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246
| Question | Answer |
|---|---|
| During a mental status examination, the nurse wants to assess a patient's affect. The nurse should ask the patient which question? | "How do you feel today?" |
| The nurse is planning to assess new memory with a patient. The best way for the nurse to do this would be to: | Give him the four unrelated words test. |
| A 45-year old woman is at the clinic for a mental status assessment. In giving her the four unrelated words test, the nurse would be concerned if she could not ___ four unrelated words____. | Recall; after a 30 minute delay |
| During a mental status assessment, which question by the nurse would best assess a person's judgement? | "Tell me what you plan to do once you are discharged from the hospital." |
| Which of these individuals would the nurse consider at highest risk for a suicide attempt? | Older adult man who tells the nurse that he is going to "join his wife in heaven" tomorrow and plans to use a gun. |
| When reviewing theuse of alcohol by older adults thenurse notes that older adults have several characteristics that can increase the risk of alcoholuse. What would increase the bioavailability of alcohol in the blood for longer periods in the older adult | Decreased liver and kidney functioning. |
| During an assessment, the nurse asks a female patient, "How many alcoholic drinks do you have a week?" Which answer by the patient would indicate at-risk drinking? | I have seven or eight drinks a week, but I never get drunk. |
| The nurse is asking an adolescent about illicit substance abuse. The adolescent answers, "Yes, I've used marijuana at parties with my friends." What is the next question the nurse should ask? | "When was the last time you used marijuana?" |
| The nurse has completed an assessment on a patient who came to the clinic for a leg injury. As a result of the assessment, the nurse has determined that the patient has at-risk alcohol use. Which action by the nurse is most appropriate at this time? | State, "You are drinking more than is medically safe. I strongly recommend that you quit drinking, and I'm willing to help you." |
| A patient is brought to the E.D. Restless, dilated pupils, sweating, runny nose, tearing eyes, complains muscle and joint pain. His gf thinks he has influenza, she got concerned when his temp went up to 39.4C. She admits he is a heavy drug user. Suspect? | Withdrawal from Heroine |
| Patient taking ipratropium reports nausea, blurred vision, has insomnia after using the inhaler. RN action to implement | Withhold medication and report symptoms |
| A patient has suddenly developed shortness of breath, appears to be in significant respiratory distress. After calling the HP and placing pt on O2, which of these actions is best for nurse to take for further assessment? | Bilaterally percuss the thorax, noting any differences in percussion tones. |
| The nurse is teaching a class on basic assessment skills. Which of these statements is true regarding the stethoscope and its use? | Although the stethoscope does not magnify sound, it does block out extraneous room noise. |
| The nurse is preparing to use a stethoscope for auscultation. Which statement is true regarding the diaphragm of the stethoscope? The diaphragm: | Is used to listen for high-pitched sounds |
| Before auscultating the abdomen for the presence of bowel sounds on a patient, the nurse should: | Check the temperature of the room, and offer blankets to the patient if he or she feels cold. |
| While measuring a patient's blood pressure, the nurse recalls that certain factors, such as _____, help determine blood pressure. | Peripheral vascular resistance |
| A nurse is helping at a health fair at a local mall. When taking blood pressure on a variety of people, the nurse keeps in mind that: | The blood pressure of a Black adult is usually higher than that of a White adult of the same age. |
| The nurse notices that a colleague is preparing to check the blood pressure of a patient who is obese by using a standard sized blood pressure cuff. The nurse should expect the reading to: | Yield a falsely high blood pressure |
| A student is late for his appointment and has rushed across campus to the health clinic. The nurse should: | Allow 5 minutes for him to relax and rest before checking his vital signs. |
| Hypoptysis (new cough) or changes in persistent cough | tuberculosis s/sx |
| The nurse is assessing a patient's pain. The nurse knows that the most reliable indicator of pain would be the: | Subjective report. |
| A patient has arthritic pain in hips for several years since hip fracture. Unable to move around in room. No complaints so far this morning. When asked she says her pain is bad this morning, 8 out of 10. What does the nurse suspect. | Has experienced chronic pain for years and has adapted to it. |
| The nurse is reviewing the principles of pain. Which type of pain is due to an abnormal processing of the pain impulse through the peripheral or central nervous system. | Neuropathic |
| The nurse hears bilateral loud, long, and low tones when percussing over the lungs of a 4 year old child. The nurse should: | Consider this finding as normal for a child this age, and proceed with the examination. |
| When assessing the quality of a patient's pain, the nurse should ask which question? | What does your pain feel like? |
| When assessing a patient's pain, the nurse knows that an example of visceral pain would be: | Cholecytisis |
