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Clinical Final L2 > Evolve quiz > Flashcards

Evolve quiz Flashcards

1
Q

What is the primary purpose of initially assessing an apical pulse

A

Establishment of a baseline as part of the patients vital signs

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2
Q

What instruction should the nurse give assistive personnel regarding the appropriate technique when measuring the adult patients apical pulse

A

Place your stethoscope at the fifth intercostal space of the left midclavicular line

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3
Q

Which action would take priority if a patients apical pulse has an irregular rhythm

A

Reassess the pulse for 1 whole minute

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4
Q

Which statement demonstrates an understanding of the importance of communicating changes in the patients apical pulse rate

A

The apical pulse increased from 78 to110 but the patient had just returned from the bathroom

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5
Q

The nurse can best determine the effect of crying on a patients apical pulse by doing what

A

Comparing the patients post crying apical pulse rate with her baseline or previous rate

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6
Q

What is the major health problem resulting from a pulse deficit

A

Deceased cardiac output is the major problem indicated by a pulse deficit. Decreased cardiac output may lead to other problems, such as activity intolerance

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7
Q

What should the nurse do when a pulse deficit is suspected

A

Ask another health care provider to count the radial pulse while the nurse counts the apical pulse

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8
Q

Which action should the nurse perform after identifying a pulse deficit

A

Assess the patient for signs of decreased cardiac output

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9
Q

You have the following information:

Oral temp = 38.6 C, radial pulse = 112 weak and thread, apical pulse =117 regular, respiration’s = 24 regular, BP = 104/50 right arm and 102/50 left arm

What is the pulse deficit

A

5

Take difference between apical and radial pulse

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10
Q

Which of the following is an early manifestation of decreased cardiac output

A

Fatigue

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11
Q

During the admissions process, the nurse initially assesses the patients radial pulse primarily for what purpose

A

Establishing a baseline

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12
Q

What will the nurse instruct nursing assistive personal to do when measuring an adult patients radial pulse

A

Palpate the patients inner wrist on the thumb side with the fingertips of your two middle fingers

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13
Q

What is the nurses priority action if a patients radial pulse has an irregular rhythm

A

Assessing the patient for a pulse deficit is useful in identifying an alteration in cardiac output

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14
Q

Inadequate oxygenation to the body will cause the radial pulse to become

A

Tachycardic

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15
Q

Which action would best asses the effect of exercise on a patients radial pulse measurement

A

Measuring the patients radial pulse before and after exercise

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16
Q

A patient with a herniated disk is scheduled for surgery to fuse two vertebrae in her cervical spine. Which activity is most likely to be a palliative factor for this patient

A

Performing moderate exercises appropriate for a patient with this kind of injury is likely to palliate the pain

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17
Q

The nurse notices that his patient has none of the signs and symptoms normally associated with pain, such as diaphoresis, tachycardia, and hypertension. The patient does however seem moody and a bit uncooperative. What conclusion does the nurse draw

A

The absence of physiological signs and symptoms is associated with chronic pain

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18
Q

Which observation indicates that a patients analgesic has been effective in managing pain that she rated a 6 out of 10 on a pain rating scale before the intervention.

A

The patient rates her current pain as 3 out of 10 on the paint rating scale

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19
Q

What will the nurse instruct NAP to do regarding the management of a patients pain

A

Let me know at lease 30 minutes before you transport her so I can administer her analgesics

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20
Q

A nurse is caring for a patient who has just had major abdominal surgery to respect a portion of his colon. What is the most reliable sign that the patient has significant time postoperative pain

A

The patient rates his pain a 7 out of 10

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21
Q

Which action can the nurse take to keep a patient from consciously controlling his her breathing during an assessment

A

Assess respiration’s after measuring the pulse so that the patient will not try to voluntarily control their breathing

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22
Q

On the last assessment of a patients respiration, her respiratory rate was 10 breaths per minute. What should the nurse do when conducting the next assessment of this patients respiratory rate

A

Count breaths for sixty seconds

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23
Q

When measuring a patients respiratory rate the nurse will count the number of completes respiratory cycles per minute. What is the definition of a respiratory cycle

A

The number of inspirations and expirations per minute

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24
Q

During the assessment of a patients respiratory rate when the second hand reaches the fifteen second mark the respiratory count is eight. What should the nurse do at this time

A

At eight in the first fifteen seconds, the patient has a rapid respiratory rate of more than twenty breaths per minute. The nurse should continue to count the breaths for a full sixty seconds

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25
Q

The nurse plans to assess a respiratory rate; however the patient has just returned from ambulation gonna to the bathroom. What should the nurse do to minimize the effect of exercise on the patinets respiratory rate

A

Waiting ten minutes before assessing respiration allows the patients oxygen demand to return to pre exercise levels

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26
Q

What is the correct order for abdominal assessment

A

Inspection
Auscultation
Percussion
Palpitation

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27
Q

How often should normal bowel sounds be heard in each quadrant of the abdomen?

