
b) Iris. c) Color vision
c) Optic disc d) Depth perception
d) Macula lutea
e) Sclera 40. A patient who can see objects clearly at 20
feet that a person with normal vision can see at
34. Which of the following belongs to the
middle ear? 40 feet has:
a) Ampullae a) 20/20 vision
b) Cochlea b) 20/40 vision
c) Ossicles c) 20/80 vision
d) Pinna d) 20/10 vision

35. The senses for dynamic equilibrium are 41. Amsler grid test is used for the assessment
located in the of:
a) Cochlea. a) Visual field defects
b) Organ of corti b) Macular degeneration
c) Semicircular canals
c) Cataracts
d) Utricle
d) Glaucoma
36. A visual acuity of 20/40 means:
31

42. The instrument used to assess intraocular a) Weber's test

pressure is called a: b) Air and bone conduction in the ear
a) Tonometer c) Sound localization
b) Ophthalmoscope d) Tympanic membrane mobility
c) Otoscope
d) Retinoscope 49. Otoscopy is used to examine the:
a) Retina
43. Which of the following is NOT a sign of b) Tympanic membrane
increased intraocular pressure? c) Optic nerve
a) Blurred vision d) Cochlea
b) Tunnel vision
c) Halos around lights 50. Weber's test is performed by:
d) Constricted pupils a) Placing a vibrating tuning fork on the
mastoid process
44. The confrontation test is used to assess: b) Placing a vibrating tuning fork on the
a) Central vision forehead
b) Peripheral vision/ Visual field c) Whispering words into the ear
c) Color vision d) Evaluating eye movements
d) Depth perception
51. The whispered voice test assesses:
45. Which of the following is NOT a common a) Central vision
color vision test? b) Peripheral vision
a) Ishihara plates c) Hearing acuity
b) Farnsworth-Munsell 100 hue test d) Olfactory function
c) Snellen chart
d) City University Color Vision Test 52. Tympanometry measures:
a) Hearing acuity
46. Ophthalmoscopy is used to examine the: b) Tympanic membrane mobility
a) Cornea c) Ocular pressure
b) Retina d) Visual field defects
c) Lens
d) Optic nerve 53. The Romberg test is used to assess:
a) Balance
47. Which of the following is NOT a common b) Visual acuity
method for testing hearing acuity? c) Hearing acuity
a) Pure-tone audiometry d) Reflexes
b) Tympanometry
c) Whisper test 54. A normal result for the Romberg test
d) Ophthalmoscopy indicates:
48. The Rinne test is used to assess: a) Positive Romberg sign
32

b) Negative Romberg sign a) Vestibular system

c) Poor hearing acuity b) Auditory nerve
d) Inflammation of the optic nerve c) Optic nerve
55. Which of the following is NOT a common d) Olfactory nerve
cause of conductive hearing loss?
a) Otitis media 61. Which of the following is NOT a part of the
b) Presbycusis Weber test procedure?
c) Otosclerosis a) Placing a vibrating tuning fork on the
d) Cerumen impaction midline of the forehead
b) Asking the patient if the sound is heard
56. A positive Rinne test result indicates: equally in both ears
a) Air conduction is better than bone c) Placing a vibrating tuning fork on the
conduction mastoid process
b) Bone conduction is better than air d) Placing a vibrating tuning fork on the
conduction vertex of the head
c) Normal hearing acuity 62. A positive result for the whisper test
d) Sensorineural hearing loss indicates:
a) Normal hearing acuity
57. A negative Weber test result indicates: b) Conductive hearing loss
a) Conductive hearing loss in the tested ear c) Sensorineural hearing loss
b) Sensorineural hearing loss in the tested d) Otitis media
ear
c) Normal hearing acuity 63. Which of the following is NOT a common
d) Presence of a middle ear infection sign of presbycusis?
a) Difficulty understanding speech in noisy
58. The Schirmer test is used to assess: environments
a) Visual acuity b) Tinnitus
b) Hearing acuity c) Dizziness
c) Tear production d) Gradual hearing loss
d) Color vision
64. Which of the following tests is used to
59. Which of the following is NOT a common assess balance and vestibular function?
symptom of an ear infection? a) Rinne test
a) Otalgia b) Romberg test
b) Tinnitus c) Whisper test
c) Diplopia d) Weber test
d) Otorrhea
65. Which of the following muscle is responsible
60. A positive Romberg test result may indicate for downward & outward movement of eye
dysfunction of the: ball?
33

