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Physical assessment

9 original SNLE questions on physical assessment, each with an explanation for all four options. Part of Nursing Fundamentals, worth 20% of the Saudi Nursing Licensure Examination.

Q01 / 09medium0 correct
Nursing Fundamentalsmediumq002

A nurse measures the vital signs of an adult patient who weighs 70 kg: BP 88/54 mmHg, pulse 118/min, respirations 24/min, temperature 38.9°C. Urine output has been 15 mL/hr for the last three hours. Which of these findings most directly measures perfusion of an end organ?

All 9 questions

Every question below, with the reasoning for all four options. Try to answer before you open one.

  1. Physical assessment · medium

    A nurse measures the vital signs of an adult patient who weighs 70 kg: BP 88/54 mmHg, pulse 118/min, respirations 24/min, temperature 38.9°C. Urine output has been 15 mL/hr for the last three hours. Which of these findings most directly measures perfusion of an end organ?

    • APulse of 118/min
    • BTemperature of 38.9°C
    • CUrine output of 15 mL/hr
    • DRespiratory rate of 24/min
    Show the answer and why the others fail

    Answer: C. Urine output of 15 mL/hr

    A
    Tachycardia is a compensatory response that defends cardiac output; it warns of a problem but says nothing about whether any specific organ is still being perfused.
    B
    Fever signals an inflammatory or infectious process and raises metabolic demand, but it is not itself a direct measure of tissue perfusion.
    C — correct
    For this 70 kg patient, 15 mL/hr equals roughly 0.21 mL/kg/hr, far below the 0.5 mL/kg/hr threshold. Reduced urine formation is the direct bedside consequence of inadequate renal perfusion, making it the only listed finding that measures an end organ's blood supply rather than the body's compensatory effort.
    D
    Tachypnea is a significant finding — a rate of 22/min or above is one of the qSOFA criteria and, alongside this patient's hypotension, points toward sepsis — but it reflects respiratory compensation rather than measuring perfusion of an end organ.

    TakeawayUrine output below 0.5 mL/kg/hr is a direct marker of end-organ hypoperfusion, unlike compensatory changes in heart rate or respiratory rate. Three hours of oliguria is a perfusion warning, not an acute kidney injury stage — KDIGO stage 1 requires that low output be sustained for at least 6 hours.

  2. Physical assessment · medium

    A nurse is preparing to measure the blood pressure of a patient who has a left arm arteriovenous fistula for hemodialysis. Which of the following actions should the nurse take?

    • AApply the cuff to the left arm directly over the fistula site.
    • BPosition the cuff on the left forearm below the fistula.
    • CObtain the blood pressure measurement using the right arm.
    • DPlace the cuff on the left thigh to avoid both arms entirely.
    Show the answer and why the others fail

    Answer: C. Obtain the blood pressure measurement using the right arm.

    A
    Applying pressure over an arteriovenous fistula can cause thrombosis, damage the fistula, and compromise vascular access for dialysis.
    B
    The entire limb with the fistula should be avoided for blood pressure measurement to prevent compromised circulation, inaccurate readings, and potential fistula damage.
    C — correct
    The arm with the fistula should never be used for blood pressure measurement. The opposite arm is the preferred site to ensure patient safety and preserve the fistula.
    D
    While the thigh is an alternative site, it is not the first choice when a healthy opposite arm is available. Thigh measurements also require a larger cuff and may be less accurate.

    TakeawayNever measure blood pressure on an arm with an arteriovenous fistula; use the opposite arm to prevent thrombosis and preserve vascular access.

  3. Physical assessment · medium

    A nurse is performing a peripheral vascular assessment on a patient who reports chronic leg pain. Which finding would the nurse interpret as most indicative of arterial insufficiency?

    • APitting edema extending from the foot to the calf
    • BIrregularly shaped ulcer with moderate to heavy exudate
    • CDependent rubor of the foot when lowered below heart level
    • DBrownish hyperpigmentation around the medial malleolus
    Show the answer and why the others fail

    Answer: C. Dependent rubor of the foot when lowered below heart level

    A
    Pitting edema is a hallmark of venous insufficiency, not arterial. In venous disease, incompetent valves lead to increased hydrostatic pressure and fluid leakage into tissues.
    B
    Irregularly shaped ulcers with exudate are typical of venous stasis ulcers, which occur due to chronic venous hypertension. Arterial ulcers are usually well-demarcated, 'punched out,' with minimal exudate and are found on pressure points.
    C — correct
    Dependent rubor, a deep red color of the foot when placed in a dependent position, is a classic sign of severe peripheral arterial disease. It occurs because ischemic tissues maximally dilate in an attempt to increase blood flow, and when the leg is dependent, gravity aids blood flow, causing the red color.
    D
    Brownish discoloration, especially in the gaiter area, is characteristic of chronic venous insufficiency due to hemosiderin deposition from red blood cell breakdown, not arterial disease.