| A 775-year old woman who has a history of diabetes and peripheral vascular disease has been trying to remove a corn on the bottom of her foot with a pair of scissors. The nurse will encourage her to stop trying to remove the corn with scissors because | The woman could be at increased risk for infection and lesions because of her chronic disease. |
| The nurse keeps in mind that a thorough skin assessment is extremely important because the skin holds information about a person's: | Circulatory status |
| A patient comes in for a physical exam and complains of "freezing to death" while waiting for her examination. The nurse notes that her skin is pale and cool and attributes this finding to | Peripheral vasoconstriction |
| A patient comes to the clinic and tells the nurse that he has been confined to his recliner chair for approximately 3 days with his feet down and he asks the nurse to evaluate his feet. During assessment the nurse might expect to find: | Caused by the complete absence of melanin pigment. |
| The nurse will perform a palpated pressure before auscultating blood pressure. The reason for this is to: | Detect the presence of an auscultatory gap |
| A patient tells the nurse that he has noticed that one of his moles has started to burn and bleed. When assessing his sin, the nurse pays special attention to the danger signs for pigmented lesions and is concerned with which additional finding? | Color variation |
| Sarcoidosis- autoimmune inflammatory disease affecting multiple organs | improved pulse oximetry values |
| A 19 year old college student is brought to the E.D with severe headache "like nothing I've ever had before" Temp is 40C and he has a stiff neck. The nurse looks for other signs and symptoms of which problem | Meningeal inflammation |
| During a well baby checkup, the nurse notices that a 1weekold infant face looks small compared with his cranium which seems enlarged. On further examination, the nurse also notices dilated scalp veins and down cast or setting sun eyes. The nurse suspects? | Hydrocephalus |
| The nurse needs to palpate the temporomandibular joint for crepitation. This joint is located just below the temporal artery and anterior to the | tragus. |
| Pt has come in for exam and states "I have this spot in front of my ear lobe on my cheek that seems to to get bigger and is tender" The nurse notes swelling below the angle of the jaw and suspects it could be inflammation of his | Parotid gland |
| A male patient with a history of acquired immunodeficiency syndrome (AIDS) has come in for an exam and he states, "I think that I have the mumps." The nurse would begin by examining the: | Parotid gland |
| In performing an exam of a 3-year-old child with a suspected ear infection, the nurse would | perform the otoscopic exam at the end of the assessment |
| The nurse is preparing an otoscopic exam of a newborn infant. Which statement is true regarding this exam | The normal membrane may appear this and opaque |
| The nurse assesses the hearing of a 7 month old by clapping hands. What is the expected response? The infant: | Turns his or her head to the localized sound |
| The nurse is performing an ear exam of an 80 year old patient. Which of these findings would be considered normal? | High tone frequency loss |
| Assessment of a 23 year old pt reveals the following: an auricle that is tender and reddish-blue in color with small vesicles. the nurse would need to know additional information that includes which of these? | Any prolonged exposure to extreme cold |
| A pregnant woman states that she ins concerned about her gums because she has noticed they are swollen and have started bleeding. what would be an appropriate response by the nurse? | Swollen and bleeding gums can be caused by the change in hormonal balance in your system during pregnancy |
| 40year old who just finished chemo for breast cancer says she is concerned about her mouth. During assessment buccal mucosa are red and raw with some bleeding, other areas have a white, cheesy coating. The nurse recognizes this abnormality is | Candidiasis |
| The nurse is assessing a patient in the hospital who has received numerous antibiotics and notices that his tongue appears to be black and hairy. In response to his concern, what would the nurse say | Black, hairy tongue is a fungal infection caused by all the antibiotics you have received |
| The nurse is assessing a patient with a history of intravenous drug abuse. In assessing his mouth, the nurse notices a dark red confluent macule on the hard palate. This could be an early sign of | acquired immunodeficiency syndrome (AIDS |
| A mother brings 4 month old with concerns regarding a small pad in the middle of upper lip that has been there since 1 month old. Infant has no health problems. Physical exam 0.5cm fleshy elevated area in the middle of upper lip. | This elevated area is a sucking tubercle caused from the friction of breastfeeding or bottle feeding and is normal |
| Which finding should the RN assess for a pt for risk of Diabetes insipidus | Polydipsia- abnormally great thirst |
| During percussion, the nurse knows that a dull percussion note elicited over a lung lobe most likely results from | increased density of lung tissue |
| The nurse is observing the auscultation technique of another nurse. The correct method to use when progressing from one auscultatory site on the thorax to another is ___ comparison | side-to side |
| When auscultating the lungs of an adult, the nurse notes that low-pitched, soft breath sounds are heard over the posterior lower lobes, with inspiration being longer than expiration the nurse interprets that these sounds are | vesicular breath sounds and normal in that location |