a) Superior Rectus 71. In which of the following auditory screening

b) Inferior Rectus test Tuning fork is not used
c) Superior oblique a) Weber Test
d) Inferior oblique b) Rinne Test
c) Whisper Test
66. All of the following are the pupillary d) All of the above
reactions EXCEPT?
a) Accomodation 72. You have tested your patient's hearing using
b) Convergence the Rinne test. The results reveal bone
c) Pupil constriction conduction is longer than air conduction. What
d) Confrontation do these findings suggest?
a) Nothing, they are normal findings
67. Ptosis is the abnormality of which eye b) Conductive hearing loss
structure? c) Perceptive hearing loss
a) Cornea d) Sensorineural hearing loss
b) Lacrimal gland
c) Eyelid 73. You are performing an otoscopic exam on a
d) Eybrows 2-year-old child. To straighten the ear canal,
you should:
68. Rosenbaum Chart is used to detect: a) Pull helix up
a) Far vision b) Pull helix down
b) Near vision c) Pull helix forward
c) Visual field d) Pull helix back
d) Muscular movement of eye
74. A six-month old male infant is brought to
69. Impaired far vision is called the emergency department by his parents for
a) Myopia inconsolable crying and pulling at his right ear.
b) Presbyopia When assessing this infant the nurse is aware
c) Hyperopia that the tympanic membrane should be what
d) Hemianopia color in a healthy ear?
a) Yellowish-white
70. Condition in which your eyelid turns inward b) Red
so that your eyelashes and skin rub against the c) Gray
eye surface is called d) Bluish-white
a) Ectropion
b) Entropion 75. What is called when a patient is
c) Ptosis experiencing buzzing in their ear?
d) Nystagmus a) Tinnitus
b) Otalgia
34

c) Otorrhea a) Anisocoria
d) None of the above b) Bipoplia
c) Bipuplia
76. The most commonly used test for accurate d) Xanthelasma
measure of visual acuity is _______.
a) Jaegar Card 81. An elderly patient complains of dry itchy
b) Confrontation Test eyes, upon closer assessment the nurse notices
c) Snellen Eye Chart that the lower lid is loose and is slightly rolling
d) Hirschberg Test outward. This abnormality is known as ____.
a) Entropion
77. A 42-year-old woman who has problems b) Esophoria
during the near vision testing due to the c) Ectropion
decrease in the power of accommodation, d) Ptosis
suffers from which of the following conditions?
a) Tropia 82. ___is an infection of the lacrimal gland,
b) Phoria while ______ is infection and blockage of the
c) Strabismus lacrimal duct and sac.
d) Presbyopia a) Esotropia, exotropia
b) Dacryocystitis, dacroadenitis
78. A fine oscillating movement best seen c) Exotropia, esotropia
around the iris during the Diagnostic Positions d) Dacroadenitis, dacryocystitis
Test is known as which of the following?
a) Exophthalmos 83. A patient comes into the clinic complaining
b) Nystagmus of pain in her right eye. On examination, the
c) Diplopia nurse sees a pustule at the lid margin that is
d) Strabismus painful to touch, red, and swollen. The nurse
recognizes that this is a
79. When one eye is exposed to bright light, a a) Chalazion.
____ occurs (constriction of that pupil) as well b) Hordeolum (stye).
as a _____ (simultaneous constriction of the c) Dacryocystitis.
other pupil). d) Blepharitis.
a) Consensual light reflex, primary light
reflex 84. Supplies the superior oblique muscle of the
b) Primary light reflex, secondary light reflex eye
c) Direct light reflex, consensual light reflex a) CN 3
d) Consensual light reflex, direct light reflex b) CN 4 Trochlear Nerve
c) CN 6
80. The term that refers to pupils with two d) CN8
different sizes is ________.
35

85. Supplies the lateral rectus muscle of the eye perform to assess for loss of high-frequency
a) CN 3 sounds?
b) CN 4 a) Rinne's test
c) CN 6 Abducens Nerve b) Romberg's test
d) CN8 c) Weber's test
d) Whisper test
86. The nurse would suspect a problem at
which area when pressure builds up on either 90. The nurse assessing for unilateral hearing
side of the tympanic membrane? loss by using a tuning fork. What test is the
a) Organ of Corti nurse performing?
b) Eustachian tube a) Watch tick test
c) Cochlea b) Whisper test
d) Vestibulocochlear nerve c) Rinne test
d) Weber's test
87. While inspecting the tympanic membrane,
the nurse notes a pearly gray and shiny
appearance. The nurse would interpret this
finding as which of the following?
a) Serous otitis media
b) Normal tympanic membrane
c) Scarring from previous infections
d) Acute otitis media

88. A nurse performs a Rinne test on a client

who relates a history of decreased hearing in
the right ear. The test demonstrates that the
client has conductive hearing loss in the right
ear. What is the correct documentation of this
test by the nurse?
a) Right: AC greater than BC; left BC greater
than AC
b) Right: BC greater than AC; left AC greater
than BC
c) Right: BC greater than AC; left BC= AC
d) Right: AC greater than BC; left AC= BC

