Health Assessment in Nursing 5th Edition by Janet R. Weber, Jane H. Kelley – Test Bank

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Health Assessment in Nursing 5th Edition by Janet R. Weber, Jane H. Kelley – Test Bank

 

Sample  Questions

 

 

Page 1

  1. A nurse has completed a comprehensive assessment of a client and has begun the

process of data analysis. Data analysis should allow the nurse to produce which of the

following direct results?

  1. A) Outcomes evaluation
  2. B) Nursing diagnoses
  3. C) Holistic interventions
  4. D) An interdisciplinary plan of care
  5. A new nursing graduate recently made an oversight during the analysis of a client’s

assessment data that resulted in a postoperative complication. What characteristic of

data analysis makes it a challenging aspect of nursing practice?

  1. A) Abnormal data must be identified.
  2. B) It requires the prior identification of nursing diagnoses.
  3. C) It requires sophisticated diagnostic reasoning skills.
  4. D) Conclusions must be clearly and accurately documented.
  5. A hospital nurse has identified a need to improve her critical thinking skills in an effort

to improve client care. The nurse should identify which of the following characteristics

of critical thinking?

  1. A) It is an innate skill that some individuals possess and which others do not.
  2. B) It does not include past experiences.
  3. C) It is based primarily on getting correct and timely information.
  4. D) It involves reflections on thoughts before reaching conclusions.
  5. The emergency department has collected extensive data from a client who has presented

with a new onset of severe abdominal pain. What nursing action should the nurse

perform before proceeding with data analysis?

  1. A) Validate the collected data.
  2. B) Formulate a nursing diagnosis.
  3. C) Make inferences about the data.
  4. D) Identify the client’s strengths.
  5. A nurse has completed a client’s initial assessment and is preparing to identify abnormal

data and the client’s strengths. Successful completion of this phase of the nursing

process most requires which of the following?

  1. A) Knowledge of anatomy and physiology
  2. B) Awareness of the client’s medical prognosis
  3. C) Inferences about the client
  4. D) Knowledge about the referral process
  5. A nurse is planning a client’s care following the completion of an initial assessment.

When formulating a risk nursing diagnosis, which piece of data would be most useful?

  1. A) The client has an elevated white blood cell count.
  2. B) The client is 66 years of age.
  3. C) The client has pain in her joints, especially in the morning.
  4. D) The client is separated from her usual social supports.
  5. During the assessment interview, the client made numerous statements that suggested

his life generally exists in a state of harmony and balance. This fact would most likely

prompt the nurse to identify which of the following?

  1. A) Actual nursing diagnosis
  2. B) Risk nursing diagnosis
  3. C) Collaborative problem
  4. D) Health promotion diagnosis
  5. A nurse is caring for a client who has been admitted with an infected venous ulcer. The

nurse determines that the client will need medical interventions as well as nursing

interventions. The nurse would identify which of the following?

  1. A) Actual nursing diagnosis
  2. B) Referral
  3. C) Risk nursing diagnosis
  4. D) Collaborative problem
  5. A nurse has assessed a client and identified data that are associated with the diagnoses

of Impaired Physical Mobility and Activity Intolerance. How can the nurse best

determine which nursing diagnosis is most applicable to the client?

  1. A) Document preliminary conclusions.
  2. B) Identify abnormal data.
  3. C) Check the defining characteristics of the diagnoses.
  4. D) Test the nursing diagnoses clinically.
  5. A nurse is analyzing the assessment data of a client who has been admitted with

exacerbation of heart failure. The nurse has determined that the cue clusters meet the

defining characteristics of specific nursing diagnoses. Which of the following would the

nurse do next?

  1. A) Explain the client’s problems to the client and his or her family.
  2. B) Verify it with the client and with other health care professionals.
  3. C) Validate the diagnosis with the physician.
  4. D) Work with the client to begin planning interventions.

Page 3

  1. A nurse’s data analysis has led to the formulation of a risk nursing diagnosis. Which of

the following best demonstrates accurate documentation of a risk nursing diagnosis?

  1. A) Risk for fatigue related to increased job demands, as manifested by feelings of

exhaustion and frequent naps

  1. B) Risk for infection, as manifested by lack of client knowledge of wound care
  2. C) Risk for violence related to history of overt, aggressive acts
  3. D) Risk for altered respiratory function related to environmental allergens, as

manifested by asthma

  1. A nurse is preparing to document conclusions after analyzing data, and he or she

includes information about related factors and manifestations. The nurse is formulating

which of the following?

  1. A) Risk nursing diagnosis
  2. B) Actual nursing diagnosis
  3. C) Collaborative problem
  4. D) Problem for referral
  5. A nurse is applying the diagnostic reasoning process in the care of a client. What is the

correct sequence of the steps that the nurse should perform?

  1. A) Check for defining characteristics.
  2. B) Draw inferences.
  3. C) Propose possible nursing diagnoses.
  4. D) Identify abnormal data and strengths.
  5. E) Cluster data.
  6. The nurse has collected objective and subjective data during the assessment of a client

who has been admitted for the treatment of an exacerbation of chronic obstructive

pulmonary disease (COPD). During the current phase of the diagnostic reasoning

process, the nurse is writing down thoughts about each cue cluster of data that was

collected. The nurse is involved in which step of the diagnostic reasoning process?

  1. A) Step One: Identify Abnormal Data and Strengths
  2. B) Step Two: Cluster Data
  3. C) Step Three: Draw Inferences
  4. D) Step Four: Propose Possible Nursing Diagnoses
  5. A nurse is determining whether the data for a client support a potential nursing

diagnosis. The nurse is most likely engaged in which step in the diagnostic reasoning

process?

  1. A) Step Three: Draw Inferences
  2. B) Step Four: Propose Possible Nursing Diagnoses
  3. C) Step Five: Check for Defining Characteristics
  4. D) Step Six: Confirm or Rule Out Diagnoses
  5. A nurse is applying the diagnostic reasoning process in the care of a client with a

number of comorbidities. Which of the following descriptions best characterizes Step

Two, Clustering Data?

  1. A) Hypothesizing of any potentially applicable health promotion diagnoses, risk

diagnoses, and actual diagnoses

  1. B) Documentation of all professional judgments along with any data that support

those judgments

  1. C) Examining identified abnormal findings and strengths for cues that are related
  2. D) Evaluation of both subjective and objective data to identify strengths and abnormal

findings

  1. An experienced nurse is teaching a recently graduated colleague about common pitfalls

encountered in the diagnostic reasoning process. The experienced nurse should identify

a need for further teaching if the new graduate identifies which of the following as a

pitfall?

  1. A) View of things as either right or wrong
  2. B) Overemphasis on details
  3. C) Inclusion of valid data
  4. D) Clustering of unrelated cues
  5. A nurse on a busy acute medical unit asks a clinical educator for suggestions on how to

best develop expertise in using diagnostic reasoning skills to arrive at correct

conclusions. Which of the following statements would be most appropriate?

  1. A) “You need to cluster the data more rapidly.”
  2. B) “This skill comes with accumulating experience.”
  3. C) “Try to be more efficient in documenting the data.”
  4. D) “This is a skill that only comes with an advanced practice designation.”

Page 5

  1. A nurse has identified a goal of developing his critical thinking skills. In order to

facilitate this goal, what action should the nurse prioritize?

  1. A) Applying quick decision-making
  2. B) Seeking new experiences
  3. C) Maintaining an open mind
  4. D) Maintaining a stable and static knowledge base
  5. After teaching a group of students about the second phase of the nursing process, the

instructor determines that additional teaching is needed when the students identify

which of the following as a component?

  1. A) Organizing data
  2. B) Clustering data
  3. C) Formulating a medical diagnosis
  4. D) Generating hypotheses
  5. An experienced medical-surgical nurse has identified critical thinking as an integral

component of diagnostic reasoning. How can the relationship between these two

concepts be best described?

  1. A) Critical thinking is the practical application of diagnostic reasoning skills.
  2. B) Critical thinking and diagnostic reasoning are synonymous.
  3. C) Critical thinking is the foundation of the process of diagnostic reasoning.
  4. D) Critical thinking is the domain of the novice nurse, whereas diagnostic reasoning is

present in experts.

  1. During an educational inservice, nursing have been encouraged to conduct a

self-appraisal of their critical thinking skills. Which of the following questions can best

guide this appraisal?

  1. A) “Do I tend to make errors in my nursing practice?”
  2. B) “Do I get good feedback from clients and their families?”
  3. C) “Am I open to the fact that I may not be right?”
  4. D) “Am I a resource to my colleagues during a crisis?”
  5. A nurse has admitted a client to the medical unit who has just been diagnosed with

endocarditis secondary to IV drug use. The nurse has completed the collection of

objective and subjective data. What question should guide the next step in the nurse’s

data analysis?

  1. A) “What are this client’s strengths?”
  2. B) “What is this client’s prognosis?”
  3. C) “Why does this client use opioids?”
  4. D) “What are this client’s hopes for the future?”
  5. The nurse is attempting to cluster the data that she collected during the initial

assessment of an older adult client. The nurse notes that the client had a swollen left

knee and complained of “a bit of soreness” in the joint, but the nurse does not have

enough data to support a nursing diagnosis of Impaired Physical Mobility. What should

the nurse do next?

  1. A) Document a suspected nursing diagnosis of Impaired Physical Mobility.
  2. B) Assess the client further for evidence of reduced mobility and decreased range of

motion.