A

5-35 times per minute

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28
Q

Which of the following is an important part of performing an abdominal assessment

A

Explaining each step of the assessment to the patient

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29
Q

What should you do if a patient is ticklish when your are palpating the abdomen

A

Place your hand over the patients hand during palpation

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30
Q

Moderate and deep palpation of the abdomen

A

May cause tenderness
Should not detect masses
May locate the margins of the liver

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31
Q

Which of the following methods is correct for examining the ear of an adult patient with an otoscope

A

Gently pulling the auricle up and back in the adult will straighten the auditory canal. Using the largest speculum that will fit comfortably is part of the otoscopic examination

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32
Q

Assessment of the ears includes which of the following

A

Inspection, palpation, and examination with an otoscope are all part of a thorough ear assessment

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33
Q

A nurse is inspecting the patients ears with an otoscope. Which of the following findings would be considered abnormal

A

The tympanic membrane should not have any perforations. A visible cone of light is a normal finding in an otoscopic examination. The tympanic membrane should appear pearly gray. A small amount of cerumen is a normal finding in an otoscopic examination

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34
Q

A whispered voice test includes which of the following

A

Having the patient wiggle a finger in the opposite ear ensures that patient is hearing the whisper in the ear being tested. A whispered voice test is performed while standing one to two feet from the patients ear. Music can be a distraction or interference with a whispered voice test

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35
Q

The rinne and Weber test measure which of the following

A

Air and bone conduction

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36
Q

When using the snellen chart, what does a vision evaluation of 20/50 mean

A

20/50 on the snellen chart means that the patient has difficulty seeing far objects clearly and can read at 20 feet what most people can read at 50 feet

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37
Q

What term refers to the constriction of the pupils when a patient focuses on an object held about ten centimeters from the nose

A

Accommodation

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38
Q

What does full movement of the eyes in the six cardinal fields of gaze reflect

A

Proper functioning of the oculomotor, trochlear, and abducens nerves plus proper functioning of the extraocular muscles is reflected by full movement of the eyes in the six cardinal fields of gaze

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39
Q

When examining the eyes, which of the following is an expected finding

A

Equal pupils

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40
Q

Which of the following are risk factors for glaucoma

A

Age over 40 years, diabetes and high blood pressure are risk factors for glaucoma

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41
Q

What is included in the preparation for an assessment of the female genitalia

A

Having the patient empty her bladder and explaining the exam thoroughly are both part of preparation for assessment of the female genitalia. If this is the patients first exam, the exam is explained thoroughly. A model or illustration is used to show the patient what will happen and what will be looked for. The head of the table is elevated slightly

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42
Q

When should gloves be changed or discarded

A

Gloves are considered contaminated as soon as you touch the genital skin, internal vaginal area, or rectum

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43
Q

Which description is consistent with normal vaginal secretions

A

Vaginal secretions that are clear or cloudy, and odorless or with a slight odor are a normal finding

44
Q

What is a Pap smear

A

A Pap smear is a screening test for cervical cancer and has contributed to a significant decline in the incidence of and mortality from cervical cancer

45
Q

Screening for endometrial cancer consists of reinforcing the need to report

A

Unexpected vaginal bleeding or spotting can be a sign of endometrial cancer

46
Q

In which patient population does benign prostatic hypertrophy occur most commonly

A

Males over 50

47
Q

Which of the following should be included in the male genital exam

A

Palpating for abnormalities, retracting and replacing the foreskin in an uncircumcised patient, and teaching a patient how to do self exams are all included in a male genital exam

48
Q

Nocturia, urine dribbles, difficulty voiding, and a small urine stream are common symptoms of which of the following conditions

A

Benign prostatic hypertrophy is common in men over 50 years of age. Nocturia, urine dribble, difficulty voiding, and a small urine stream are common symptoms of benign prostatic hypertrophy

49
Q

Which of the following patients are considered at increased risk for colon cancer

A

Both a history of chronic inflammatory bowl disease and a family history of adenomatous polyposis put a patient at increased risk for colon cancer