| The nurse is auscultating the chest in an adult. which technique is correct | firmly holding the diaphragm of the stethoscope against the chest |
| The nurse is percussing over the lungs of a patient with pneumonia. The nurse knows that percussion over an area of atelectasis in the lungs will reveal | dullness |
| During precordial assessment on pt who is 8 months pregnant, the nurse palpates the apical impulse at the fourth left intercostal space lateral to the midclavicular line. This finding would indicate? | Displacement of the heart from elevation fo the diaphragm |
| In assessing for S4 heart sounds with a stethoscope the nurse would listen with the | bell of the stethoscope at the apex with the patient in the left lateral position. |
| A 70year old pt with hx of hypertension has bp of 19]80/100, HR of 90. The nurse hears extra heart sound at the apex immediately before S1. The sound is only heard with bell while pt is on the left lateral position. This is most likely | Atrial gallop |
| Nurse is performing cardiac assessment on 65 year old 3 days after myocardial infarction. Heart sounds are normal when supine, but when sitting and leaning forward, high pitched, scratchy sound is heard with diaphragm at apex. It disappears on inspiration | The nurse suspects inflammation of the pericordium. |
| When the nurse is testing the triceps reflex, what is the expected response | Extension of the forearm |
| The nurse is testing superficial reflexes on adult pt. When stroking up the lateral side of the sole and across ball of foot, the nurse notices plantar flexion of toes. How should the nurse document this finding | Plantar reflex present |
| OTC decongestants-- can increase IOP | can increase HR and BP |
| Assessment of 1 month old, the nurse notices lack of response to noise or stimulation. Mother says he has been sleeping all the time, when awake all he does is cry. The cry is very high pitched and shrill. What should the nurse's appropriate response be | refer the infant for further testing |
| Which of these tests would the nurse use to check the motor coordination of an 11 month old | Denver ll |
| To assess the head control of a 4 month old infant, the nurse lifts up the infant in a prone position while supporting his chest. the nurse looks for what normal response? The infant: | Raises the head, and arches the back |
| The nurse knows that a common assessment finding in a boy younger than 2 years old is | the presence of a hydrocele, or fluid in the scrotum |
| Genital assessment on a middle aged man, the nurse notices multiple soft moist painless papules in the shape of a cauliflower like patches scattered across the shaft of the penis. These lesions are characteristics of | Genital warts |
| 15 year old boy is seen for complaints of "dull pain and pulling" in the scrotal area. On exam, the nurse palpates a soft, irregular mass posterior to and above the testis on the left. Mass collapses when pt is supine and refills when he is upright. | Varicocele |
| Genitourinary asses. on a 16 y.o male. the nurse notices swelling in the scrotum that increases w/ increased intra-abdominal pressure and decreases when he is lying down. Pain when straining. | indirect inguinal hernia |
| A woman is 8 weeks pregnant. Nurse reads on her chart the her cervix is softened and looks cyanotic. The nurse knows the woman is exhibiting ___ sign and ____ sign | Goodell; Chadwick |
| Generally, the changes normally associated with menopause occur because the cells in the reproductive tract are | estrogen dependent |
| the nurse is reviewing the changes that occur with menopause. Which changes are associated with menopause | uterine and ovarian atrophy, along with a thinning of the vaginal epithelium |
| Primary reason for teaching pt pursed lip breathing | Promote CO2 elimination |
| 54 y.o woman who has just completed menopause in in the clinic for yearly physical exam. Which of these statements should the nurse include in patient education? "A postmenopausal woman: | should be aware that she is at increased risk for dyspareunia (painful intercourse) because of decreased vaginal secretion |
| A woman is in the clinic for an annual gynecologic exam. The nurse should begin the interview with the | Menstrual history, because it is generally nontreathening. |
| During an assessment of a hospitalized patient, the nurse pinches a fold of skin under the clavicle or on the forearm to test the | mobility and tugor |
| When assessing the neurologic system of a hospitalized patient during morning rounds, the nurse should include which of these during the assessment | patient's ability to communicate |
| when assessing a patient's general appearance, the nurse should include which question | does the patient appropriately respond to questions |
| The nurse is palpating the fundus of a pregnant woman. .Which statement about palpation of the fundus is true? | After 20 weeks gestation, the number of centimeters should approximate the number of weeks gestation |
| the nurse is palpating the abdomen of a woman who is 35 weeks pregnant and notices that the fetal head is facing downward toward the pelvis. the nurse would document this as fetal | presentation |
| A patient who had recent abdominal surgery is becoming increasingly agitated and confused. He has pulled out his IV and NG tube. his skin is pale and clammy. HR 120, BP 130/60. HP has been called. What nursing action is most important at this time | stay with the patient and have another nurse obtain needed supplies |
| Which patient is at greatest risk for injury and requires the nurse's immediate attention. The patient who had a(n) | needle liver biopsy 1 hour ago and is now thrashing about in bed complaining of severe abdominal pain |