  1. C) Make a referral to the physical therapist.
  2. D) Plan interventions that will conservatively manage the client’s joint dysfunction.
  3. A nurse has been clustering the data that he collected during the initial assessment of a

frail elderly client. When making inferences about the data clusters, the nurse is unsure

whether to associate a cluster of data with a nursing diagnosis or with a collaborative

problem. What question may best guide the nurse’s decision?

  1. A) “Can an unlicensed care provider meet this person’s needs?”
  2. B) “Is this problem acute or is it chronic?”
  3. C) “Can this issue be addressed on an outpatient basis?”
  4. D) “Does this issue require medical intervention?”
  5. A nurse is providing care for a client who has longstanding type 2 diabetes. In recent

days, the client’s blood glucose levels have been higher and more volatile than usual.

After drawing this inference, the nurse should take what action?

  1. A) Make appropriate referrals
  2. B) Assess the client more frequently
  3. C) Document the medical diagnosis of hyperglycemia
  4. D) Beginning collecting subjective data
  5. The nurse’s assessment of a client with a decreased level of consciousness reveals that

the client is incontinent of urine. During the process of data analysis, the nurse would be

justified in identifying what risk nursing diagnosis?

  1. A) Risk for Injury related to urinary incontinence
  2. B) Risk for Infection related to urinary incontinence
  3. C) Risk for Bowel Incontinence related to urinary incontinence
  4. D) Risk for Impaired Skin Integrity related to urinary incontinence

Page 7

  1. A nurse has selected several nursing diagnoses in the process of data analysis of a client

with poorly controlled type 1 diabetes. One of these diagnoses is Ineffective Health

Maintenance related to infrequent blood glucose monitoring as manifested by elevated

HgA1C. The nurse recognizes the need to corroborate this diagnosis with the client.

How should the nurse best do this?

  1. A) “I think you have a nursing diagnosis of Ineffective Health Maintenance.”
  2. B) “Would you agree that there’s room for improvement in your routines around blood

sugar monitoring?”

  1. C) “After assessing you, I believe that you’re not maintaining your health effectively,

specifically around your diabetes.”

  1. D) “How do you think that you could better maintain your health?”
  2. Data analysis of assessment data from a client who presented to the emergency

department has resulted in the nurse making a syndrome nursing diagnosis. What is a

primary characteristic of this type of diagnosis?

  1. A) The client’s health problem cannot be conveyed using standard nursing language.
  2. B) The client’s current signs and symptoms are the result of a longstanding health

problem.

  1. C) The client has health problems that will require multidisciplinary care.
  2. D) The client has a number of nursing diagnoses that typically occur together.
  3. A nurse has collecting extensive data during a client assessment and is performing the

first step in the process of data analysis. Successful completion of this step requires the

nurse to do which of the following?

  1. A) Differentiate between expected findings and abnormal findings.
  2. B) Validate nursing diagnoses with the client and the client’s family.
  3. C) Integrate the client’s medical diagnosis with nursing diagnoses.
  4. D) Perform health promotion education.

 

Page 1

  1. The nurse is assessing a client’s psychosocial development in light of Freud’s theory.

The nurse would interpret the client’s status as the outcome of conflict between what

variables?

  1. A) Cultural norms and personality traits
  2. B) Biological desires and social expectations
  3. C) Sexual desires and relational desires
  4. D) Sociocultural norms and health needs
  5. A client admits to the nurse that she feels guilty for not providing more direct care for

her ill mother. According to Freud, the moral component of this client’s feelings results

from which of the following?

  1. A) Defense mechanisms
  2. B) The superego
  3. C) The id
  4. D) The ego
  5. A school nurse who provides care in a middle school works exclusively with

adolescents. According to Erikson’s theory of psychosocial development, what task will

underlie much of the students’ behavior?

  1. A) Exerting influence over others
  2. B) Evaluating the merits of their parents’ beliefs
  3. C) Appraising religious dogma
  4. D) Establishing a personal identity
  5. An infant was removed from her home by social services because of the dangerous and

neglectful conditions that existed. According to Erikson, failure of the infant to resolve

the central crisis of infancy may lead to what personality characteristics later in life?

  1. A) Suspicion and fear
  2. B) Aggression and antagonism
  3. C) Dependency and relational entanglement
  4. D) Depression and introversion
  5. The nurse is applying Piaget’s theory of development to a client’s health history. This

approach to analysis will prioritize what activity on the part of the client?

  1. A) Learning
  2. B) Imitating
  3. C) Indulging
  4. D) Desiring

Page 2

  1. The nurse is analyzing the data obtained from a client interview. When applying the

principles of Kohlberg’s theory of development, the nurse should prioritize data related

to what domain?

  1. A) The client’s moral behavior
  2. B) The client’s relationships
  3. C) The client’s health
  4. D) The client’s sexual identity
  5. The nurse is working with an older adult client and is attempting to determine whether

the client deems her life to have been meaningful and valuable. As well, the nurse has

addressed the client’s acceptance of the inevitability of death. This nurse’s actions are

best understood within the ideas of which theorist?

  1. A) Freud
  2. B) Erikson
  3. C) Piaget
  4. D) Kohlberg
  5. The nurse is assessing a client’s cultural identity and affiliation during the health

interview. How best can the nurse elicit this information?

  1. A) ìWhat are your race and culture?î
  2. B) ìWould you describe yourself as American?î
  3. C) ìHow would you describe your cultural values?î
  4. D) ìWith which cultural group do you most closely identify?î
  5. The nurse is conducting a health interview and is addressing the client’s current

stressors. What is the primary rationale for including stress as a focus of psychosocial

assessment?

  1. A) Stress provides the main impetus for psychosocial development and adaptation.
  2. B) Psychosocial development cannot progress normally in the presence of stress.
  3. C) Psychosocial stress has a major influence on health in many domains.
  4. D) The results of the health interview are distorted when the client is experiencing

stress.

  1. The nurse is conducting a health interview and has asked the client, ìHow would you

describe yourself to others?î The client’s response informs the nurse’s assessment of

which of the following?

  1. A) The client’s morality and honesty
  2. B) The client’s aspirations
  3. C) The client’s self-concept
  4. D) The client’s superego

Page 3

  1. During the health interview of a new client, the nurse has explored the client’s decisionmaking

strategies. These data are most essential to the developmental theory of which

theorist?

  1. A) Freud
  2. B) Kohlberg
  3. C) Piaget
  4. D) Erikson
  5. The nurse is assessing an older adult’s psychosocial development with reference to

Freud’s theory of development. What observation by the nurse would most clearly

suggest healthy development within this theoretical framework?

  1. A) The client is able to describe challenges that he has overcome.
  2. B) The client has eliminated conflictual relationships from his life.
  3. C) The client is able to delegate care to others when necessary.
  4. D) The client appears to have dealt effectively with recent losses.
  5. The nurse is applying the principles of Freud’s theory of psychosocial development

during the health assessment of a young adult client. What assessment question is most

likely to elicit data that are meaningful within this theoretical framework?

  1. A) ìDo you have a sufficient number of friends?î
  2. B) ìDo you have a satisfying sexual relationship?î
  3. C) ìHow do you feel about your cultural background?î
  4. D) ìDo you consider yourself to be a good person?î
  5. The nurse is assessing a young adult client in light of Erikson’s theory of psychosocial

development. During this life stage, what assessment finding would most clearly

suggest a lack of successful development?

  1. A) The client is dissatisfied with her current job.
  2. B) The client describes herself as lonely and isolated.
  3. C) The client has been diagnosed with bipolar disorder.
  4. D) The client had a child when she was in her late teens.
  5. What action on the part of a middle-aged client would best exemplify Erikson’s concept

of generativity?

  1. A) Being able to accurately evaluate the merits of others’ ideas
  2. B) Emphasizing the importance of one’s knowledge and skill set
  3. C) Consistently increasing one’s income
  4. D) Guiding and mentoring individuals who are younger

Page 4

  1. The nurse’s interview with an older adult client reveals that he bitterly regrets some of

the financial decisions that he made when he was younger. The nurse recognizes that

unless the client is able to accept these undesirable aspects of life, what outcome is

likely?

  1. A) The client will adopt antisocial behaviors late in life.
  2. B) The client will die prematurely.
  3. C) The client will gradually abandon significant relationships.
  4. D) The client will live with despair during his final years of life.
  5. When appraising a young adult’s psychosocial development within the framework of

Erikson’s theory, what question should guide the nurse’s data collection and analysis?

  1. A) Can the client successfully solve problems?
  2. B) Has the client successfully achieved intimacy?
  3. C) Has the client learned to trust others?
  4. D) Can the client teach life skills to others?
  5. What assessment finding would most clearly suggest to the nurse that a young adult

client has failed to attain normal development within Piaget’s framework?

  1. A) The client has difficulty understanding abstract reasoning in written form.
  2. B) The client has a recent history of tumultuous interpersonal relationships.
  3. C) The client is often defiant toward authority figures.
  4. D) The client is unwilling to accept responsibilities in the workplace.
  5. Assessment of an older adult client suggests that the client does not possess formal

operational thinking. Within Piaget’s framework of development, what nursing

diagnosis is the most likely consequence of this developmental deficit?

  1. A) Spiritual distress
  2. B) Ineffective health maintenance
  3. C) Ineffective sexuality pattern
  4. D) Risk for suicide
  5. The nurse has identified abnormal findings when reviewing a young adult client’s health

history. Within Kohlberg’s theory of psychosocial development, what behavioral

characteristic is the nurse most likely to observe?