50
Q

Which possible signs and symptoms of testicular cancer should be reported to a physician

A

A lump, tenderness, or swelling in the scrotum or testicles; unexplained weight loss; and breast development in a male can all be signs of testicular cancer

51
Q

Where is the apical impulse located

A

In the fifth intercostal space at the midclavicular line

52
Q

Auscultatory sites of the heart include

A

Aortic, pulmonic, tricuspid and mitral area

53
Q

Which of the following findings during a cardiac assessment of an adult patient are considered normal

A

S1 & 2 sounds

54
Q

The S1 heart sound

A

The S1 heart sound is heard best at the apex of the heart. The S1 hear sound results from closure of the mitral and tricuspid valves. The S1 hear sound markets the start of systole

55
Q

When palpating the carotid arteries

A

Palpating one artery at a time and feeling for thrills are part of a complete assessment of the carotid arteries

56
Q

What is an increased thoracic curvature, common in older, called

A

Kyphosis

57
Q

Which of the following techniques is used to assess muscle strength in a patient

A

Muscle strength is tested for symmetry and grade. Strength should be bilaterally symmetric with full motion against resistance

58
Q

Neck flex ion and extension should be

A

45 degrees

59
Q

Which of the following findings in a musculoskeletal assessment would be considered abnormal

A

Both nodules and bogginess are considered abnormal findings

60
Q

What does a goniometer measure

A

Angles of extension and flex ion

61
Q

What questions can you ask a patient to assess his or her state of consciousness

A

Begin with asking the patient todays date, then ask the patient to state his or her name. A patient should be oriented to time, place and person and be able to respond appropriately to questions about the environment

62
Q

Which of the following cranial nerves is assessed by holding a scented object under the patients nose

A

The olfactory nerve is assessed by having a patient close his or her eyes, inhale deeply, and identifying the smell. The facial nerve is assessed by observing the patient making specific facial movements. The oculomotor nerve is assessed by inspecting the eyelids and by checking the pupils. The acoustic nerve is assessed by performing the whispered voice test

63
Q

What are the snellen and rosenbaum charts used to assess

A

The optic nerve.
Snellen = distance vision
Rosenbaum = tests near vision

64
Q

Which of the following are included in the assessment of mental status

A

Speech and language, emotional stability, and physical appearance and behavior are all part of a thorough assessment of mental status

65
Q

Which of the following actions are part of the assessment of the glossophryngeal and vagus nerves

A

Both testing the gag reflex and having the patient swallow are part of a thorough assessment of the glossopharyngeal and vagus nerves. When the posterior wall of the pharynx is touched, the patient should gag and the uvula should stay midline. Have the patient drink some water while you observe her ability to swallow.

66
Q

Which test or tests assess accuracy of movement

A

The finger to finger test is used to assess accuracy of movement. The patient’s movements should be rapid, smooth and accurate with no past pointing. The finger to nose test is used to assess accuracy of movement. The patients movements should be rapid, smooth and accurate, even with increasing speed. The heel to shin test is used to assess accuracy of movement. The patient should move his heel in a straight line without deviations to the side

67
Q

What should the nurse do if a patient displays staggering or loss of balance during the Romberg test

A

Delay other balance tests

68
Q

How would you assess sensitivity to superficial pain

A

Touching the patient with the sharp side of a broken tongue blade and allowing 2 seconds between stimuli are both part of a thorough assessment for superficial pain sensation.

69
Q

A deep tendon reflex with a. Normal response is scored as

A

2+ is considered an active or expected response for deep tendon reflex; this is a normal response. 0 indicates no response for deep tendon reflex; this is an abnormal response. 1+ indicates a sluggish or diminished response for dtf; this is abnormal. 3+ is a brisker than expected or slightly hyperactive response; this is abnormal.

70
Q

Which of the following tips will assist with eliciting the patellar and Achilles deep tendon reflexes

A

Have the patient focus on pulling his or her clasped hands apart

71
Q

Which of the following is the correct way to assess a patients nose for latency

A

Patency of nares is assessed by occluding one at a time

72
Q

What is the correct way to palpate the frontal sinuses

A

Press the thumbs against the brow bones

73
Q

The gag reflex should be

A

Testing with a tongue blade on each side of the oropharynx is part of assessing the gag reflex. The gag reflex should be present on both sides

74
Q

Which structures are included in a complete assessment of the mouth

A

Lips, mucosa, teeth, gums, tongue, floor of mouth, and hard and soft palates are all evaluated