89. The nurse is assessing auditory acuity in a

college student. Which test would the nurse
36

Unit-6 Assessment of an Elderly Client

1. Which of the following is NOT a typical age- 5. What is the purpose of assessing the elderly
related change in the elderly? client's nutritional status?
a) Decreased muscle mass a) To monitor weight loss
b) Increased bone density b) To identify risk factors for malnutrition
c) Slower reaction time c) To ensure adequate intake of vitamins and
d) Reduced skin elasticity minerals
2. What is the primary purpose of assessing an d) All of the above
elderly client? 6. Which assessment tool is commonly used to
a) Diagnosing diseases assess fall risk in the elderly?
b) Determining their independence level a) Berg Balance Scale
c) Developing a treatment plan b) Timed Up and Go Test
d) Identifying risk factors and addressing c) Tinetti Performance-Oriented Mobility
health concerns Assessment
3. In performing a physical assessment for an d) All of the above
older adult, the nurse anticipates finding which 7. Which of the following is NOT a common
of the following normal physiological changes of assessment parameter for assessing pain in the
aging? elderly?
a) Increased perspiration a) Verbal pain scale
b) Increased airway resistance b) Visual analog scale
c) Increased salivary secretions c) Pain Assessment in Advanced Dementia
d) Increased pitch discrimination (PAINAD) scale
4. How often should an elderly client's d) Glasgow Coma Scale
functional status be assessed? 8. What is the purpose of assessing an elderly
a) Annually client's medication use?
b) Every 5 years a) To ensure compliance with prescribed
c) As needed medications
d) Semi-annually b) To identify potential drug interactions
c) To monitor for adverse drug reactions
37

d) All of the above 13. Which assessment parameter is important

9. Which assessment tool is commonly used to for assessing risk of dehydration in the elderly?
assess activities of daily living (ADLs) in the a) Skin turgor
elderly? b) Blood pressure
a) Katz Index of Independence in Activities of c) Urine output
Daily Living d) All of the above
b) Lawton Instrumental Activities of Daily 14. Which assessment tool is commonly used to
Living Scale assess mobility in the elderly?
c) Barthel Index a) Timed Up and Go Test
d) All of the above b) 30-Second Chair Stand Test
10. Which of the following is NOT a common c) Six-Minute Walk Test
assessment parameter for assessing skin d) All of the above
integrity in the elderly? 15. What is the primary purpose of assessing an
a) Braden Scale elderly client's sensory function?
b) Waterlow Scale a) To identify risk factors for falls
c) Glasgow Coma Scale b) To assess their ability to perform activities
d) Norton Scale of daily living
11. The most common affective or mood c) To identify potential barriers to
disorder of old age is communication
a) Dementia d) All of the above
b) Depression 16. Which assessment parameter is important
c) Delirium for assessing risk of pressure ulcers in the
d) Alzheimer's. elderly?
12. Which assessment tool is commonly used to a) Mobility
assess depression in the elderly? b) Nutritional status
a) Geriatric Depression Scale (GDS) c) Skin integrity
b) Hamilton Rating Scale for Depression d) All of the above
(HAM-D) 17. Which assessment tool is commonly used to
c) Beck Depression Inventory (BDI) assess risk of delirium in the elderly?
d) All of the above a) Confusion Assessment Method (CAM)
b) Mini-Mental State Examination (MMSE)
38

c) Montreal Cognitive Assessment (MoCA) 22. Which assessment tool is commonly used to
d) All of the above assess risk of osteoporosis in the elderly?
18. What is the primary purpose of assessing an a) Dual-energy X-ray absorptiometry (DEXA)
elderly client's bladder function? scan
a) To identify risk factors for urinary tract b) Fracture Risk Assessment Tool (FRAX)
infections c) TUG test
b) To assess the need for toileting assistance d) All of the above
c) To evaluate the effectiveness of 23. What is the primary purpose of assessing an
incontinence management strategies elderly client's oral health?
d) All of the above a) To identify risk factors for aspiration
19. The three common conditions affecting pneumonia
cognition in the older adults are: b) To assess their ability to eat and
a) Stroke, MI, Cancer communicate
b) Cancer, Alzheimer's disease, Stroke c) To identify potential barriers to oral
c) Delirium, Depression, Dementia hygiene
d) Blindness, Hearing loss, Stroke d) All of the above
20. A nurse is collecting data from an older 24. Which assessment parameter is important
adult client as part of a comprehensive physical for assessing risk of depression in the elderly?
examination. Which of the following findings a) Social support network
should the nurse expect as associated with b) Functional status
aging? c) Medication use
a) Decreased height d) All of the above
b) Nail thickening 25. Which assessment tool is commonly used to
c) Decreased bladder capacity assess risk of cardiovascular disease in the
d) All of the above elderly?
21. Which assessment parameter is important a) Framingham Risk Score
for assessing risk of aspiration in the elderly? b) Modified Rankin Scale
a) Cognitive function c) Glasgow Coma Scale
b) Swallowing ability d) All of the above
c) Mobility 26. What is the primary purpose of assessing an
d) All of the above elderly client's sleep patterns?
39