  1. A) The client has difficulty trusting others.
  2. B) The client is easily manipulated by others.
  3. C) The client is unable to weigh options when presented with a dilemma.
  4. D) The client makes decisions without considering the impact on others.

Page 5

  1. When applying Kohlberg’s theory of moral development to the status of an older adult

client, on what assessment finding would the nurse focus?

  1. A) The relationship between the client’s stated beliefs and his actions
  2. B) The client’s ability to discern the motivations of others
  3. C) The client’s adherence to rules, laws, and norms
  4. D) The client’s ability to tolerate differing views
  5. During the health interview, a client demonstrates the ability to describe healthy and

unhealthy aspects of her thinking patterns. The nurse would conclude that this client has

attained which level of development within Piaget’s framework?

  1. A) Circular operational
  2. B) Preoperational
  3. C) Concrete operational
  4. D) Formal operational
  5. Assessment reveals that a young adult has failed to achieve Erikson’s central task of his

current stage of development. What nursing diagnosis would the nurse associate most

closely with this finding?

  1. A) Risk for compromised human dignity
  2. B) Anxiety
  3. C) Ineffective sexuality pattern
  4. D) Social isolation
  5. The nurse’s assessment suggests that a 10-year-old has failed to achieve Erikson’s

central task of this stage of development. What nursing diagnosis should most likely be

included in the child’s plan of care?

  1. A) Risk for injury
  2. B) Chronic low self-esteem
  3. C) Fear
  4. D) Disturbed thought processes
  5. What statement by a middle-aged adult would most clearly suggest successful

achievement of Erikson’s central task during this stage of development?

  1. A) ìI’m doing a lot of volunteering in order to give back to the community.î
  2. B) ìI’ve started to exercise more regularly so that I don’t put on extra weight.î
  3. C) ìI socialize with my coworkers a lot more than I did when I was younger.î
  4. D) ìOverall, my marriage is likely stronger than it was when we first got married.î

Page 6

  1. The nurse is assessing an adult client’s self-image during the health history interview.

What assessment question is most likely to elicit meaningful data?

  1. A) ìWhat are the activities that give you the most joy?î
  2. B) ìWhat would you describe as your main strengths and weaknesses?î
  3. C) ìDo you consider yourself to be a particularly religious person?î
  4. D) ìWhat actions are you taking to improve your life?î
  5. The nurse is assessing an adult client for the presence of Piaget’s formal operations stage

of development. What assessment question should the nurse ask the client?

  1. A) ìHow do you usually go about making difficult decisions?î
  2. B) ìDo you consider yourself to be an intelligent person?î
  3. C) ìHow would you describe your relationship with authority figures?î
  4. D) ìIn relationships, do you consider yourself to be a ‘giver’ or a ‘taker’?î
  5. The nurse has observed that a client adheres rigidly to the norms of her family and her

culture. In the context of Freud’s theory of development, this pattern of behavior is

attributable to the action of what component of personality?

  1. A) The id
  2. B) The ego
  3. C) The superego
  4. D) The identity
  5. A school nurse is working with kindergarten students. Within Kohlberg’s framework of

moral development, the nurse should recognize that these students’ moral reasoning is

primarily motivated by which of the following?

  1. A) An innate conscience
  2. B) Fear of the negative consequences of individual actions
  3. C) Motivation to exhibit behaviors that are culturally normalized
  4. D) Adherence to basic moral beliefs
  5. The school nurse has learned that a 14-year-old student is having social difficulties.

According to Erikson, what is the most likely source of this child’s stress?

  1. A) The student is experiencing moral dilemmas.
  2. B) The student is having difficulty creating an identity.
  3. C) The student is experiencing a sexual crisis.
  4. D) The student having difficulty understanding the viewpoints of others.

Page 7

 

 

Page 1

  1. A palliative care nurse is explaining the basis of pain to a group of nurses who provide

care on a general medical unit. Which of the following factors would the nurse include?

Select all that apply.

  1. A) Physiologic
  2. B) Psychosocial
  3. C) Cutaneous
  4. D) Somatic
  5. E) Visceral
  6. A group of students is reviewing information about pain transmission and the fibers

involved. The students demonstrate understanding when they state that A-delta primary

afferent fibers transmit pain that is felt as which of the following?

  1. A) Burning
  2. B) Throbbing
  3. C) Sharp
  4. D) Aching
  5. A nurse is assessing the pain of a client who has had major surgery. The client also has

been experiencing depression. Which of the following principles should guide the

nurse’s assessment of a client’s pain?

  1. A) The client is likely experiencing less pain than he is reporting.
  2. B) The client’s depression exists independently of the level of pain.
  3. C) It is likely that the client’s pain rating will be influences by his emotional state.
  4. D) The degree of surgery will be the key indicator for level of pain experienced.
  5. A client has received a diagnosis of chronic nonmalignant pain. The nurse who is

planning this client’s nursing care should understand that this client has experienced this

pain for at least how many months?

  1. A) 3
  2. B) 6
  3. C) 9
  4. D) 12
  5. A nurse educator is presenting an in-service program to a group of nurses who will be

working on an oncology unit. Which of the following characteristics of cancer pain

should the nurse describe?

  1. A) Its basis is usually chronic neuropathy.
  2. B) It is most often caused by a specific recent trauma.
  3. C) It usually appears in the first month after cancer develops.
  4. D) It is typically caused by compressed peripheral nerves.

Page 2

  1. A nurse is admitting a client to the postsurgical unit following breast reconstruction

surgery. Which of the following would the nurse use as the primary assessment for the

client’s pain?

  1. A) The client’s spiritual view of the pain
  2. B) Current pain therapies used preoperatively
  3. C) The client’s report of her pain
  4. D) Psychosocial questions related to her perceptions of pain
  5. The nurse is using the Verbal Descriptor Scale to assess a client’s pain. The nurse will

prioritize which of the following data?

  1. A) The client’s facial expressions
  2. B) The client’s report on a 0 to 10 numeric scale
  3. C) The client’s rating on a 0 to 10 visual analog scale
  4. D) The client’s explanation of how her pain feels
  5. The nurse collects vital signs on a hospital client who has recently been experiencing

pain. Which of the following would suggest most strongly to the nurse that the client is

experiencing pain?

  1. A) Respiratory rate of 18 breaths per minute
  2. B) Temperature of 99.1∞F
  3. C) Heart rate of 110 beats per minute
  4. D) Blood pressure of 120/70 mm Hg
  5. Based on the analysis of assessment data from a client with pain, the nurse writes a

health promotion diagnosis. Which of the following diagnoses would be most

appropriate?

  1. A) Readiness for enhanced spiritual well-being related to coping with prolonged

physical pain

  1. B) Risk for activity intolerance related to chronic pain and immobility
  2. C) Bathing self-care deficit related to severe pain
  3. D) Chronic pain related to chronic inflammatory process of rheumatoid arthritis
  4. A nurse is preparing to document a collaborative problem for a client with pain. Which

of the following would be most appropriate?

  1. A) ìImpaired physical mobility related to chronic painî
  2. B) ìRisk for powerlessness related to chronic painî
  3. C) ìReadiness for enhanced comfort levelî
  4. D) ìRC: peripheral nerve compressionî

Page 3

  1. The nurse is assessing a client whose chronic pain is poorly controlled. Which

assessment finding should the nurse expect under these circumstances?

  1. A) Decreased heart rate
  2. B) Hypoglycemia
  3. C) Increased urinary output
  4. D) Decreased gastric motility
  5. A client rates his pain as 9 on a scale of 1 to 10. The nurse would expect to assess which

of the following?

  1. A) Constricted pupils
  2. B) Hypotension
  3. C) Increased serum glucose
  4. D) Flaccid muscles
  5. The nurse is assessing a client’s pain. Which question would be most appropriate to ask

the client when the goal is to identify precipitating factors that might have exacerbated

the pain?

  1. A) ìWhat were you doing when the pain first stated?î
  2. B) ìDo concurrent symptoms accompany the pain?î
  3. C) ìWhen did the pain start?î
  4. D) ìIs the pain continuous or intermittent?î
  5. A client has questioned why the nurse asked him how his family members usually treat

their pain. Which of the following would be the most appropriate response by the nurse?

  1. A) ìIt is just a way for me to more fully understand you and your upbringing.î
  2. B) ìIt helps me to direct interventions toward your cultural history.î
  3. C) ìIt helps me to determine how the family understands and perceives pain.î
  4. D) ìIt will allow me to see if you are more likely to react to pain in a negative manner.î
  5. When assessing pain in an older adult client who is alert and oriented, which assessment

tool would be most appropriate to use?

  1. A) Numerical rating scale
  2. B) Faces Pain Scale-Revised
  3. C) FLACC Scale
  4. D) Graphic rating scale

Page 4

  1. The nurse is observing a client for evidence of pain. Which of the following would most

likely lead the nurse to suspect that the client may be experiencing pain?

  1. A) Frequent questioning
  2. B) Slumped posture
  3. C) Eye contact
  4. D) Periodic position changes
  5. A nurse is creating a concept map of the pathophysiology of pain. The nurse should

identify which of the following as being responsible for transmitting pain sensations to

the central nervous system?

  1. A) Transduction
  2. B) Modulation
  3. C) Nociceptors
  4. D) Cytokines
  5. A client who has fractured her arm is describing her pain as ìexcruciating.î The nurse

determines that the client is most likely experiencing what type of pain?

  1. A) Cutaneous
  2. B) Visceral
  3. C) Deep somatic
  4. D) Radiating
  5. The nurse is assessing the client’s perception of pain and the client’s description of its

intensity and quality. Which dimension of pain is the nurse evaluating?

