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WorksheetsHA FINAL
Total questions: 50
Worksheet time: 25hrs 0mins
A nurse assesses a 68-year-old with dyspnea and a productive cough. On posterior chest, tactile fremitus is increased over the right lower lobe, percussion is dull, and bronchial breath sounds are heard in that area. Which finding most strongly supports the nurse’s suspected diagnosis?
Hyperresonance to percussion over the affected area
Equal chest expansion bilaterally without lag
Whispered pectoriloquy present over the right lower lobe
Diffuse expiratory wheezes throughout both lungs
During cardiac auscultation of a 56-year-old, the nurse hears a soft, low-pitched extra sound immediately after S2 at the apex with the bell, most pronounced in left lateral decubitus. Which interpretation is most accurate?
S3 consistent with volume overload and possible heart failure
S4 consistent with stiff ventricle from long-standing hypertension
Opening snap of mitral stenosis
Pericardial friction rub from pericarditis
A 34-year-old presents with unilateral calf pain after a 6-hour flight. The leg is warm, swollen, and tender with increased circumference compared to the other leg. Which initial nursing action is most appropriate?
Encourage ambulation to promote venous return
Apply firm massage to the calf to relieve pain
Elevate the leg and notify the provider immediately
Place a heating pad to increase blood flow
The nurse assesses orthostatic vital signs. Supine BP is 128/78 mmHg and HR 78. After standing 3 minutes, BP is 104/66 and HR 102 with dizziness. Which interpretation is most accurate?
Normal postural change, no intervention
Orthostatic hypotension likely due to volume depletion or meds
Hypertensive crisis requiring IV antihypertensives
Vasovagal episode; advise breath-holding
A patient reports chest pain. Which description most strongly suggests myocardial ischemia needing urgent evaluation?
Sharp, localized pain reproducible with palpation, worsened by movement
Pressure-like substernal pain radiating to the left arm, occurring with exertion and relieved by rest
Pleuritic pain worse on inspiration, relieved by leaning forward
Burning epigastric pain after large meals, improved with antacids
On cardiac exam, where is the point of maximal impulse (apical impulse) normally palpated in adults?
2nd intercostal space at right sternal border
3rd intercostal space at left sternal border
5th intercostal space at left mid-clavicular line
4th intercostal space at right sternal border
A nurse suspects peripheral arterial disease (PAD) in a 72-year-old with calf pain when walking. Which additional finding most strongly supports PAD?
Brown hyperpigmentation around ankles with pitting edema
Dependent rubor and delayed capillary refill in toes
Warm skin temperature with normal pulses
Pain relieved by standing still with legs dependent
A 24-year-old with asthma presents with severe respiratory distress but minimal breath sounds (“silent chest”). SpO2 is 86% on room air. Which priority action is most appropriate?
Encourage slow deep breathing exercises
Administer short-acting bronchodilator and prepare for escalation
Perform chest physiotherapy to mobilize secretions
Position supine to reduce work of breathing
A nurse notes a lateral displacement of the apical impulse to the 6th intercostal space, anterior axillary line. Which condition is most consistent?
Right ventricular hypertrophy
Left ventricular hypertrophy or dilation
Pericardial effusion
Aortic stenosis with small left ventricle
In assessing jugular venous pressure (JVP), the nurse positions the patient at 30–45 degrees. Which finding indicates elevated right atrial pressure?
Visible external jugular veins only when seated upright
Jugular venous pulsation 5 cm above the sternal angle at 45 degrees
Carotid pulse amplitude increased with inspiration
Apical impulse not palpable
A patient with right upper quadrant pain and fever has a positive Murphy sign. Which structure is most implicated?
Appendix
Gallbladder
Spleen
Stomach
Which abdominal exam sequence is correct and why?
Inspect → Palpate → Percuss → Auscultate, because palpation stimulates bowel activity
Inspect → Auscultate → Percuss → Palpate, because palpation/percussion can alter bowel sounds
Auscultate → Palpate → Percuss → Inspect, because listening must occur before exposure
Percuss → Auscultate → Inspect → Palpate, because percussion is least invasive
A nurse assesses a 78-year-old with new confusion, dry mucous membranes, tachycardia, orthostatic hypotension, and dark urine. Which intervention is most appropriate first?
Restrict fluids to prevent overload
Encourage fluid intake and evaluate intake and output closely
Start diuretics to reduce edema
Administer antipyretics regardless of temperature
During cranial nerve testing, the tongue deviates to the right when protruded. Which nerve and side is likely affected?
Cranial nerve XII, right side
Cranial nerve XII, left side
Cranial nerve VII, right side
Cranial nerve VII, left side
A nurse suspects pericarditis. Which auscultatory finding supports this diagnosis?