a) To identify risk factors for falls c) Dry cerumen

b) To assess their quality of life d) Hair in the ear canal
c) To identify potential sleep disorders 31. Which of the following is considered
d) All of the above geriatric syndrome?
27. Which assessment parameter is important a) Incontinence
for assessing risk of heat-related illnesses in the b) Falls
elderly? c) Delirium
a) Mobility d) All of the above
b) Sensory function 32. Activity of daily living include all except?
c) Medication use a) Dressing
d) All of the above b) Toileting
28. A nurse is performing a musculoskeletal c) Feeding
assessment on an older adult living d) Playing Sports
independently. What normal physiologic 33. Which of the following is not a common age
changes of aging related change of skin of a elderly client?
a) Muscle atrophy a) Skin wrinkles
b) Slowed movement b) Senile pupura
c) Widened gait c) Hypo/Hperpigmentation
d) All of the above d) Soft & moist skin
29. _________ is the use of multiple 34. All of the following are the age related
medications, often inappropriately and changes of eyes in elderly client except?
excessively, at the same time. a) Sunken eyes
a) Polypharmacy b) Ectropion & entropion
b) Multiple pharmacy c) Increased visual acuity
c) Extension pharmacy d) Arcus senilis
d) Saturated pharmacy 35. Which of the following is the most common
30. The 75-year-old patient has normal age- defect of ears in elderly people?
related changes in his ear that include all of the a) Sensorineural hearing loss
following except: b) Conductive hearing loss
a) Dry and wrinkled skin on the auricle c) Otitis media
b) Otitis Externa d) Increase speech discrimination
40

36. Which of the following statement is correct c) Ability to hear

regarding elderly age related changes? d) Ability to see
a) Mass & strength of muscles increases 40. The nurse is performing an assessment on
b) Decreased stroke volume and cardiac an older adult client. Which assessment data
output would indicate a potential complication
c) Increase sense of smell associated with the skin?
d) Decreased BP a) Crusting
b) Wrinkling
37. A woman brings her 84-yr-old mother to the c) Deepening of expression lines
office for evaluation of new symptoms, which d) Thinning and loss of elasticity in the skin
include a newly observed apathy, plus
tachycardia, weight loss, fatigue, weakness, 41. The long-term care nurse is performing
palpitations, and tremor. Which of the following assessments on several of the residents. Which
is the likely diagnosis? are normal age-related physiological change(s)
a) Myocardial infarction the nurse expects to note?
b) Hypothyroidism a) Increased heart rate
c) Hyperthyroidism b) Decline in visual acuity
d) Heart failure c) Decreased respiratory rate
38. Which of the following is erroneously d) Decline in long-term memory
considered part of normal aging and is 42. A nursing intervention for a elderly patient
therefore often underreported by patients and with constipation is to:
their family members? a) Avoid the urge to defecate.
a) Gait disturbance b) Limit fluid intake.
b) Decreased strength c) Give prune juice with a noncarbonated
c) Vaginal dryness drink.
d) Decreased appetite d) Encourage bran cereal or whole-grain
39. Which of the following should the clinician breads.
evaluate to ensure accurate results when 43. Which mental change is associated with
testing mental status in an older patient? aging?
a) Ability to walk a) Confusion
b) Ability to rise from a chair b) Gradual decline in cognitive skills
41

c) Depression a) Deficiencies in protein intake are

d) Inappropriate behavior common with aging.
44. An elderly patient has acute confusion after b) Malnutrition is the most common
undergoing abdominal surgery. The patient nutritional disorder among the elderly
most likely has: living in the community.
a) Delirium. c) Increased caloric consumption is needed
b) Anxiety. as one ages.
c) Dementia. d) The serum albumin is a good reflection of
d) Depression protein stores.
45. A patient in the middle stage of Alzheimer's 49. The best approach to taking the health
disease (AD) may exhibit which characteristic or history of an elderly client is to:
behavior? a) Start with an open-ended question
a) Mild depression b) Start with the review of systems
b) Hallucinations c) Focus on the chief complaint
c) Weight loss d) Complete the history before conducting
d) Impaired mobility the examination
46. The most common disability among the 50. The leading cause of traumatic death in the
elderly is elderly is due to:
a) Locomotor disability a) Motor vehicle accidents
b) Visual disability b) Pedestrian injuries
c) Hearing disability c) Falls
d) Speech disability d) Burns
47. Which of the following are the potential
problems of elderly people?
a) Sensory impairment
b) Incontinence
c) Falls and safety issues
d) All of the above
48. What statement is true about nutrition
intake in the elderly?
42