  1. A) Physical
  2. B) Sensory
  3. C) Behavioral
  4. D) Cognitive
  5. When attempting to assess a client’s pain, which of the following actions should the

nurse perform first?

  1. A) Observe behaviors in the client.
  2. B) Obtain a client self-report.
  3. C) Search for possible causes of pain.
  4. D) Ask family members about the client’s pain.

Page 5

  1. A hospital’s protocols for assessment have been modified in light of standards

established by the Joint Commission. What change would bring practice into alignment

with these standards?

  1. A) Teaching all new clients about the basic pathophysiology of pain
  2. B) Assessing clients’ pain objectively rather than subjectively
  3. C) Identifying pain as the fifth vital sign and assessing clients accordingly
  4. D) Triaging clients according to the type of pain that they are experiencing
  5. An emergency department nurse is assessing a client’s complaint of upper abdominal

pain. Using the COLDSPA mnemonic, with what assessment question would the nurse

begin?

  1. A) ìCan you describe to me how your pain feels?î
  2. B) ìHow would you rate your pain on a 10-point scale?î
  3. C) ìIs your pain affecting your ability to cope?î
  4. D) ìWould you describe your pain as acute, or as chronic?î
  5. A nurse is providing care for an 84-year-old client who has diagnoses of middle-stage

Alzheimer disease and a femoral head fracture. What assessment tool should the nurse

use to assess the client’s pain?

  1. A) Graphic Rating Scale
  2. B) Numeric Rating Scale (NRS)
  3. C) Verbal Descriptor Scale
  4. D) Faces Pain Scale-Revised (FPS-R)
  5. A female client with bone cancer is experiencing pain that has become more severe over

the past several days. When modifying the client’s plan of care, the nurse identifies a

need to assess the affective dimension of the client’s pain. How can the nurse best

accomplish this goal?

  1. A) Document the ways that the client’s pain affects her activities of daily living.
  2. B) Determine whether the client is able to independently treat her pain.
  3. C) Closely monitor the effects of the client’s pain on her emotions.
  4. D) Ask the client to rate her pain during every physiological assessment.
  5. A nurse is attempting to apply the principles of cultural competency in the care of a 72-

year-old Asian-American woman who has a spinal cord compression. Which of the

following statements should guide the nurse’s care?

  1. A) The client may view pain as a sign of weak character.
  2. B) The client may be reluctant to accept opioids.
  3. C) The client may tend to overreport her pain.
  4. D) The client may be unable to understand quantitative assessment scales.

Page 6

  1. A female client with advanced-stage vascular dementia has been showing signs of pain

over the past several hours. The nurse is unable to obtain a self-report from the client

due to her cognitive impairment. When applying the Hierarchy of Pain Assessment

Techniques, how should the nurse proceed with assessment?

  1. A) Search for potential causes of pain.
  2. B) Ask the client’s family if they believe she is in pain.
  3. C) Perform interventions as if the client were in pain.
  4. D) Use a visual assessment tool rather than a verbal tool.
  5. A nurse is admitting a client to the postsurgical unit from the postanesthetic care unit.

The nurse has transferred the client from the stretcher to a bed and asked the client if he

is experiencing pain. The client acknowledges that he is in pain. What should be the

nurse’s next action?

  1. A) Ask the client to briefly explain his cultural background.
  2. B) Assess the client’s pain according to COLDSPA.
  3. C) Assess the client’s self-management skills.
  4. D) Assess the client’s pain by obtaining a set of vital signs.
  5. A nurse is providing care to a client who has been in a motor vehicle accident and who

has facial lacerations and a pelvic fracture. How can the nurse best determine the

reliability and accuracy of data obtained during a pain assessment?

  1. A) Ask the primary care provider to validate the assessment data.
  2. B) Compare the findings to the client’s preinjury level of health.
  3. C) Compare the findings to the most recent previous pain assessment.
  4. D) Validate the assessment data with the client.
  5. A nurse is performing a detailed pain assessment of a client who has sought care for

debilitating migraines. When assessing for precipitating factors, what question should

the nurse ask?

  1. A) ìIs there anything that’s given you relief in the past?î
  2. B) ìHave your migraines gotten more severe in the last few months?î
  3. C) ìWhat were you doing immediately before your last migraine?î
  4. D) ìHow long does a typical migraine last?î
  5. An older adult client with osteoarthritis has tearfully admitted to the nurse that she is no

longer able to climb the stairs to the second floor of her house due to her knee pain.

What nursing diagnosis is suggested by this client’s statement?

  1. A) Ineffective coping related to knee pain
  2. B) Activity intolerance related to knee pain
  3. C) Ineffective role performance related to osteoarthritis
  4. D) Situational low self-esteem related to osteoarthritis

 

 

Page 1

  1. The nurse is interviewing a female Hispanic client who is scheduled for a cardiovascular

education program. The client states, ìI can’t eat and I don’t sleep because my daughter

left to return to Mexico. I am sad and nervous. I need rest.î The nurse suspects that she

is suffering from susto. Which action by the nurse would be best?

  1. A) Give her a multivitamin supplement.
  2. B) Encourage her to exercise.
  3. C) Reschedule the education program.
  4. D) Refer her to a counselor.
  5. A nurse is admitting a client who is from another culture. Prior to caring for a client

from another culture, the nurse should place primary importance on which action?

  1. A) Examining personal biases and prejudices
  2. B) Researching characteristics of the specific culture
  3. C) Asking colleagues about ways to approach the client
  4. D) Developing awareness of the culture’s health practices
  5. A nurse educator is leading a group of nurses in exercises aimed at improving cultural

competence. Which of the following would the educator use to best describe an aspect

of the term ìcultureî?

  1. A) Transmission occurs to another generation through genetics.
  2. B) It is shared through norms for behaviors, values, and beliefs.
  3. C) It is adapted to a specific environment.
  4. D) It is experienced by all people even without human contact.
  5. A nurse states, ìHispanic people have no clue about primary prevention of illness.î The

nurse is demonstrating which of the following?

  1. A) Stereotyping
  2. B) Ethnicity
  3. C) Cultural incompetence
  4. D) Prejudice
  5. A nurse is assessing a client of East Asian descent. Which biological variation would

the nurse expect?

  1. A) Dry cerumen in the client’s ears
  2. B) Profuse perspiration in the client’s axillary area
  3. C) Strong body odor
  4. D) Longer eustachian tubes

Page 2

  1. A nurse who provides care in a busy, inner-city clinic performs physical examinations

on clients of various cultures. In a client from which group would the nurse expect to

find the greatest amount of body odor from perspiration?

  1. A) Inuit
  2. B) Asian
  3. C) Caucasian
  4. D) Native American
  5. An African-American woman collapses at the funeral of her mother and later states that

she could hear everything people were saying to her but, for a brief period, she could not

move. The nurse interprets this as which of the following?

  1. A) Spell
  2. B) Falling out
  3. C) Empacho
  4. D) Susto
  5. A nurse has identified the goal of becoming more culturally sensitive and competent.

What is the primary rationale for cultural sensitivity in health care settings?

  1. A) Recognize that cultural diversity exists.
  2. B) Understand individual differences.
  3. C) Prevent offending the client.
  4. D) Obtain accurate assessment data.
  5. Based on a colleague’s feedback, a nurse learns that she is aware of cultural differences

in a general way but does not know what the specific differences are or how to

communicate with a person of a specific culture. This nurse exhibits which of the

following?

  1. A) Unconscious incompetence
  2. B) Conscious incompetence
  3. C) Conscious competence
  4. D) Unconscious competence
  5. A group of students is reviewing material on cultural competence. The students

demonstrate understanding of this concept when they identify which of the following as

the starting point?

  1. A) Cultural awareness
  2. B) Cultural desire
  3. C) Cultural skill
  4. D) Cultural knowledge

Page 3

  1. A male Hispanic client describes the fact that he mixed hot and cold foods, causing

them to lump together and ìget stuck in his intestines,î causing diarrhea and abdominal

pain. The nurse would document this as which of the following?

  1. A) Empacho
  2. B) Susto
  3. C) Mal ojo
  4. D) Mal puesto
  5. The nurse attends a Native-American Alcoholic Anonymous support group and

develops close relationships with three group members. The nurse is demonstrating

which of the following?

  1. A) Cultural desire
  2. B) Cultural awareness
  3. C) Cultural encounter
  4. D) Cultural knowledge
  5. The nurse is preparing to lead a health promotion activity among a group of clients from

different cultures. The nurse would expect that which client would require the least

amount of personal space?

  1. A) Latin American
  2. B) Asian
  3. C) American
  4. D) Middle Easterner
  5. A nurse is modifying an Asian client’s diet to accommodate the concept of hot and cold.

The nurse demonstrates an understanding of this concept when identifying which of the

following as a cold condition?

  1. A) Diabetes
  2. B) Pneumonia
  3. C) Sore throat
  4. D) Hypertension
  5. When reviewing cultural differences that relate to the incidence and prevalence of

disease among various cultural groups, the nurse would expect to see the highest

prevalence of asthma in which group?

  1. A) Non-Hispanic blacks
  2. B) Caucasians
  3. C) African Americans
  4. D) Southeast Asians

Page 4

  1. The nurse is assessing the diet and nutritional status of a client from a different culture.

Which of the following questions would be appropriate for the nurse to ask? Select all

that apply.

