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    Exam Review

    1. When observing a 2-year-old client for pain, which behavior should the nurse prioritize in the FLACC scale assessment?
      A)
      The parent rating the child’s pain on a scale of 1 to 10
      B)
      The client explaining how they got injured
      C)
      The child writing their pain level
      D)
      Facial expression of the child
    2. A client presents with decreased flexion of the right elbow and reports significant pain when performing activities involving this joint. What is the most appropriate nursing action to facilitate the assessment of this client's range of motion?
      A)
      Apply a heat pack to the elbow prior to assessment to relax the muscles
      B)
      Request the client to perform active ROMs independently without assistance
      C)
      Cradle the client's joint and perform passive ROM exercises gently to assess movement
      D)
      Instruct the client to stretch the arm and attempt to lift weights
    3. What anatomical landmark is critical for identifying rib locations when beginning a respiratory assessment?
      A)
      The Angle of Louis
      B)
      The iliac crest
      C)
      The acromion process
      D)
      The xiphoid process
    4. During a skin examination of an older adult, which finding should the nurse recognize as potentially abnormal and warrant further investigation?
      A)
      A black mole or one with multiple colors
      B)
      Skin tags
      C)
      Age spots (lentigo)
      D)
      Seborrheic keratosis
    Page 1 of 13

    Exam Review

    1. A nurse at an extended care facility is instructing a class of assistive personnel (AP) about client use of assistive devices during ambulation. Which of the following instructions should the nurse give the APs about the clients' use of a cane?
      A)
      "The grip should be level with the client's waist
      B)
      "When the client moves, he should move the cane forward first."
      C)
      "The client should hold the cane on the weak side of his body."
      D)
      "The client should first move the strong leg, then the weak one”
    2. When assessing an older adult client, you note diminished peripheral pulses in the lower extremities. What should be the nurse's next step in assessment or intervention?
      A)
      Administer oxygen to improve circulation
      B)
      Document findings and send the client for a CT scan.
      C)
      Perform a capillary refill test on the toes.
      D)
      Immediately apply warm compresses to the feet
    3. When assessing the upper extremities, which finding would warrant immediate concern
      A)
      Presence of healed scars on the forearm
      B)
      Tenderness elicited during palpation of the elbow joint
      C)
      Firm muscle mass on palpation
      D)
      Symmetric mice bilaterally
    4. During an assessment of a client’s shoulders and upper extremities, which unexpected finding warrants further investigation?
      A)
      Symmetrical swelling in both shoulders
      B)
      Muscle atrophy observed in the upper arm
      C)
      Mild erythema around the shoulder joint
      D)
      Presence of muscle spasms during evaluation
    Page 2 of 13

    Exam Review

    1. A nurse is assessing the vital signs of a 6-month-old infant. Which of the following respiratory rates would be within the expected reference range?
      A)
      44 breaths per minute
      B)
      20 breaths per minute
      C)
      70 breaths per minute
      D)
      12 breaths per minute
    2. A nurse is caring for an E-month-old infant who screams when the parent leaves the room. The parent begins to cry and says, "I don't understand why my child is so upset. I've never seen my child act this way around others before." Which of the following statements should the nurse make?
      A)
      "This is a typical reaction for a child who is sick”
      B)
      "This is a normal, expected reaction for a child of this age”
      C)
      This is a response to an overstimulating environment."
      D)
      "This is a common reaction to an overexposure to caregivers."
    3. An older adult client presents with sudden onset of confusion, difficulty speaking, and weakness on one side of the body. Given these signs, which diagnosis should the nurse prioritize ruling out?
      A)
      Severe dehydration
      B)
      Transit ischemic Attack (TIA)
      C)
      Seizure activity
      D)
      Dementia
    4. An older adult client presents with shortness of breath and fatigue but has no prior diagnosis of heart failure. Which unexpected finding might suggest a cardiovascular change associated with aging that requires further investigation?
      A)
      Stable blood pressure readings
      B)
      Normal respiratory rate and pattern
      C)
      Increased heart rate during exercise
      D)
      Presence if edema in lower extremities
    Page 3 of 13