Unit-7 Assessment of Pediatric & Children

1. Neonate is considering children age up to? b) Moro reflex

a) Up to 1 year c) Babinski reflex

b) 1 month to 6 months d) Palmar reflex

c) 1-28 days 5. Which of the following is not a common

principal of pediatric assessment?
d) First 24 hours
a) Head to toe assessment
2. Infancy determines the age of children
b) Expose body parts as necessary
a) 0 to 2 years
c) Go from simple to complex
b) 1 month to 6 months
d) Assessment should not be done in
c) 1-28 days presence of parents
d) First 24 hours 6. Which of the following is NOT a common site
for temperature assessment in newborns?
3. Which of the following is not a main
characteristic of Infancy? a) Axilla
a) High speed of learning b) Ear canal
b) Curious nature c) Rectum
c) Learning through imitation d) Forehead
d) Process of reflection 7. What is the heart rate range for a newborn
immediately after birth Up to 1 month?
4. What is the Apgar score used to assess?
a) 40-60 bpm
a) Newborn's reflexes
b) 60-100 bpm
b) Newborn's neurological development
c) 100-140 bpm
c) Newborn's overall condition at birth
d) 70-180 bpm
d) Newborn's feeding ability
8. Which of the following is not a component of
pediatric health history?
4. Which of the following reflexes is typically
a) Past history
present in a healthy newborn?
b) Birth history
a) Plantar grasp
43

c) Feeding history a) Newborn's reflexes

d) Migration history b) Newborn's neurological development

9. What is the average respiratory rate range c) Newborn's overall condition at birth
for a newborn in awaken conditions?
d) Newborn's feeding ability
a) 10-20 breaths per minute
14. Which of the following is a characteristic of
b) 20-30 breaths per minute a preterm newborn?

c) 30-40 breaths per minute a) Birth weight above 2500 grams

d) 40-50 breaths per minute b) Gestational age of 38 weeks or more

10. Which of the following is NOT a common c) Presence of lanugo

measurement taken during a newborn
assessment? d) Fully developed sucking reflex

a) Blood pressure 13. What is the primary purpose of assessing

fontanel’s in a newborn?
b) Head circumference
a) Assessing hydration status
c) Length
b) Determining neurological development
d) Weight
c) Evaluating head circumference
11. A nurse weights a newborn and his weight is
less than 1500g in which class of weight occur d) Monitoring for signs of infection
this child?
14. What is the typical appearance of a healthy
a) Extremely low birth weight newborn's skin?

b) Very low birth weight a) Cyanotic

c) Low birth weight b) Mottled

d) Normal birth weight c) Jaundiced

12. The condition when a baby doesn’t receive d) Pallor

enough oxygen before, during or just after birth
15. Which of the following is NOT a
is called
characteristic of vernix caseosa?
a) Tacypnea
a) White, cheesy substance
b) Asphyxia
b) Protects skin from amniotic fluid
c) VSD
c) Present in preterm but not full-term
d) Orthopnea newborns

13. What is the Apgar score used to assess? d) Absent in post-term newborns
44

16. Which of the following reflexes is tested by c) Collecting blood for newborn screening
stroking the newborn's cheek? tests

a) Rooting reflex d) Measuring head circumference

b) Moro reflex 21. Which of the following is NOT a common

sign of hypoglycemia in a newborn?
c) Palmar grasp reflex
a) Tremors
d) Stepping reflex
b) Poor feeding
17. What is the purpose of the neonatal
screening test? c) Hypertension

a) Assessing Apgar score d) Lethargy

b) Detecting congenital abnormalities 22. What is the typical range for newborn blood
pressure?
c) Evaluating reflexes
a) 60/40 mmHg
d) Measuring temperature
b) 80/40 mmHg
18. Which of the following is a sign of a healthy
newborn's hearing? c) 100/60 mmHg

a) Startles in response to loud noise d) 120/80 mmHg

b) Absence of startle reflex 23. What is the term for the soft spots on a
newborn's skull?
c) Lack of response to voices
a) Sutures
d) Inability to turn head towards sound
b) Fontanel’s
19. What is the term for the yellowing of a
newborn's skin and eyes due to elevated c) Fissures
bilirubin levels?
d) Foramina
a) Jaundice
24. Which of the following is NOT a component
b) Cyanosis of the newborn physical examination?