  1. A) ìWhat foods do you commonly eat?î
  2. B) ìDo you have any special routines for eating?î
  3. C) ìAre there any foods that you can’t eat?î
  4. D) ìDo you eat three meals a day?î
  5. E) ìDo you have certain foods to keep you healthy?î
  6. When considering the various cultural aspects associated with death rituals, which of the

following should guide a nurse’s practice?

  1. A) Most cultures have similar durations for the length of time a person grieves.
  2. B) A person’s view of death is likely to be different from the original ethnic group’s

practice.

  1. C) Responses to death and grief are fairly consistent among different cultures.
  2. D) Rituals for burial and bereavement are likely to reflect original cultural practices.
  3. A nurse is assessing an Asian client and observes several reddened and bruised areas on

the skin. Further assessment reveals that the client was using cupping to treat back pain.

The nurse understands this as which of the following?

  1. A) Placing heated glass jars on the skin that are allowed to cool
  2. B) Rubbing ointment into the skin with a spoon
  3. C) Attaching smoldering herbs to acupuncture needles
  4. D) Placing warm burning herbs directly on the skin
  5. A nurse educator is reviewing the unit’s resources about religious groups and their views

about blood and blood products, organ donation, and autopsy. A member of which

group is most likely to refuse a blood transfusion?

  1. A) Christian Scientists
  2. B) Jehovah’s Witnesses
  3. C) Orthodox Jews
  4. D) Roman Catholics
  5. A cardiac care nurse works with a diverse client population. The nurse would assess a

client from which cultural group for an increased effect of an antihypertensive

medication?

  1. A) Eskimos
  2. B) Native Americans
  3. C) Hispanics
  4. D) Chinese

Page 5

  1. A nurse’s reflection of his practice reveals that he tends to see his own culture as the

ìgold standardî to which all other cultures should aspire. This nurse should create

learning goals to address what phenomenon?

  1. A) Ethnocentrism
  2. B) Unconscious incompetence
  3. C) Stereotyping
  4. D) Acculturation
  5. A nurse is participating in an educational exercise in which she is conducting a selfexamination

of her own biases. This activity addresses what construct of cultural

competence?

  1. A) Cultural desire
  2. B) Cultural knowledge
  3. C) Cultural skill
  4. D) Cultural awareness
  5. A nurse is caring for a 70-year-old client from a different culture whose breast cancer

has metastasized. The nurse observes that the client tends to defer responsibility for

decision making around treatment options to her eldest son. How should the nurse

respond to this?

  1. A) Explain the disconnect between the client’s practice and the principle of client

autonomy.

  1. B) Confirm that the client wants her son to make decisions and follow those decisions

accordingly.

  1. C) Attempt to dialogue with the client when her son is not present.
  2. D) Refer the family to social work in order to further explore alternative decisionmaking

practices.

  1. A clinic nurse is conducting a comprehensive assessment of a 70-year-old male client of

Native American ethnicity. The nurse observes that the client rarely makes eye contact

and holds his head low during the assessment. How should the nurse best interpret this

practice?

  1. A) The client may not understand the purpose of the assessment.
  2. B) The client may be showing the nurse respect.
  3. C) The client may be a victim of intimate partner violence.
  4. D) The client may not trust the nurse’s expertise.

Page 6

  1. A nurse is validating assessment findings with a client, and the client proceeds to

describe some of the psychological and spiritual components that she believes underlie

her disease process. This understanding of the cause of illness is most closely associated

with which of the following?

  1. A) Northern European cultures
  2. B) The Western biomedical model
  3. C) African-American culture
  4. D) Asian cultures
  5. A nurse is working with a 22-year-old woman of Asian ethnicity who has been

diagnosed with bipolar disorder. When planning culturally appropriate care, the nurse

should consider which of the following?

  1. A) There may a lack of acceptance that the client’s behavior is abnormal.
  2. B) The client’s family may see her illness as punishment for misdeeds.
  3. C) The client’s family may see her psychiatric disorder as evidence of bad character.
  4. D) There may be shame associated with having a psychiatric disorder.
  5. A nurse is assessing an African-American client who has a longstanding diagnosis of

hypertension. The nurse should be aware that the client may experience a greater-thanaverage

effect of what medication?

  1. A) A diuretic
  2. B) An angiotensin-converting enzyme inhibitor
  3. C) A calcium channel blocker
  4. D) A beta-adrenergic blocker
  5. A nurse will be working in a clinic in South Asia for several weeks, where the majority

of residents have darkly pigmented skin. The nurse should expect a higher-than-average

incidence of what integumentary health problem?

  1. A) Contact dermatitis
  2. B) Vitiligo
  3. C) Psoriasis
  4. D) Eczema
  5. A nurse is relying heavily on gestures and simplified language during the assessment of

a client from another culture who speaks minimal English. During the lengthy

assessment, the nurse asks the client if she is ìokayî by making a circle with his thumb

and forefinger. The nurse should be aware of which of the following?

  1. A) In some cultures, this gesture denotes confusion.
  2. B) In some cultures, this gesture is offensive.
  3. C) This gesture has meaning only in American cultures.
  4. D) In some cultures, this gesture denotes pain.

Page 7

  1. A nurse admits to a colleague, ìI sometimes tend to avoid clients from other cultures

because it’s awkward and it’s usually frustrating for me and for the client.î This nurse is

likely lacking in what construct of cultural competency?

  1. A) Cultural desire
  2. B) Cultural knowledge
  3. C) Cultural health
  4. D) Cultural harmony

 

 

Page 1

  1. Assessment of a client reveals a history of insulin-dependent diabetes mellitus, weight

loss, polyuria, poor skin turgor, nausea, loss of appetite, and a blood glucose level

measured by finger stick of 348 mg/dL. Which of the following nursing diagnoses

would be the nurse’s priority?

  1. A) Risk for imbalanced fluid volume related to inadequate oral intake and frequent

urination

  1. B) Imbalanced nutrition: more than body requirements related to diabetes
  2. C) Potential complication: hypertension
  3. D) Powerlessness related to diabetes self-care and management
  4. The nurse’s assessment reveals that a client is in a low percentile for midarm muscle

circumference (MAMC) and a high percentile for triceps skin fold (TSF) thickness.

Which of the following would be appropriate?

  1. A) Teaching the client muscle-building exercises
  2. B) Discussing ways to increase body fat stores
  3. C) Assisting client in reducing the amount of fluid build-up
  4. D) Encouraging the use of a multivitamin supplement
  5. An adult client weighs 175 pounds and is 5 feet 6 inches tall. The nurse determines that

the client’s body mass index is which of the following?

  1. A) 12
  2. B) 18
  3. C) 25
  4. D) 28
  5. A client weighs 106 pounds and is 5 feet 5 inches tall. As a result, her ideal body weight

is 120 pounds. After determining the client’s percentage of ideal body weight, which of

the following should the nurse conclude?

  1. A) Client is mildly malnourished.
  2. B) Client is experiencing moderate malnutrition.
  3. C) Severe malnutrition is present.
  4. D) The client’s body weight is within 10% of ideal body weight.
  5. A nurse is reviewing the laboratory test results of an adult client who has numerous

chronic health challenges. Which assessment result would alert the nurse to potential

malnutrition?

  1. A) Hemoglobin of 13.1 g/dL
  2. B) Hematocrit of 40%
  3. C) Serum albumin of 2.6 g/dL
  4. D) Total protein of 7 g/dL

Page 2

  1. The nurse should prioritize assessments related to overhydration for a client

experiencing which of the following health problems?

  1. A) Early congestive heart failure
  2. B) Chronic emphysema
  3. C) Newly diagnosed hepatitis C virus infection
  4. D) Adult respiratory distress syndrome
  5. The nurse is assessing a client who has been admitted with signs and symptoms that are

consistent with malnutrition. Which of the following physiological phenomena would

the nurse recognize as an early indicator of malnutrition?

  1. A) Protein stores are lower than normal
  2. B) Bone is metabolized to compensate for missing nutrients
  3. C) Calcium levels decrease
  4. D) Hemoglobin levels decrease
  5. A client is receiving an intradermal injection to evaluate general immunity during a

nutritional assessment. Which of the following conclusions is suggested if the client has

no reaction?

  1. A) It indicates high cholesterol and triglyceride levels.
  2. B) It shows a sacrifice of skeletal muscle proteins and blood proteins.
  3. C) It is indicative of unhealthy dietary habits.
  4. D) It may be immunosuppression resulting from undernourishment.
  5. The nurse is preparing to perform a nutritional assessment of a newly admitted client.

Which of the following questions would be most appropriate to use when initiating the

assessment?

  1. A) ìDid you eat breakfast today?î
  2. B) ìHow many meals do you eat each day?î
  3. C) ìCan you tell me what you’ve eaten in the last 24 hours?î
  4. D) ìHow often do you eat out?î
  5. A nurse is assessing a client’s skeletal muscle mass in the context of a comprehensive

nutritional assessment. Which measurement would yield the most valid and reliable

data?

  1. A) Body mass index
  2. B) Triceps skin fold measurement
  3. C) Mid-arm circumference
  4. D) Waist circumference

Page 3

  1. When evaluating nutrition in an adult female client, which laboratory value would most

concern the nurse?

  1. A) Hemoglobin A1c of 9%
  2. B) Serum albumin of 4.9 g/dL
  3. C) Total protein of 6.7 g/dL
  4. D) Hematocrit of 39%
  5. A nurse weighs a client today and finds that the client’s weight has increased 2.2 lbs

from the previous day. The nurse interprets this finding as suggesting a fluid gain of

which amount?

