MNExam

Question 1

The nurse uses the Braden Scale in the extended care facility to determine risk for pressure ulcer development. Based on this scale. What is the best score for a braden scale for most risk?

Answer 1

12

Question 2

Which test would be most appropriate for the nurse to perform when assessing eye muscle strength and cranial nerve function?

Answer 2

Extra ocular movement test

Question 3

An hallucination is a disorder of

Answer 3

Perception

Question 4

A 55-year old patient is being evaluated for a hearing impairment. Which question would provide the most useful information?

Answer 4

“Are you having difficulty hearing high-frequency sounds?”

Question 5

A false fixed belief that is out of keeping with a persons knowledge and culture is known as a

Answer 5

delusion

Question 6

Pressure injuries form primarily as a result of

Answer 6

tissue necrosis

Question 7

A nurse is preparing to assess the distant visual activity of a patient who wears reading glasses. What kind of statement would be appropriate

Answer 7

Ask the patient to remove the glasses before testing

Question 8

A nurse is having difficulty determining a patients heart sounds, specifically S1 and S2. Which of the following would be appropriate for the nurse to do next?

Answer 8

Palpate the carotid pulse while auscultating the heart.

Question 9

What is the name given to the condition where the patient has an acute confusional state, stemming from an infection?

Answer 9

Delirium

Question 10

A patient complains of headaches each morning that disappear after getting out of bed. What would be the most appropriate thing for the nurse to do next?

Answer 10

Use an appropriate framework to find out more information about the headaches.

Question 11

When a patient is immobile, how often should the patient have a position change to prevent skin breakdown?

Answer 11

2 hourly

Question 12

A nurse is preparing to assess an adult patients body temp. At which time of the day would the nurse expect to obtain the lowest body temp?

Answer 12

Early Morning

Question 13

A novice nurse is practicing how to complete a comprehensive assessment to gain confidence and skill. Which of the following would be most important for the nurse to remember?

Answer 13

Establish a routine for the assessment

Question 14

Which one of the following is a myth about pain in the older adult?

Answer 14

Elderly people who are confused or cognitively impaired do not have pain

Question 15

When a patient is in supine position, what are the potential sites of pressure injury the nurse should assess?

Answer 15

Unprotected pressure points at sacrum, heels, scapulae, elbows and back of head.

Question 16

Prolonged, intense pressure affects cellular metabolism by decreasing or obliterating blood flow, resulting in tissue schema and ultimately tissue death. There are 4 stages of pressure injury formation. The nurse observes partial- thickness skin loss involving the epidermis and possibly dermis. What stage will the nurse document in the patient records.

Answer 16

Stage II

Question 17

Nurses should be aware of the verbal and non-verbal ways patients can communicate discomfort. What would be an appropriate assessment tool to use with young children?

Answer 17

A faces pain scale

Question 18

What is the name given to the progressive deteriorating organic mental disorder that is associated with the ageing process?

Answer 18

Dementia

Question 19

The nurse Auscultating a patients blood pressure, and identifies which of the following as the portion of the blood pressure cycle, reflecting the break in sounds occurring between the first and second sounds?

Answer 19

Auscultatory Gap

Question 20

An older adult female patient is concerned because her skin is very dry. She asks the nurse why she has dry skin now when she never had dry skin before. The nurse responds to the patient based on the understanding that dry skin is normal with ageing due to a decrease of what?

Answer 20

Sebaceous glands

Question 21

Elderly patients who are experiencing confusion are best managed by:

Answer 21

providing simple directions with physical assistance if necessary.

Question 22

When a patient fabricates events to full in memory gaps this is called

Answer 22

confabulation

Question 23

The nurse is educating the patient about narcotic analgesics for pain relief. Included in the teaching is the fact that narcotic analgesics may cause:

Answer 23

Constipation

Question 24

Which of the following is correct in relation to delirium :

• It is an acute confusional state
• there is no available treatment.
• It is important to find the cause
• the core impairment is related to alertness, attention and awareness.

Answer 24

There is no available treatment

Question 25

For which patients condition would the nurse most likely expect a capillary refill time longer than two seconds

Answer 25

peripheral vascular disease

Question 26

The nurse patient is assessing a patients first heart sound. The nurse interprets this finding as indicating which heart action?

Answer 26

Closure of the atrioventricular valves.

Question 27

A nurse examines the eye of an older adult patients. what is something a nurse documents as a normal finding?

Answer 27

Ectropion

Question 28

During the skin assessment if an older adult patients who had a stroke, the nurse noted a reddened area over the coccyx. The nurses next actions for this client should include:

Answer 28

reposition the patient off the coccyx and reassess in one hour

Question 29

The nurse is preparing to assess a patients apical pulse. The nurse would palpate at which location

Answer 29

5th intercostal space, left midclavicular line.

Question 30

Chronic nonmalignant pain is:

Answer 30

pain prolonged, varies in intensity and lasts longer than 6 months.

Question 31

A nurse is presenting an educational class to a local community about vision and eye health. As part of the presentation the nurse explains how visual perception occurs. Which of the following would the nurse include in the explanation.

Answer 31

involves light rays sticking the retina.

Question 32

A nursing student who cares for patients should be aware of which of the following as the most important way of reducing disease transmission

Answer 32

Hand hygiene

Question 33

During an assessment of a patient with a severe asthma attack which part of the body would nurse assess for central cyanosis?

Answer 33

oral mucosa

Question 34

A patient has sustained an injury to the cerebellum. What nursing assessment will give you objective data relating to this injury?

Answer 34

Neurological

Question 35

When a patient describes their pain as coming on quickly and being of short duration what type of pain would this be?

Answer 35

Acute

Question 36

A 60-year old patient has difficulty hearing high-pitched sounds/ The nurse would document this finding as what?

Answer 36

Presbycusis

Question 37

Your patient tells you that during an altercation with another patient, they left anxious and like their heart was pounding. What is a correct description of this?

Answer 37

The heart is attempting to increase cardiac output

Question 38

The nurse is aware that is is important to break the chain of infection. An example of a nursing intervention that is implemented to reduce as a reservoir of infection for a patient is:

Answer 38

changing soiled dressings

Question 39

When performing a comprehensive assessment, which part of the body would the nurse assess the motor function of cranial nerve VII

Answer 39

Face and head

Question 40

When performing a physical examination of an older adult patient, what would be the most appropriate way?

Answer 40

Try to minimise position changes.

Question 41

A patient asks why cerumen is important because it “just clogs up the ear anyway”. Which response would be most appropriate?

Answer 41

“it helps create smoothness of the external auditory canal”

Question 42

A nurse shines a light into one eye during ocular exams and the pupil of the other constricts. The nurse interprets this as what

Answer 42

consensual response.

Question 43

When a patient is lying in a prone position, what are they potential pressure injury risk area the nurse should assess for?

Answer 43

Unprotected pressure points at the chin, elbow, hips, knees and toes.

Question 44

An older adult male patient states that he has trouble cutting his toenails because they are hard and thick, and the nurse notes that they are very long and unkempt. Which system would be most important for the nurse to assess?

Answer 44

circulatory

Question 45

There are several instruments for assessing patients who are at risk of developing a pressure ulcer. The Braden Scale is one of these commonly used. What are risk factors are assessed using the Braden Scale?

Answer 45

Sensory perception, moisture, activity, mobility, nutrition, friction, shear.