c) Pallor a) Head-to-toe assessment

d) Mottling b) Neurological assessment

20. What is the purpose of the heel stick c) Hearing test

procedure in newborns?
d) Cardiovascular assessment
a) Assessing temperature
25. What is the recommended position for
b) Evaluating reflexes newborns during sleep to reduce the risk of
sudden infant death syndrome (SIDS)?
45

a) On their backs 30. Normal range of head circumference of new

born is________.
b) On their stomachs
a) 45-49cm
c) On their sides
b) 33-35.5 cm
d) Elevated on pillows
c) 22-26cm
26. Which of the following is a sign of
respiratory distress in a newborn? d) 53-55.5cm

a) Regular breathing pattern 31. Generally, a newborn's head is about half

the baby's body length in cm plus ______.
b) Grunting sounds
a) 5cm
c) Pink skin color
b) 7cm
d) Heart rate of 120 bpm
c) 10cm
27. Apgar score was firstly introduced
by_______ in_______. d) 15cm

a) Dr. William 1855 32. The posterior fontanelle closes between

b) Dr. Virginia 1952 a) 7-28 days

c) Dr. Wilson 1956 b) 2-3 months

d) Robert brown 1808 c) 6-12 months

28. If muscles are loose and floppy, the infant d) 18-21 months
scores for muscle tone on Apgar score is_____.
33. Normal Length of newborn is_______.
a) 0
a) 44-55cm
b) 1
b) 33-35.5 cm
c) 2
c) 22-26cm
d) 3
d) 55.5-65cm
29. If the body is pink and the extremities are
blue, the infant scores _____ for color on Apgar 34. Nurse Humid doing assessment of a neonate
scoring. and he sharp tap on the glabella of baby and he
produces momentary tight closer of the eyes
a) 0 humid asses which reflex?

b) 1 a) Moro reflex

c) 2 b) Rooting reflex

d) 3 c) Glabellar reflex
46

d) Babinski reflex b) 4th ICS medial left mid clavicular line

35. When does the rooting reflex typically c) 5th ICS mid clavicular line
disappear?
d) 2nd ICS left sterna border
a) 1-2 months
40. Which of the following muscle growth
b) 3-4 months strength is consider normal for 15 months child

c) 6-7 months a) Sits only with support

d) 9-10 months b) Pulls self to standing position

36. The sucking reflex usually disappears c) Walks alone well

around:
d) Jumps in place
a) 1 month
41. At what age a child can says Mama, Dada, 2
b) 3 months other words; imitates animal sounds

c) 6 months a) 10 months

d) 10-12 months b) 12 months

37. There is extension of the arm and leg on the c) 13-15 months
side to which head is turned and flexion of the
arm and leg on the contra lateral side is called d) 18-21 months

a) Moro reflex 42. Which of the following is the correct

expected fine motor development of a 12
b) Rooting reflex months child?

c) Palmar grasp reflex a) Only can transfer objects between hands

d) Tonic neck reflex b) Pick up small objects

38. Normal range of chest circumference of a c) Feeds self with cup and spoon
new born is________.
d) Builds 2-blocks tower
a) 45-49cm
43. A nurse assess a child and find that her feet
b) 30-33cm fingers and toes are wholly fused this defect is
called
c) 22-26cm
a) Polydactyly
d) 53-55.5cm
b) Syndactyly
39. Apical pulse of a child under 7 years old is
located in c) Multidactyly

a) 4th ICS right sterna border d) Fuseddactyly

47

44. When does the placing/stepping reflex b) 37-42 weeks

typically disappear?
c) less than 37 weeks
a) 2 months
d) 13-15 months
b) 3-4 months
49. Moro reflex we can use for assessment of
c) 6-7 months which cranial nerve of an infant?

d) 9-10 months a) Olfactory nerve (CN I),

45. Which one of the following reflex is persist b) Vestibulocochlear nerve (CN VIII)
life time
c) Trochlear nerve (CN IV)
a) Withdrawal reflex
d) Glossopharyngeal nerve (CN IX)
b) Sucking reflex
50. What does APGAR stand for?
c) Babinski reflex
a) Assisted Prenatal Growth Assessment
d) Tonic neck reflex Record

46. By holding the baby in prone position and b) Appearance, Pulse, Grimace, Activity,
stroking with the finger at the back parallel to Respiration
spine, first one side and then other side the
trunk will curved towards the stimulated side c) Antenatal Physical Growth and Assessment
the reflex is called Report

a) Parachute reflex d) Assessment of Preterm Gestational Age

Readiness
b) Gallant reflex
51. At what time points are APGAR scores
c) Babinski reflex typically recorded after birth?

d) Tonic neck reflex a) 5 and 15 minutes

47. All of the following reflexes are appears at b) 1 and 5 minutes

birth except______________ which appears at
9-12 months. c) 10 and 20 minutes

a) Parachute reflex d) 3 and 8 minutes

b) Gallant reflex 52. Which of the following is NOT assessed in

the APGAR scoring system?
c) Babinski reflex
a) Skin color
d) Tonic neck reflex
b) Heart rate
48. Duration for Normal term baby is
c) Weight
a) 3-4 months
d) Reflex irritability
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53. A newborn with an APGAR score of 7 at 1 c) 2

minute is considered:
d) 3
a) In good condition
58. In the APGAR scoring system, what does the
b) In need of immediate resuscitation "G" stand for?