Harsh systolic ejection murmur at right upper sternal border
Blowing holosystolic murmur at apex radiating to axilla
Scratchy, high-pitched sound best heard when the patient leans forward
Early diastolic blowing murmur along left sternal border
A patient presents with unilateral leg swelling, warmth, and tenderness and now has acute chest pain and dyspnea. What is the priority action?
Elevate the affected leg and provide warm compresses
Encourage ambulation to prevent further clot formation
Activate emergency response; suspect pulmonary embolism
Administer aspirin and observe
A nurse performs the Allen test before placing a radial arterial line. Which outcome indicates adequate collateral circulation?
Hand remains pale after release of ulnar artery
Color returns to the hand within 3–5 seconds after release
Capillary refill greater than 4 seconds in all fingers
Doppler signal absent in radial artery
The nurse hears fine crackles at the lung bases of a patient with dyspnea. Which mechanism best explains this sound?
Airflow through narrowed bronchi
Movement of air through fluid in small airways or alveoli
Vibration of thick secretions in large airways
Upper airway obstruction at the larynx
A 70-year-old with long-standing hypertension has a new S4 at the apex. What does this indicate?
Early diastolic rapid filling due to volume overload
Atrial contraction against a stiff ventricle
Valve leaflet calcification causing opening snap
Pericardial friction from inflammation
Which finding most strongly suggests venous insufficiency rather than arterial disease?
Ulcer at the medial malleolus with irregular margins and heavy exudate
Cool, hairless skin with decreased pulses and toe ulcers
Dependent rubor and delayed capillary refill
Claudication relieved by rest and legs dependent
The nurse evaluates a patient's Mini-Cog. The patient recalls 0 of 3 words and draws an abnormal clock. What is the most appropriate conclusion?
Normal cognition; no further testing needed
Possible cognitive impairment; further evaluation warranted
Acute delirium due to infection
Major depressive episode
Which is the most accurate statement about assessing carotid arteries?
Palpate both carotids simultaneously to compare amplitude
Auscultate for bruits and palpate one side at a time to prevent syncope
Massage the carotid sinus to assess baroreceptor function
Perform vigorous palpation to detect thrills
A patient reports epigastric pain radiating to the back with nausea. The pain worsens after fatty meals. Which organ is most likely involved?
Gallbladder
Pancreas
Stomach
Spleen
During respiratory assessment, the nurse notes decreased breath sounds and dullness to percussion over the right lower posterior lung with tracheal deviation to the left. Which condition is most likely?
Right lower lobe pneumonia
Large right pleural effusion
Right pneumothorax
Diffuse bronchospasm
A patient with suspected appendicitis has right lower quadrant pain, fever, and rebound tenderness. Which additional sign would most strengthen the diagnosis?
Murphy sign
Rovsing sign (pain in RLQ with LLQ palpation)
Grey Turner sign (flank ecchymosis)
Cullen sign (periumbilical ecchymosis)
The nurse hears a grade 3/6 systolic murmur at the right upper sternal border radiating to the carotids. Which condition is most consistent?
Mitral regurgitation
Aortic stenosis
Pulmonic regurgitation
Tricuspid stenosis
A 55-year-old with PAD has an ankle–brachial index (ABI) of 0.68. Which interpretation is correct?
Normal perfusion
Borderline PAD
Moderate PAD
Severe ischemia
The nurse notes jugular venous distention (JVD) and bilateral crackles in a patient with shortness of breath. Which heart failure side is most implicated by the JVD?
Left-sided failure
Right-sided failure
High-output failure
Diastolic-only failure
A patient complains of calf pain after walking two blocks, relieved by rest. Pulses are diminished and the foot is cool. Which teaching is most appropriate?
Wear high-compression stockings daily
Elevate legs above heart level for relief
Begin a supervised walking program and stop smoking
Increase fluid intake and salt to improve perfusion
While inspecting the abdomen, the nurse observes visible peristaltic waves moving across the epigastrium and hears high-pitched, tinkling bowel sounds. Which condition is most likely?
Normal variant in thin individuals
Early small bowel obstruction
Peritonitis with ileus
Hepatomegaly
A patient presents with a pulsatile abdominal mass, back pain, and a bruit over the aorta. Which action is most appropriate?
Deep palpation to assess the mass more precisely
Immediate provider notification; suspect abdominal aortic aneurysm
Apply firm abdominal binders to reduce pulsation
Encourage supine exercises to relieve pain
In a suspected pericardial friction rub, which maneuver best enhances auscultation?
Have the patient take shallow breaths and lie supine
Have the patient lean forward and exhale fully
Place the stethoscope diaphragm over the carotids
Ask the patient to perform Valsalva maneuver
A 62-year-old with chronic venous insufficiency asks about ulcer care. Which statement is most accurate?