| What could a nurse say who believed that a nursing student has a duty to understand pertinent clinical information to make sound clinical judgments | you should be honest when critically reflecting on your strengths and weaknesses |
| As a graduate nurse, which statement strongly suggests future success in the current nursing practice environment | I am actively involved in decision making on the unit |
| Which of the following is an example of an anxiety causing situation below that is potentially caused by a role transition from LPN/LVN to RN | Managing care based on your knowledge and skills |
| The patient reports intense pain and rates in 10 he is talking and laughing on the phone but interrupts his conversation to ask for pain meds. The nurse would make a decision about administration of meds. based on which indicator of pain | The patient's subjective statements about the pain |
| The nurse asks a hospitalized patient to sign the operative consent. The patient tells the nurse, "I do not really understand what is involved in the surgery." The nurse should: | Delay the patient's signature on the consent form and notify the surgeon that the informed consent process is not complete |
| If a patient refuses a med or is undergoing a diagnostic test that results in a missed dose of medication, the nurse will document the omission on the medication administration record an: | document why the dose was not given |
| A pt weighed 200lb 6 months ago. He now weighs 160. He has not been trying to loose weight. Based on the defining characteristics of nutrition, less than body requirements, the nurse's best response is | That is a significant weight loss. How would you account for it? |
| The nurse enters the room of a sleeping pt to administer the 0200 dose of antibiotic that is q6h. Which action is most effectively maintain a therapeutic blood level of this medication | Awaken the patient and administer the medication |
| The nurse is to take a meal tray to a patient the nurse knows nothing about. Before leaving the tray with the patient, which is the most critical safety factor the nurse should determine | The patient's ability to swallow is intact |
| A nurse notices that the respiratory therapist assigned to his unit frequently forgets to raise the bed rails after completing treatments. The nurse's best action is to | Discuss the problem with the therapist |
| Nurse assigned to care for an elderly confused pt. The pt son is sitting at the bedside and is watching a loud tv program. The nurse needs to complete the respiratory and cardiac assessment and vitals. What would be the best approach to this situation | I need a quiet environment while I listen to your mother's chest. I will need to turn the tv down until I'm finished |
| A graduate RN onthe telemetry unit is onthe way tothe nurse's station to chart and suddenly hears from a pt room HelpNurse This is not the assigned pt. Other's also hear and run w/ crash cart. Thebeginning RNmust realize theimportance ofidentifying and | Correcting weaknesses. Leveraging strengths |
| Which comments by the graduate RN are examples of interventions that will lead to a successful transition into professional nursing | May I care for pt's with COPD? I feel I need more experience with that pulmonary condition. Thanks for your insights about knowing when to appropriately call HP. Now hat my new role is an RN, I would like to be treated as any. new graduate RN |
| When providing discharge teaching for a client with uric acid calculi, the nurse would include an instruction to avoid which type of diet? | High purine |
| Parents of a child diagnosed with bacterial meningitis are asking the nurse ?s regarding the disease process. Which description about development of sequelae in infants with bacterial meningitis is most accurate | They usually occur during the first 2 months of life |
| Nurse is caring for a pt with chronic hypertension, struggles with med compliance due to financial issues. When reviewing recent lab work results, which reflects the client's bp issues | blood urea nitrogen (BUN) creatinine calcium |
| The nurse is caring for a client who has a type 1 second degree atrioventricular (AV) block. Which ECG rhythm would the nurse expect to see | 4 |
| Nurse is caring for a client who has been placed on phenobarbital 30mg daily for newly diagnosed seizure activity. Which instructions would be included in teaching the pt specifically related to anticonvulsant drug efficacy? | Avoid all bp readings and trauma to right arm. Assessing the shunt by auscultating a bruit Completing arm and finger exercises |
| float nurse assigned to a surgical unit. The nurse is receiving 2 clients from the post-anesthesia care unit (PACU) at the same time. When delegating tasks to other unit personnel whoare not known tothe nurse which questions would be most important to ask | Are you comfortable in performing the tasks being assigned? |
| The nurse is triaging phone calls at a local pediatricians office. which statement by the parent of the child being treated for pinworms indicates that further teaching is needed? | I'll warn my child to avoid sharing hairbrushes and hats to prevent spreading pinworms to others |
| Nurse is caring for homeless pt w/ pneumonia. Lab test reveals BUN 180, creatinine 30, potassium 6.2, and hemoglobin 6.2%. Based on the HP order bleow, which drug would the nurse question | Gentamicin sulfate |
| The nurse is caring for a client with a nasogastric tube and in mitt restraints. Which nursing action is required every 1 to 2 hours | Remove restraints and assess skin and circulation |
Created by:
HessA813