c) Severely compromised a) Gasping

d) Unresponsive b) Grip

54. A newborn with an APGAR score of 0-3 c) Grimace

indicates:
d) Grunt
a) Excellent health
59. What is the score range for the
b) Moderate distress "Appearance" category in the APGAR scoring
system?
c) Severe distress and requires immediate
resuscitation a) 0-1

d) Mild respiratory issues b) 0-2

55. What is the normal range for a full-term c) 0-3

newborn's Apgar score at 1 minute?
d) 0-10
a) 0-3
60. Which of the following is NOT an indication
b) 4-6 for performing an APGAR assessment?

c) 7-10 a) Neonatal resuscitation

d) 11-14 b) Routine newborn care

56. Which of the following APGAR categories c) Monitoring the baby's response to birth
assesses muscle tone?
d) Assessing the need for a Cesarean section
a) A (Appearance)
61. At what point in time is the APGAR score
b) P (Pulse) usually reassessed if the initial score is low?

c) G (Grimace) a) 10 minutes

d) A (Activity) b) 5 minutes

57. A newborn with a heart rate of fewer than c) 2 minutes

100 beats per minute receives what score in the
Pulse category? d) 15 minutes

a) 0 62. A newborn with blue extremities but a pink

body would most likely score a _ in the
b) 1 "Appearance" category.
49

a) 0 d) Tonic neck reflex

b) 1 67. When does the Moro reflex typically

disappear?
c) 2
a) 1-2 months
d) 3
b) 3-4 months
63. Which of the following is true regarding
APGAR scoring? c) 6-7 months

a) It predicts long-term neurological d) 9-10 months

outcomes.
68. Which reflex involves the baby's toes
b) It solely reflects the baby's health at birth. fanning out and then curling in when the sole of
the foot is stroked?
c) It is not useful in guiding immediate medical
interventions. a) Moro reflex

d) It is only applicable to preterm infants. b) Rooting reflex

64. A newborn with a vigorous cry and active c) Palmar grasp reflex
movement but a blue coloration receives what
score in the "Activity" category? d) Babinski reflex

a) 0 69. The Babinski reflex is normally present until:

b) 1 a) 3 months

c) 2 b) 6 months

d) 3 c) 9 months

65. Which reflex is elicited by stroking the d) 12 months

infant's cheek or edge of the mouth?
70. Which reflex is elicited by gently pressing on
a) Moro reflex the infant's palm, causing them to grasp tightly?

b) Rooting reflex a) Moro reflex

c) Palmar grasp reflex b) Rooting reflex

d) Stepping reflex c) Palmar grasp reflex

66. The Moro reflex is also known as the: d) Babinski reflex

a) Startle reflex 71. The rooting reflex helps infants with:

b) Sucking reflex a) Sucking

c) Babinski reflex b) Grasping

50

c) Walking a) 1-2 months

d) Hearing b) 3-4 months

72. Which reflex involves the infant's legs c) 5-6 months

moving in a walking motion when held upright
with their feet touching a solid surface? d) 7-8 months

a) Moro reflex 77. Which reflex involves the infant arching

their back, extending their arms and legs, and
b) Rooting reflex then bringing inwards?

c) Palmar grasp reflex a) Moro reflex

d) Stepping reflex b) Rooting reflex

73. The stepping reflex usually disappears c) Asymmetric tonic neck reflex
around:
d) Galant reflex
a) 1 month
78. The Galant reflex is typically present until:
b) 3 months
a) 1 month
c) 6 months
b) 3 months
d) 9 months
c) 6 months
74. Which reflex is characterized by the infant
turning their head in the direction of a touch on d) 9 months
the cheek or mouth?
79. Which reflex involves the infant sucking
a) Moro reflex rhythmically when a finger or nipple is placed in
their mouth?
b) Rooting reflex
a) Moro reflex
c) Palmar grasp reflex
b) Rooting reflex
d) Babinski reflex
c) Sucking reflex
75. What is the purpose of the tonic neck
reflex? d) Babinski reflex

a) Assisting with feeding 80. The age at which the infant achieve early
head controls with bobbing motion when pulled
b) Enhancing visual tracking to sit is

c) Aiding in crawling a) 2 months

d) Facilitating turning in bed b) 3 months

76. When the tonic neck reflex is typically c) 4 months

observed in infants?
51

d) 6 months delivery, the nurse prepares to prevent heat

loss in the newborn resulting from evaporation
81. The nurse is assessing a newborn that had by:
undergone vaginal delivery. Which of the
following findings is least likely to be observed a) Warming the crib pad
in a normal newborn?
a) Uneven head shape b) Turning on the overhead radiant warmer

b) Respirations are irregular, abdominal, 30-60 c) Closing the doors to the room
bpm
d) Drying the infant in a warm blanket
c) (+) moro reflex
86. A nurse in the newborn nursery is
d) Heart rate is 80 bpm monitoring a preterm newborn infant for
respiratory distress syndrome. Which
82. The age at which the infant can reach an assessment signs if noted in the newborn infant
object, grasp it and bring it to mouth and seems would alert the nurse to the possibility of this
exited when see the food is syndrome?