Keep legs dependent to improve arterial inflow
Compression therapy is beneficial unless severe arterial disease coexists
Ulcers on toes indicate venous etiology
Avoid walking; rest with bedrest to prevent edema
The nurse evaluates cranial nerves in a stroke patient. Which finding localizes a central facial nerve lesion?
Complete paralysis of one side of the face including the forehead
Lower facial weakness with preserved forehead movement
Loss of taste on anterior two-thirds of the tongue
Inability to close both eyes tightly
A patient with suspected dehydration has poor skin turgor. On which site is assessing turgor most reliable in older adults?
Dorsum of the hand
Over the sternum or forearm
Abdomen
Cheek
A nurse hears late inspiratory crackles that do not clear with coughing, most prominent at the bases. Which condition is most consistent?
Chronic bronchitis
Asthma
Heart failure with pulmonary edema
Laryngotracheitis
During carotid auscultation, the nurse hears a bruit. What is the most likely pathophysiologic cause?
Turbulent blood flow due to arterial narrowing
Valve leaflet vibration causing regurgitant flow
Venous hum from jugular valves
Increased stroke volume in athletes
A patient has a new diastolic murmur along the left sternal border, best heard with the diaphragm while the patient leans forward. Which lesion is most likely?
Aortic regurgitation
Mitral stenosis
Pulmonic stenosis
Tricuspid regurgitation
In assessing a patient's oral cavity, which finding most strongly suggests oral candidiasis (thrush)?
Leukoplakia that does not scrape off
Creamy white plaques that scrape off leaving an erythematous base
Aphthous ulcers on the buccal mucosa
Smooth, beefy red tongue
A nurse suspects lymphedema in a patient with unilateral nonpitting edema and thickened skin. Which additional finding strengthens the suspicion?
Stemmer sign positive (cannot pinch skin at base of toes/fingers)
Generalized pitting edema to the knees
Varicosities and hemosiderin staining
ABI of 1.1
A patient with peritonitis is most likely to have which combination of findings?
Hyperactive bowel sounds, soft abdomen, minimal tenderness
Absent bowel sounds, board-like rigidity, severe rebound tenderness
Tympany throughout, no guarding, normal vitals
Visible peristalsis with tinkling sounds, no pain
During a mental health assessment, which approach is most therapeutic for suspected intimate partner violence?
“You need to leave immediately; it’s dangerous.”
“Your safety is our priority. Do you feel safe at home?”
“Why didn’t you report this sooner?”
“I’ll keep this between us no matter what.”
A patient with suspected stroke shows arm drift, facial asymmetry, and slurred speech. What is the priority action?
Obtain detailed family history before calling
Call emergency services immediately (time is brain)
Start IV fluids and observe for 4 hours
Administer high-dose aspirin without imaging
The nurse notes a positive Brudzinski sign. Which interpretation is most accurate?
Cervical radiculopathy from disc herniation
Meningeal irritation, often due to meningitis
Lower motor neuron lesion of CN XI
Benign positional vertigo
The nurse suspects anterior epistaxis. Which intervention is most appropriate?
Tilt head back and apply ice to the neck
Lean forward and apply pressure to the soft part of the nose for 10–15 minutes
Insert cotton swabs into the nares deeply
Pack the posterior nasopharynx at bedside
A 79-year-old with unintended weight loss, poor dentition, and social isolation is admitted. Which nursing intervention is most appropriate initially?
Start diuretics to improve appetite
Order a high-protein, high-calorie diet and consult nutrition
Restrict fluids to prevent edema
Begin strict bedrest to conserve energy
In assessing for venous valve competence, which test is most appropriate?
Allen test
Trendelenburg test or manual compression test
Ankle-brachial index
Valsalva maneuver
A nurse evaluates an S2 split that increases with inspiration and disappears with expiration. Which interpretation is most accurate?
Paradoxical split due to left bundle branch block
Fixed split due to atrial septal defect
Physiologic split due to delayed pulmonic closure on inspiration
Pathologic split due to severe aortic stenosis
The nurse is assessing skin lesions and uses ABCDE criteria. Which finding is most concerning for melanoma?
Symmetric brown macule 4 mm with smooth borders
Asymmetric variegated lesion 8 mm with irregular borders and recent growth
Firm papule 2 mm with uniform color
Flesh-colored dome-shaped papule unchanged for years
A patient's abdominal exam: hypoactive bowel sounds, diffuse tenderness, voluntary guarding, and low-grade fever two days post-op. Which is the most likely cause?
Early small bowel obstruction
Postoperative ileus
Acute pancreatitis
Acute cholecystitis