    TakeawayDependent rubor is a key sign of severe peripheral arterial disease, reflecting maximal vasodilation in ischemic tissue. In contrast, venous insufficiency typically presents with edema, hemosiderin staining, and irregular ulcers.

  4. Physical assessment · medium

    A nurse is assessing a 65-year-old patient who is 3 days post-operative following a total hip replacement. The patient reports pain in the right calf. Which assessment finding would most strongly suggest the presence of a deep vein thrombosis (DVT)?

    • ADiminished pedal pulses in the affected leg
    • BUnilateral swelling of the right calf
    • CBilateral pitting edema in the lower extremities
    • DPositive Homan's sign
    Show the answer and why the others fail

    Answer: B. Unilateral swelling of the right calf

    A
    Diminished pedal pulses suggest arterial insufficiency rather than venous thromboembolism; DVT primarily affects the venous system and pulses are usually unchanged.
    B — correct
    Unilateral leg swelling, particularly in a patient with risk factors such as recent orthopedic surgery, is a classic and highly suggestive physical finding for DVT.
    C
    Bilateral edema typically indicates a systemic issue such as heart failure, renal disease, or venous insufficiency, not an acute unilateral DVT.
    D
    Homan's sign (calf pain on dorsiflexion of the foot) is an unreliable and non-specific indicator of DVT; it can be present in many other conditions and is absent in many confirmed DVTs.

    TakeawayUnilateral leg swelling is a key physical finding for DVT; Homan's sign is unreliable and should not be used as a sole diagnostic indicator.

  5. Physical assessment · easy

    A nurse is assessing a patient admitted with dyspnea and bilateral lower extremity edema. To accurately evaluate for jugular venous distention, which action should the nurse take?

    • AAsk the patient to stand and turn the head to the left.
    • BPosition the patient supine with the head of the bed flat.
    • CHave the patient sit upright and lean forward.
    • DElevate the head of the bed to 30-45 degrees.
    Show the answer and why the others fail

    Answer: D. Elevate the head of the bed to 30-45 degrees.

    A
    Standing is not a standard position for JVD assessment; it may alter venous return and does not provide a reliable measurement.
    B
    A flat position can cause distention of the jugular veins even in individuals without heart failure, leading to a false-positive finding.
    C
    Sitting upright may cause the jugular veins to collapse, making it difficult to assess distention; this position is used for assessing murmurs, not JVD.
    D — correct
    Elevating the head of the bed to 30-45 degrees allows optimal visualization of the internal jugular vein pulsations and accurate estimation of central venous pressure.

    TakeawayElevate the head of the bed to 30-45 degrees to properly assess jugular venous distention; a flat position can cause false-positive findings.

  6. Physical assessment · medium

    A 58-year-old patient with a history of alcohol-related cirrhosis presents with progressive abdominal distension. The nurse performs abdominal percussion with the patient supine, noting dullness in the flanks and tympany near the umbilicus. Which additional finding would best confirm the presence of ascites?

    • AThe dullness shifts to the dependent side when the patient turns laterally
    • BDullness remains in the same flank when the patient turns to the opposite side
    • CTympany is heard over all abdominal quadrants in the supine position
    • DA palpable fluid wave is felt on the opposite abdominal wall with a single hand
    Show the answer and why the others fail

    Answer: A. The dullness shifts to the dependent side when the patient turns laterally

    A — correct
    Shifting dullness is a reliable physical sign of ascites: free fluid gravitates to the dependent area, while air-filled bowel floats to the top, causing the percussion note to change from dull to tympanic in the previously dull flank.
    B
    Fixed dullness that does not shift with position change suggests a solid mass, organomegaly, or loculated fluid, not freely mobile ascitic fluid.
    C
    Generalized tympany suggests gaseous distension, not free fluid. In ascites, dependent dullness is expected in the flanks when supine.
    D
    A fluid wave can indicate ascites but is less sensitive and may be falsely positive due to transmission through subcutaneous fat; it requires a third hand to block transmission along the abdominal wall.

    TakeawayShifting dullness is a sensitive and specific percussion sign for ascites, relying on the movement of free fluid with gravity.