  1. A) 0.5 liters
  2. B) 1.0 liters
  3. C) 1.5 liters
  4. D) 2.0 liters
  5. The nurse analyzes the data obtained from a client’s nutritional assessment and develops

a health promotion diagnosis related to nutrition for a client. Which of the following

would be the best example?

  1. A) Health-seeking behaviors related to desire and request to alter amount of food

intake

  1. B) Imbalanced nutrition: less than body requirements related to inadequate caloric

intake

  1. C) Imbalanced nutrition: more than body requirements related to excessive caloric

intake

  1. D) Ineffective thermoregulation related to decreased adaptability to cold secondary to

decreased subcutaneous tissue

  1. The nurse is collecting data from a client about his nutrition. Which of the following

would the nurse document as objective data?

  1. A) Client states he is not eating well.
  2. B) Client complains of nausea and vomiting.
  3. C) Clients experiences urinary frequency.
  4. D) Tenting of client’s skin observed upon skin pinch.
  5. A nurse in the intensive care unit is calculating an acutely ill client’s 24-hour fluid

balance. The nurse should include insensible fluid losses of what volume when

performing this assessment?

  1. A) 100 to 300 mL
  2. B) 450 to 650 mL
  3. C) 800 to 1000 mL
  4. D) 1200 to 1400 mL

Page 4

  1. A nurse is assessing a client for possible fluid overload. Which of the following

assessment findings is most consistent with this diagnosis?

  1. A) Venous filling of 3 seconds
  2. B) Distended neck veins with head elevated at 45 degrees
  3. C) Moist, plump tongue
  4. D) Boggy eyeball
  5. During a nutritional assessment, the client asks the nurse for suggestions to improve her

diet. The nurse identifies a nursing diagnosis of health-seeking behaviors related to

desire to improve diet. Which of the following suggestions would be most appropriate?

  1. A) ìThe majority of your diet should consist of whole grains.î
  2. B) ìChoose low-fat versions of milk products such as yogurt.î
  3. C) ìDrink at least 2 to 3 glasses of fruit juices a day.î
  4. D) ìEat fewer orange vegetables and more dark green vegetables daily.î
  5. A group of students is reviewing information about general assessment indicators of

nutritional status. The students demonstrate a need for additional review when they

identify which of the following as an indicator of adequate nutritional status?

  1. A) Flat, firm abdomen
  2. B) Brittle hair
  3. C) Pink mucous membranes
  4. D) Elastic skin
  5. When obtaining the nutritional health history from a female client, which of the nurse’s

questions would best elicit information about the client’s knowledge of her own health

status?

  1. A) ìAre you now or have you been on a diet recently?î
  2. B) ìHow much fluid do you drink in a day?î
  3. C) ìWhat are your height and usual weight?î
  4. D) ìCan you tell me what you consider to be a healthy meal?î
  5. The nurse needs to obtain the height of a client who is unable to stand. Which of the

following would the nurse do?

  1. A) Estimate the height while the client is lying in bed.
  2. B) Measure the distance from the top of the client’s head to his ankles.
  3. C) Measure from client’s arm span using one of his arms outstretched.
  4. D) Extend a ruler from the forehead to the tip of the client’s toes.

Page 5

  1. An older adult client has presented to the emergency department with signs and

symptoms of dehydration. When assessing the client for risk factors that may have

contributed to this condition, what question should the nurse prioritize?

  1. A) ìDo you use any over-the-counter dietary supplements?î
  2. B) ìAre you familiar with the USDA’s MyPlate recommendations?î
  3. C) ìHave you ever been diagnosed with heart disease?î
  4. D) ìAre you currently taking any diuretic medications?î
  5. An older adult client has a body mass index of 15.5 and is consequently considered to

be underweight. The client lives alone and states that she has ìnever been a heavy eater.î

How can the nurse most accurately assess the client’s nutritional habits?

  1. A) Assess the client’s waist circumference and waist-to-hip ratio.
  2. B) Measure the client’s mid-arm circumference.
  3. C) Elicit the client’s 24-hour food recall.
  4. D) Have the client describe an ìidealî meal.
  5. During a new client’s nutritional assessment, the nurse asks the client’s height and usual

weight. The client states that he has no idea how much he weighs. How should the nurse

respond?

  1. A) ìDo you feel like your weight has increased, decreased, or stayed the same lately?î
  2. B) ìWhy do you feel that it’s not important to monitor your weight?î
  3. C) ìIn a typical day, what do you eat and drink?î
  4. D) ìHow would you describe your feelings around your body type and body mass?î
  5. A hospital nurse is performing a nutritional assessment of a 39-year-old obese client

who has been recently diagnosed with type 2 diabetes. The nurse has completed the

collection of subjective data and is preparing to proceed with objective data collection.

Which principle should guide the nurse’s subsequent actions?

  1. A) There are likely to be inconsistencies between subjective data and objective data.
  2. B) The nurse should be aware that the client may find assessment embarrassing.
  3. C) The nurse should avoid performing anthropometric measurements due to the

client’s obesity.

  1. D) The assessment should be performed over a series of brief sessions rather than one

continuous assessment.

Page 6

  1. During an initial prenatal visit, the nurse is performing a nutritional assessment of a

woman who has just learned that she is pregnant for the first time. The nurse has

determined that the client has an average stature and is 5 feet, 3 inches tall. What is this

client’s ideal body weight?

  1. A) 105 lbs.
  2. B) 115 lbs.
  3. C) 125 lbs.
  4. D) 135 lbs.
  5. A client’s recent complaints of polyuria have prompted a full diagnostic work-up for

diabetes mellitus, including a nutritional assessment. To determine the client’s body

mass index (BMI), the nurse must know which of the following assessment parameters?

Select all that apply.

  1. A) Gender
  2. B) Age
  3. C) Weight
  4. D) Waist circumference
  5. E) Height
  6. The nurse is completing a comprehensive nutritional assessment and has assessed and

documented the client’s triceps skin fold thickness (TSF) using calipers. This assessment

finding allows the nurse to determine which of the following?

  1. A) The client’s ratio of muscle to adipose tissue
  2. B) The client’s body mass index
  3. C) The client’s proportion of muscle mass
  4. D) The amount of the client’s subcutaneous fat stores
  5. A nurse at a long-term care facility is completing the nutrition assessment of a man who

has just moved to the facility. The nurse has lowered the client’s arm and observed how

long it takes for venous filling, then raised the same arm and watched how long it takes

to empty. After determining that venous filling and emptying each take approximately

10 seconds, the nurse should perform further assessments related to what health

problem?

  1. A) Fluid volume deficit
  2. B) Third spacing
  3. C) Ascites
  4. D) Malnutrition

Page 7

  1. The nurse is providing care for a client with a history of chronic heart failure. The client

is in bed with the head of her bed at 45 degrees, and the nurse is assessing the client’s

neck veins. What assessment finding would be most consistent with a nursing diagnosis

of fluid volume excess related to chronic heart failure?

  1. A) The client’s carotid arteries are not palpable.
  2. B) The client’s jugular veins are clearly visible and firm to palpation.
  3. C) The client’s carotid pulses are asymmetrical and difficult to palpate.
  4. D) The client’s carotid pulses are easier to palpate than the jugular pulses.
  5. An obese teenage boy from a culture that values increased body mass has been referred

to the clinic. The nurse is assessing him for malnutrition based on his electronic health

record and current health complaints. His mother questions the nurse’s rationale, stating,

ìAnyone can see he’s not malnourished. Just look at the size of him!î How should the

nurse best respond?

  1. A) ìPeople sometimes become obese because their bodies are storing up nutrients that

they often lack.î

  1. B) ìIt’s actually very possible for a person to be overweight but have inadequate

nutrition.î

  1. C) ìAssessment for malnutrition is a standard component of a larger nutritional

assessment, which is very important for your son’s health.î

  1. D) ìActually, there’s very little relationship between body mass and nutritional state.î

 

Page 1

  1. The nurse is preparing to palpate a client’s temporal artery. The nurse would place the

hands at which location?

  1. A) On each side of the client’s face, anterior and inferior to the ears
  2. B) On each side between the top of the ear and the eye
  3. C) Bilaterally, parallel to and anterior to the sternomastoid muscle
  4. D) Inferior to the lower jaw beneath the client’s tongue
  5. A nurse is preparing to assess an adult client’s carotid pulses. Which of the following

actions would be contraindicated?

  1. A) Asking the client to flex his or her neck
  2. B) Compressing the arteries bilaterally
  3. C) Performing the examination while the client is seated
  4. D) Asking the client to swallow water
  5. The nurse’s assessment reveals that a male client can neither turn his head against

resistance nor shrug his shoulders. The nurse should document a potential deficit in the

functioning of which cranial nerve?

  1. A) Abducens (VI)
  2. B) Accessory (XI)
  3. C) Hypoglossal (XII)
  4. D) Trochlear (IV)
  5. During the health history, a client describes recent episodes of intermittent facial pain

lasting several minutes. The nurse should recognize that this complaint is suggestive of

what health problem?

  1. A) Trigeminal neuralgia
  2. B) Migraine headache
  3. C) Meningitis
  4. D) Temporomandibular joint dysfunction
  5. A client describes her frequent headaches as being severe and lasting for days. The

client’s positive response to what question would most clearly suggest to the nurse that

these headaches are migraines?

  1. A) ìDo they occur after you have been tense or anxious?î
  2. B) ìWhen you consume alcohol, do you get a headache?î
  3. C) ìDo you have any eye symptoms, such as tearing?î
  4. D) ìDo you have any visual changes before the headache?î

Page 2

  1. Which factor, if present in a client’s lifestyle and health practices assessment, would

alert the nurse to the need for performing a more thorough head and neck assessment?