75
Q

During vocalization, the soft palate

A

Raises symmetrically

76
Q

When should you check the patient’s BP to assess for orthostatic hypotension

A

While the patient is sitting and standing

77
Q

In which position should the patient be placed in order to palpate the popliteal pulse

A

Have the patient lie prone with the knee flexed

78
Q

Hearing a bruit in an artery is a sign of which of the following conditions

A

An obstruction

79
Q

Normal capillary refill is less than 2 seconds and is assessed by

A

Pressing on the nail bed until it blanches and observing how quickly full color returns

80
Q

What is a depression that is left after pressing a finger or thumb on swollen tissue called

A

Pitting edema

81
Q

The ABCD rule of melanoma includes

A

Asymmmetry of shape, border irregularity and color variation, diameter larger than the eraser of a pencil

82
Q

Which of the following is considered an abnormal finding in an older adult

A

A malignant melanoma is a type of skin cancer, which is an abnormal finding

83
Q

Skin inspection and palpation includes assessment for

A

Color, uniformity, symmetry, skin lesions, skin temperature

84
Q

An abnormal angle between the nail base and the nail is called clubbing and may indicate which of the following conditions

A

Cardiopulmonary disorder

85
Q

Which are the best places to check the skin for tenting, which is a sign of dehydration

A

The forearm and the sternum are the best areas

86
Q

When palpating the thorax, which of the following would be an abnormal finding

A

Tenderness, pulsation, masses

87
Q

When percussing the thorax which of the following would be a normal finding

A

Resonance over the lung fields, dullness over the ribs, heart and diaphragm

88
Q

Normal breath sounds include

A

Vesicular sounds

89
Q

When auscultating the lungs, it is important to

A

Compare each side bilaterally, note abnormal sounds, ask the patient to take slow, deep breaths

90
Q

Which of the following indicates normal respiratory function

A

Symmetrical chest expansion

91
Q

A nurse is assessing a patients neck with the patient seated. Which of the following is considered an unexpected finding

A

Jugular vein distention

92
Q

A nurse is inspecting the patients ears with an otoscope. Which of the following findings would be considered normal

A

Small amount on cerumen

93
Q

In which arteries are bruits considered normal

A

Never

94
Q

Neck rotation on each side would be

A

70 degrees on each side. Neck flexion and extension should each be 45 degrees

95
Q

Which of the following cranial nerves is assessed by observing the patient making specific facial movements

A

Cranial nerve 7 (VII)

96
Q

For which reflex is the normal response plantar flexion of the foot

A

For the Achilles reflex, the examiner strikes the Achilles tendon at the level of the ankle malleoli; in response, the foot should plantar flex. The normal response for the brachioradialis reflex is forearm pronation and elbow flexion. The normal response for the patellar reflex is lower leg extension. The normal response for the triceps reflex is arm extension at the elbow.

97
Q

What is the purpose of having the patient clench his teeth and smile

A

Having the patient clench the teeth and smile tests CN VII and lets you observe tooth occlusion. In proper occlusion, the upper and lower molars interdigitate, and the premolars and canines interdigitate.

98
Q

Which of the following is not included in a head to toe assessment

A

An exercise stress test

99
Q

Why is it important to have equipment and supplies organized before the exam

A

It avoid interruptions and delays

100
Q

Which of the following is part of monitoring and care

A

Ask the patient is they have any questions or concerns about the exam

101
Q

When preparing to measure the height and weight of a newly admitted patient, why would the nurse ask about the patient’s ability to stand?

A

Before measuring height and weight, the nurse asks about the patient’s ability to stand in order to determine if the patient is steady enough to stand without assistance while having his or her height measured.

102
Q

A nursing assistive personnel (NAP) is preparing to weigh a resident in a skilled nursing facility. The patient is usually weighed in street clothing and socks, with his shoes off. The patient is currently wearing street clothing with shoes and socks. What will the NAP do to ensure that the patient’s weight is correctly measured?

A

Since the patient is usually weighed in street clothing and socks, the NAP should remove the patient’s shoes and leave his socks on.

103
Q

Which step must be taken to ensure accurate measurement of a patients daily weight

A

Ask the patient to void before he or she is weighed

104
Q

As the nurse is conducting an admission interview, the patient states, “I’ve lost 30 pounds over the last 4 months.” Which question might the nurse ask to determine if the weight loss was intentional or unintentional?

A

Have you been following a specific diet

105
Q

For which patient would the nurse instruct NAP to weigh a patient with a bed scale

A

Patient who has heart failure and a consequent inability to bear weight

Clinical Final L2 (1 decks)

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