a) 4 months a) Hypotension and Bradycardia

b) 5 months b) Tachypnea and retractions

c) 6 months c) Acrocyanosis and grunting

d) 7 months d) The presence of a barrel chest with grunting

83. By the age of 7 months the infant is able to 87. A nurse is assessing a newborn infant who
do all the following EXCEPT was born to a mother who is addicted to drugs.
Which of the following assessment findings
a) Transfer object from hand to hand would the nurse expect to note during the
assessment of this newborn?
b) Bounces actively
a) Sleepiness
c) Cruises
b) Cuddles when being held
d) Grasp uses radial palm
c) Lethargy
84. Which vital sign is included in the Apgar
score? d) Incessant crying
a) Temperature 88. A nurse prepares to administer a vitamin K
injection to a newborn infant. The mother asks
b) Heart rate
the nurse why her newborn infant needs the
c) Meconium staining injection. The best response by the nurse would
be:
d) Oedema
a) “Your infant needs vitamin K to develop
85. A nurse in a delivery room is assisting with immunity.”
the delivery of a newborn infant. After the
52

b) “Vitamin K will protect your infant from 92. When performing a newborn assessment,
having jaundice.” the nurse should measure the vital signs in the
following sequence:
c) “Newborn infants are deficient in vitamin
K, and this injection prevents your infant from a) Pulse, respirations, temperature
abnormal bleeding.”
b) Temperature, pulse, respirations
d) “Newborn infants have sterile bowels, and
vitamin K promotes the growth of bacteria in c) Respirations, temperature, pulse
the bowel.”
d) Respirations, pulse, temperature
89. A nurse in a newborn nursery receives a
93. The nurse is aware that a healthy
phone call to prepare for the admission of a 43-
newborn’s respirations are:
week-gestation newborn with Apgar scores of 1
and 4. In planning for the admission of this a) Regular, abdominal, 40-50 per minute,
infant, the nurse’s highest priority should be to: deep
a) Connect the resuscitation bag to the b) Irregular, abdominal, 30-60 per minute,
oxygen outlet shallow
b) Turn on the apnea and cardiorespiratory c) Irregular, initiated by chest wall, 30-60 per
monitors minute, deep
c) Set up the intravenous line with 5% d) Regular, initiated by the chest wall, 40-60
dextrose in water per minute, shallow
d) Set the radiant warmer control 94. A newborn has small, whitish, pinpoint
temperature at 36.5* C (97.6*F) spots over the nose, which the nurse knows
are caused by retained sebaceous secretions.
90. Vitamin K is prescribed for a neonate. A
When charting this observation, the nurse
nurse prepares to administer the medication in
identifies it as:
which muscle site?
a) Milia
a) Deltoid
b) Lanugo
b) Triceps
c) Whiteheads
c) Vastus lateralis
d) Mongolian spots
d) Biceps
95. While assessing a 2-hour old neonate, the
91. The primary critical observation for Apgar
nurse observes the neonate to have
scoring is the:
acrocyanosis. Which of the following nursing
a) Heart rate actions should be performed initially?

b) Respiratory rate a) Activate the code blue or emergency

system
c) Presence of meconium
b) Do nothing because acrocyanosis is
d) Evaluation of the Moro reflex normal in the neonate
53

c) Immediately take the newborn’s a) Lanugo

temperature according to hospital policy
b) Milia
d) Notify the physician of the need for a
cardiac consult c) Nevus flammeus

96. The nurse is aware that a neonate of a d) Vernix

mother with diabetes is at risk for what
99. A woman delivers a 3,250 g neonate at 42
complication?
weeks’ gestation. Which physical finding is
a) Anemia expected during an examination if this
neonate?
b) Hypoglycemia
a) Abundant lanugo
c) Nitrogen loss
b) Absence of sole creases
d) Thrombosis
c) Breast bud of 1-2 mm in diameter
97. A client has just given birth at 42 weeks’
gestation. When assessing the neonate, which d) Leathery, cracked, and wrinkled skin
physical finding is expected?
100. Soon after delivery, a neonate is admitted
a) A sleepy, lethargic baby to the central nursery. The nursery nurse
begins the initial assessment by:
b) Lanugo covering the body
a) Auscultate bowel sounds.
c) Desquamation of the epidermis
b) Determining chest circumference.
d) Vernix caseosa covering the body
c) Inspecting the posture, color, and
98. A mother of a term neonate asks what the respiratory effort.
thick, white, cheesy coating is on his skin.
Which correctly describes this finding? d) Checking for identifying birthmarks.

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