  7. Physical assessment · easy

    A nurse is performing a physical assessment on a patient with advanced liver cirrhosis. The nurse asks the patient to extend both arms and dorsiflex the wrists. After a few seconds, the patient's hands exhibit a series of rapid, non-rhythmic flexion-extension movements at the wrists. Which finding should the nurse document?

    • ATrousseau's sign
    • BIntention tremor
    • CAsterixis
    • DResting tremor
    Show the answer and why the others fail

    Answer: C. Asterixis

    A
    Trousseau's sign is a carpopedal spasm induced by inflating a blood pressure cuff above systolic pressure, indicating hypocalcemia, and is not a flapping movement of the wrists.
    B
    Intention tremor is a rhythmic, oscillatory movement that worsens during voluntary, goal-directed movement, such as reaching for an object, and is not elicited by sustained posture.
    C — correct
    Asterixis is a flapping motion caused by brief, intermittent losses of postural muscle tone (negative myoclonus), commonly associated with hepatic encephalopathy. It is best elicited by having the patient extend the arms and dorsiflex the wrists.
    D
    Resting tremor is a rhythmic oscillation that occurs when the limb is fully supported and at rest, diminishing with voluntary movement, and is characteristic of Parkinson's disease, not sustained wrist dorsiflexion.

    TakeawayAsterixis is a sign of metabolic encephalopathy, often hepatic, characterized by brief lapses of postural tone when the patient maintains wrist dorsiflexion. It is not a tremor but a negative myoclonus.

  8. Physical assessment · medium

    A nurse is assessing a 65-year-old patient with a history of heart failure who reports progressive dyspnea. On percussion of the posterior chest, the nurse notes dullness over the right lower lobe. Which additional finding would support a diagnosis of pleural effusion rather than lobar pneumonia?

    • AWhispered pectoriloquy over the dull area
    • BDiminished breath sounds over the dull area
    • CIncreased tactile fremitus over the dull area
    • DEgophony over the dull area
    Show the answer and why the others fail

    Answer: B. Diminished breath sounds over the dull area

    A
    Whispered pectoriloquy, where whispered words are heard clearly, indicates lung consolidation (pneumonia). In pleural effusion, fluid dampens sound transmission, so whispered sounds are not clearly heard.
    B — correct
    Pleural effusion separates the lung from the chest wall with fluid, resulting in diminished or absent breath sounds. In pneumonia, consolidation transmits sound more effectively, leading to bronchial breath sounds.
    C
    Increased tactile fremitus indicates lung consolidation, as in lobar pneumonia, because sound vibrations travel better through solid tissue than air. In pleural effusion, fluid blocks vibration, causing decreased fremitus.
    D
    Egophony (a change from 'E' to 'A' sound) is a sign of lung consolidation, typical of lobar pneumonia. In pleural effusion, breath sounds are diminished and egophony is absent over the fluid.

    TakeawayPleural effusion reduces breath sounds and tactile fremitus due to fluid insulating the lung, while lobar pneumonia increases sound transmission through consolidated tissue, causing bronchial breath sounds, egophony, and whispered pectoriloquy.

  9. Physical assessment · medium

    A nurse is assessing a 24-year-old patient admitted with fever, severe headache, and photophobia. The patient reports neck stiffness. The nurse gently flexes the patient's neck and observes involuntary flexion of the hips and knees. Which assessment finding is this?

    • APositive Brudzinski's sign
    • BPositive Hoffman's sign
    • CPositive Babinski reflex
    • DPositive Kernig's sign
    Show the answer and why the others fail

    Answer: A. Positive Brudzinski's sign

    A — correct
    Brudzinski's sign is positive when passive neck flexion causes involuntary hip and knee flexion, a screening sign for meningeal irritation with low sensitivity.
    B
    Hoffman's sign is tested by flicking the nail of the middle finger; a positive response (thumb and index finger flexion) suggests an upper motor neuron lesion.
    C
    Babinski reflex is elicited by stroking the lateral sole of the foot; dorsiflexion of the great toe and fanning of other toes indicates an upper motor neuron lesion.
    D
    Kernig's sign is tested by flexing the hip and knee to 90 degrees and then extending the knee; pain or resistance suggests meningeal irritation but has low sensitivity.

    TakeawayBrudzinski's sign is a screening maneuver for meningeal irritation: passive neck flexion triggers involuntary hip and knee flexion. It has low sensitivity in adults, so a negative sign does not rule out meningitis.