  1. A) Alcohol abuse
  2. B) Recreational drug use
  3. C) Smokeless tobacco use
  4. D) Multiple sex partners
  5. A nurse is preparing a presentation for a local community group about preventing

traumatic brain injury. The nurse would discuss which measure as prevention of the

leading cause?

  1. A) Safe use of firearms
  2. B) Safe use of machinery
  3. C) Falls prevention
  4. D) Domestic violence prevention
  5. A nurse is palpating the head and neck of a newly referred client. Which of the

following would the nurse suspect if assessment reveals that the client’s skull and facial

bones are larger and thicker than normal?

  1. A) Acromegaly
  2. B) Brain tumor
  3. C) Paget disease
  4. D) Parkinson disease
  5. When talking to a client before starting the physical exam, the nurse notes that the client

consistently tilts her head to one side. Which of the following should the nurse examine

first?

  1. A) Hearing acuity
  2. B) Thyroid gland
  3. C) Mental status
  4. D) Lymph nodes
  5. The nurse assesses a client and palpates a temporal artery that is hard, thick, and tender

with absent pulsations. The nurse would gather additional information related to which

aspect of health?

  1. A) Mental status
  2. B) Hearing
  3. C) Neurologic status
  4. D) Vision

Page 3

  1. A nursing educator is evaluating a colleague’s examination of a client’s thyroid gland.

The educator would determine that the nurse needs additional instruction when the nurse

demonstrates which technique?

  1. A) Inspection
  2. B) Auscultation
  3. C) Palpation
  4. D) Percussion
  5. A nurse is palpating the position of the client’s trachea. At which anatomic site would

the nurse first position a finger for palpation?

  1. A) Sternocleidomastoid muscle
  2. B) Sternal notch
  3. C) Submental space
  4. D) Supraclavicular space
  5. When preparing to assess a client’s thyroid gland, the nurse should ensure that which

piece of equipment is readily available?

  1. A) Penlight
  2. B) Tongue depressor
  3. C) Centimeter-scale ruler
  4. D) Cup of water
  5. Which of the following findings should the nurse document after assessing the thyroid

gland of an older adult without abnormalities?

  1. A) Nodularity
  2. B) Tenderness
  3. C) Enlargement
  4. D) Bruits
  5. A nurse is assessing an adult client’s neck. Which of the following would be most

appropriate when auscultating the client’s thyroid gland for bruits?

  1. A) Hyperextend the client’s neck.
  2. B) Turn the client’s head to the right.
  3. C) Have the client swallow water.
  4. D) Have the client hold his or her breath.

Page 4

  1. A nurse is preparing to palpate a client’s submental lymph nodes. At what anatomic

location should the nurse position his or her hands?

  1. A) At the angle of the client’s mandible
  2. B) At the base of the client’s skull
  3. C) On the area behind the client’s ears
  4. D) Behind the tip of the client’s mandible
  5. The nurse can best palpate the superficial cervical nodes, the deep cervical chain, and

the supraclavicular nodes by first locating which muscle?

  1. A) Infraspinous
  2. B) Sternomastoid
  3. C) Trapezius
  4. D) Platysma
  5. A nurse has completed an assessment of a client’s lymph nodes. Which of the following

data would the nurse document as an abnormal finding?

  1. A) Diameter: 0.75 cm
  2. B) Mobile
  3. C) Tender
  4. D) Discrete
  5. The nurse is assessing the face of a client with a diagnosis of Parkinson’s disease. Which

of the following would the nurse most likely assess?

  1. A) Sunken face
  2. B) Drooping of one side
  3. C) Masklike expression
  4. D) Asymmetry of earlobes
  5. During a health history, a client reports complaints of headaches. Which of the

following would lead the nurse to suspect that the client is experiencing cluster

headaches?

  1. A) Pain radiating from eye to temporal region
  2. B) Throbbing and severe pain
  3. C) Report of ringing in the ears prior to headache
  4. D) Complaint of sensitivity to light

Page 5

  1. A nurse is assessing the head and neck of an adult client. Which vertebra should the

nurse identify as a landmark in order to locate the client’s other vertebrae?

  1. A) C3
  2. B) C5
  3. C) C7
  4. D) T2
  5. A nurse is conducting a focused head and neck assessment of a client. When preparing

to assess the client’s thyroid gland, the nurse should be aware of which of the following

principles?

  1. A) The thyroid gland is not normally palpable in female clients.
  2. B) Many clients have an additional (third) thyroid lobe.
  3. C) The thyroid gland is not normally palpable until clients are in their thirties or

forties.

  1. D) Palpation creates a risk of rupturing the thyroid gland in some older adult clients.
  2. A nurse is providing care at an inner-city shelter, and a man who frequents the shelter

presents with a significant frontal growth that is located midline at the base of his neck.

The nurse should recognize the need for what referral?

  1. A) Referral for further assessment of thyroid function
  2. B) Referral for assessment of cranial nerve function
  3. C) Referral for assessment of lymphatic system function
  4. D) Referral for further assessment of swallowing ability
  5. A community health nurse is planning a health promotion campaign that will focus on

cancer prevention. Which educational intervention should the nurse select in order to

most influence participants’ risks of head and neck cancers?

  1. A) Teaching about genetic screening
  2. B) A nutritional health program
  3. C) Teaching about monthly self-examination
  4. D) A smoking cessation program
  5. Assessment of an adult female client’s face reveals a moon shape, increased hair

distribution, and a reddened tone to the client’s cheeks. What collaborative problem is

most clearly suggested to the nurse by these assessment data?

  1. A) RC: Thyroid crisis
  2. B) RC: Cerebrovascular accident
  3. C) RC: Cushing’s syndrome
  4. D) RC: Acromegaly

Page 6

  1. A nurse is working with a client who has a history of headaches. When preparing to

assess the client’s temporomandibular joint (TMJ), the nurse should provide what

instruction?

  1. A) ìI’m going to press on several different places below and in front of your ear.î
  2. B) ìI’m going to put my fingers in front of your ears and ask you to open your mouth

wide.î

  1. C) ìTurn so I can see the side of your face and then open your mouth wide like you’re

yawning.î

  1. D) ìWhen I place my hands on your cheeks, clench your teeth and then relax them.î
  2. A nurse is performing a head and neck assessment of a client who is newly admitted to

the hospital unit. When preparing to assess the client’s thyroid gland, what landmarks

should the nurse first identify? Select all that apply.

  1. A) Sternocleidomastoid muscle
  2. B) Hyoid bone
  3. C) Cricoid cartilage
  4. D) Carotid artery
  5. E) Esophagus
  6. The nurse is assessing the head and neck of a 51-year-old male client. Following

inspection and palpation of the client’s thyroid gland, the nurse determines that the gland

is enlarged. What is the next action that the nurse should perform?

  1. A) Obtain a full set of vital signs.
  2. B) Percuss the client’s thyroid.
  3. C) Auscultate the client’s thyroid.
  4. D) Perform a swallowing assessment.
  5. A client’s recent weight loss and diarrhea has been attributed to hyperthyroidism. When

auscultating the client’s thyroid gland, what assessment finding is most consistent with

this diagnosis?

  1. A) Audible referred breath sounds at the site of the thyroid
  2. B) An audible S3 sound at the site of the thyroid
  3. C) A sound of turbulent blood flow in the thyroid
  4. D) Irregular S1 and S2 rhythms in the thyroid

Page 7

  1. A nurse has completed the assessment of an older adult client’s head and neck and is

now analyzing the assessment findings. Which of the following findings should the

nurse attribute to age-related physiological changes?

  1. A) Increased size of a single thyroid nodule
  2. B) A nonpalpable carotid pulse
  3. C) Decreased strength of temporal artery pulsations
  4. D) Tenderness of lymph nodes on palpation

 

 

Page 1

  1. When assessing the client’s ear, which finding should the nurse identify as indicating a

need for further assessment and possible treatment?

  1. A) Darwin tubercle
  2. B) Red, flaky cerumen
  3. C) Tender tragus
  4. D) Pearly gray tympanic membrane
  5. A client asks why cerumen is important, stating, ìIt just clogs up the ears anyway.î How

should the nurse best describe the purpose of cerumen?

  1. A) ìIt helps protect the delicate ear drum from loud noise that may be damaging.î
  2. B) ìIt helps to keep the ear drum soft and functioning well.î
  3. C) ìIt helps to amplify the sound waves through the inner ear.î
  4. D) ìIt helps create the translucent, pearly color of the ear drum.î
  5. A client’s electronic health record states that he has been diagnosed with sensorineural

hearing loss. Which condition should the nurse most likely identify as a cause?

  1. A) Perforated eardrum
  2. B) Otosclerosis
  3. C) Inner ear problem
  4. D) Otitis media
  5. A 55-year-old client is being evaluated for a suspected hearing impairment. Which of

the nurse’s health interview questions is most likely to yield relevant data?

  1. A) ìAre you having difficulty hearing high-frequency sounds?î
  2. B) ìDo you notice any drainage from your ears?î
  3. C) ìAre you experiencing any pain in your ears?î
  4. D) ìHave you felt any popping sensations in your ears?î
  5. A client presents to an ambulatory clinic with purulent, bloody drainage of the ear.

Which of the following should the nurse assess first?

  1. A) Assess the client’s tympanic membrane.
  2. B) Palpate the client’s tragus.
  3. C) Inspect the client’s external ear canal.
  4. D) Perform hearing assessments.