    Exam Review

    1. During the anterior chest auscultation of a client, what is the most critical action the nurse should take to ensure accurate assessment of lung sounds?
      A)
      Use the stethoscope over clothing to reduce friction and noise
      B)
      instruct the client to breathe in deeply through their nose while listening
      C)
      only auscultate on the left side as it has fewer lobes and compare
      D)
      Position the stethoscope at the midclavicular line and listen to breathing sounds during inspiration and expiration
    2. An older adult with newly diagnosed osteoporosis asks about dietary recommendations to protect bone health What advice should the nurse provide?
      A)
      Limit dairy products to reduce fat intake
      B)
      Adopt a high protein diet to strengthen bones
      C)
      Avoid all pressed foods to protect bone integrity
      D)
      increase calcium rich and vitamin D rich food intake
    3. A nurse notices intercostal retractions in an infant with irregular breathing. What action should be prioritized?
      A)
      Administer oxygen therapy via nasal cannula.
      B)
      Reposition the infant to improve alignment and breathing
      C)
      Ask the caregiver about recent exposure to illness
      D)
      Refer for critical congenital heart disease screening
    4. While assessing the sensory development of a 2-month-old infant, which finding should most alert the nurse to a possible sensory deficit?
      A)
      The infant startles briefly when touched gently on the arm
      B)
      The infant does not turn the head or eyes toward a familiar voice or sound.
      C)
      The infant exhibits frequent cupping and occasional sighing during sleep.
      D)
      The infant occasionally fixates on a brightly colored toy for several second
    Page 4 of 13

    Exam Review

    1. During a musculoskeletal assessment, what would be the most appropriate action if unilateral swelling is noted in the shoulder?
      A)
      Document the swelling and proceed to assess other body systems.
      B)
      Ask the client to perform active range of motion exercises to reduce swelling
      C)
      Perform a focused palpation of the area to check for tenderness or crepitus.
      D)
      Continue the assessment and reassess the swelling at a later time.
    2. A client presents with a respiratory rate of 30min and oxygen saturation of 89%. What priority action should the nurse take?
      A)
      Call for an ECG to check heart rhythm
      B)
      Document the findings
      C)
      Administer supplemental oxygen
      D)
      Reassess vital signs in 15 minutes
    3. During an assessment, you observe that a client has cyanotic lips and slow, shallow breathing What should be your priority action?
      A)
      Start the client on intravenous fluids immediately
      B)
      Perform a complete cardiovascular exam
      C)
      Check blood glucose levels.
      D)
      Administer Supplemental oxygen and monitor oxygen saturation
    4. A nurse is preparing to perform an abdominal assessment on a child. Identify the sequence the nurse should follow. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)
      A)
      Superficial palpation
      B)
      Deep palpation
      C)
      Inspection
      D)
      Auscultation
    Page 5 of 13

    Exam Review

    1. A client demonstrates hesitancy and visible discomfort when completing shoulder range of motion exercises. What is the most appropriate intervention?
      A)
      Encourage the client to continue exercises despite discomfort to improve mobility
      B)
      Apply heat therapy immediately to relieve discomfort.
      C)
      Document the finding and monitor for worsening symptoms over the next week
      D)
      Assess for accompanying swelling, erythema, or deformity in the affected shoulder
    2. A nurse is conducting an in-service training for pediatric nurses about assessing developmental delays in infant gross motor skits. Which of the following findings should the nurse prioritize as an indication of potential gross motor delay in a 9-month-old infant?
      A)
      The infant does not babble or imitate sounds
      B)
      The infant cannot pick up small objects using a pincer grip
      C)
      The infant is unable to visually track moving objects.
      D)
      The infant is unable to sit without support
    3. An older adult cent presents with shortness of breath and peripheral edema. Which unexpected cardiovascular finding should the nurse prioritize investigating?
      A)
      High cholesterol levels
      B)
      increased heart rate during exercise
      C)
      Irregular heart rhythm.
      D)
      Heart murmur detected upon auscultation
    4. A nurse is assessing an older adult client with complaints of generalized weakness. Which of the following neurological findings would be considered expected in this population?
      A)
      Slower reaction times during voluntary movements
      B)
      A grade of 4+ deep tendon reflexes in the lower extremities
      C)
      Significant difficulty with both voluntary and involuntary movements
      D)
      Loss of motor function in both upper and lower limb
    Page 6 of 13