Page 2

  1. A 66-year-old client states that he has increasing difficulty hearing high-pitched sounds.

The patient’s statement most likely suggests that he has what diagnosis?

  1. A) Vertigo
  2. B) Otalgia
  3. C) Tinnitus
  4. D) Presbycusis
  5. A client who works in a manufacturing plant is attending a teaching session on plant

safety. Which of the following would be an important risk prevention measure to teach

regarding hearing?

  1. A) Limiting loud noise exposure to 1 hour per day
  2. B) Taking a 10-minute break every 2 hours
  3. C) Wearing ear protection when in the work environment
  4. D) Cleaning ears regularly to prevent ear infections
  5. A nurse palpates a client’s ear and finds that the tragus is exquisitely tender. The nurse

should suspect which of the following health problems?

  1. A) Otitis media
  2. B) Otitis externa
  3. C) Ruptured tympanic membrane
  4. D) Mastoiditis
  5. The emergency department nurse notes a clear, watery discharge from the client’s ear

following a bicycle accident. Which of the following actions should the nurse do next?

  1. A) Refer the client immediately for further evaluation.
  2. B) Assess for foreign body impaction.
  3. C) Examine for postauricular cysts.
  4. D) Position the patient to facilitate drainage.
  5. While using an otoscope to assess the ears of an 8-year-old boy, the nurse observes

white spots on the boy’s tympanic membrane. The nurse also observes that no redness is

present. Which action would be most appropriate?

  1. A) Assess the boy for previous trauma to his skull.
  2. B) Determine whether impacted cerumen is present.
  3. C) Ask the mother whether the child has had numerous ear infections.
  4. D) Assess the child for further symptoms of acute otitis media.

Page 3

  1. After having a client perform a Romberg test, which of the following would indicate to

the nurse that the test is negative?

  1. A) Client moves the feet apart during the test
  2. B) Client sways slightly during the test
  3. C) Client maintains the position during the test
  4. D) Client keeps his or her eyes close during the test
  5. The results of a client’s Rinne test suggest that bone conduction and air conduction are

both reduced. Which of the following would be most appropriate?

  1. A) Perform a Romberg test.
  2. B) Take a swab of the client’s tympanic member.
  3. C) Repeat the test in 5 to 10 minutes.
  4. D) Refer the client for further evaluation.
  5. The nurse has completed a focused ear and hearing assessment and gathered the

following data: the client speaks very softly, denies hearing loss, and has never had and

cannot afford additional hearing tests; the client fails the whisper test. Which nursing

diagnosis would be most appropriate?

  1. A) Ineffective health maintenance related to denial of hearing problem and inadequate

resources for additional testing

  1. B) Impaired social interaction, related to decreased ability to maintain contact with

friends

  1. C) Impaired verbal communication, related to lack of understanding of hearing deficit
  2. D) Readiness for enhanced communication related to auditory integrity and need for

hearing therapy

  1. The nurse is performing an ear assessment of an adult client. Which of the following

actions constitutes the correct procedure for using an otoscope when examining the

client’s ears?

  1. A) Keeping the dominant hand away from the client’s head
  2. B) Inserting the speculum down and forward into the ear canal
  3. C) Using the smallest speculum on the otoscope head
  4. D) Holding the otoscope in the nondominant hand
  5. During a Weber test, the client reports lateralization of sound to the good ear. How

should the nurse interpret this assessment finding?

  1. A) The good ear cannot receive sound vibrations.
  2. B) There is a dysfunction of the middle ear.
  3. C) The poor ear is receiving sound vibrations by air.
  4. D) There is a sensorineural hearing impairment.

Page 4

  1. A nurse is performing an otoscopic exam of a client’s right tympanic membrane. At

which location would the nurse document seeing the cone of light if it were in the

appropriate place?

  1. A) In the center of the membrane
  2. B) In the 5 o’clock position
  3. C) In the 7 o’clock position
  4. D) In the upper left quadrant
  5. While inspecting the client’s tympanic membrane, the nurse notes a pearly gray and

shiny appearance. The nurse would interpret this finding as which of the following?

  1. A) Scarring from previous infections
  2. B) Otitis media
  3. C) Normal tympanic membrane
  4. D) Otitis externa
  5. The nurse is preparing to perform the Rinne test on a client. The nurse should place the

tuning fork at which location first?

  1. A) Center of the client’s forehead
  2. B) On the client’s mastoid process
  3. C) In front of the client’s external auditory canal
  4. D) At the base of the client’s skull
  5. A nurse is preparing a teaching session for a group of new parents about ear infections

and measures to prevent them. The nurse is planning to address the reasons why

children are more susceptible to these infections than adults. Which of the following

would the nurse describe?

  1. A) Young children have a tendency to stick objects into their ear canal.
  2. B) The size and shape of children’s eustachian tubes makes them vulnerable.
  3. C) Children’s immune systems lack the maturity to fight infections.
  4. D) Children generally have poorer hygiene than adults.
  5. Which of the following, if obtained during the health history, would alert the nurse to a

possible risk factor for ear-related problems?

  1. A) Frequent use of acetaminophen (Tylenol)
  2. B) Frequent use of cotton-tipped applicators inside the ear
  3. C) Preference for showers rather than baths
  4. D) In adequate hygiene practices

Page 5

  1. The nurse’s assessment of an older adult client’s ears and hearing suggests the possible

presence of conductive hearing loss. Which of the following is the most likely etiology

of this abnormal assessment finding?

  1. A) Otitis media
  2. B) Cranial nerve VIII damage
  3. C) Trauma to the temporal lobe
  4. D) Age-related hearing changes
  5. A client has sought care at the clinic, telling the nurse, ìThis ringing in my ears has gone

on for weeks, and it’s driving me crazy.î The patient denies exposure to excessive noise

levels. The nurse recognizes the likely presence of tinnitus and should follow up with

which of the following questions?

  1. A) ìDid your parents even complain of something similar?î
  2. B) ìWhat medications are you currently taking?î
  3. C) ìHow would you describe your overall level of health?î
  4. D) ìHow do you usually clean your ears?î
  5. A clinic client’s primary complaint is earache (otalgia). Consequently, the nurse’s

assessment is focusing on potential causes of the client’s pain. What question should the

nurse include in the health interview?

  1. A) ìWhat do you do for a living?î
  2. B) ìDo you know if your vaccinations are up to date?î
  3. C) ìDo you take over-the-counter medications or supplements?î
  4. D) ìHave you been swimming lately?î
  5. The nurse’s assessment of an 81-year-old client’s hearing has corroborated her recent

history of hearing loss. The nurse questions the client about her use of hearing aids, to

which the client responds, ìI’ve got enough frustration in my life without having to

fiddle with those.î The nurse should suspect which of the following?

  1. A) The client may misunderstand the factors underlying her hearing loss.
  2. B) The client may have had a negative experience with hearing aids in the past.
  3. C) The client may be unable to afford the cost of hearing aids.
  4. D) The client may be unwilling to adhere to treatment regimens.
  5. A nurse health promotion teaching is focusing on hygiene and the prevention of illness.

When instructing clients how to clean their ears, what action should the nurse

recommend?

  1. A) Washing with a warm, moist washcloth
  2. B) Gently irrigating with normal saline
  3. C) Cleaning with cotton-tipped applicator
  4. D) Irrigating with mildly soapy water

Page 6

  1. A 2-year-old girl has been brought to the ambulatory clinic by her mother who states,

ìShe’s put a pea in her ear, and I think she did it 2 days ago because that was the last

time we ate them.î The nurse’s otoscopic examination confirms the presence of this

foreign body in the girl’s middle ear. How should the nurse best respond to this

assessment finding?

  1. A) Attempt to remove the pea using sterile forceps.
  2. B) Irrigate the ear canal with warm tap water to remove the pea.
  3. C) Instruct the mother to watch the girl’s ear closely and return for care if it does not

fall out in the next few days.

  1. D) Refer the girl to her primary care provider for prompt removal of the pea.
  2. Otoscopic examination of a 69-year-old client’s tympanic membrane reveals that it is

red, bulging, and distorted. The nurse also notes a diminished light reflex. To what

should the nurse most likely attribute this assessment finding?

  1. A) Repeated ear infections
  2. B) Trauma
  3. C) Age-related changes
  4. D) Acute otitis media
  5. A nurse is conducting a focused ear and hearing assessment of an adult client who has a

history of mild hearing loss. When performing the whisper test, what instruction should

the nurse begin with?

  1. A) ìPlease close your eyes and listen carefully to what I say.î
  2. B) ìPlease cover your ear that has the weakest hearing.î
  3. C) ìPlease tell me when you can hear me talking.î
  4. D) ìPlease repeat the words that I say.î
  5. The nurse is completing a client’s ear assessment. What assessment finding would

indicate the need to perform Weber’s test?

  1. A) The client has unilateral hearing loss.
  2. B) The client has suspected otitis externa.
  3. C) The client is older than age 65.
  4. D) The client has a history of stroke.

Page 7

  1. A 12-year-old boy has been brought to the emergency department after being hit in the

head with a pitch during a baseball game. The emergency department nurse’s

comprehensive assessment includes examination of the boy’s ears with an otoscope.

What assessment finding would suggest trauma to the middle ear or inner ear?

  1. A) White spots on the tympanic membrane
  2. B) Dark red or bluish tympanic membrane
  3. C) Yellowish, bulging tympanic membrane
  4. D) Clear tympanic membrane