Week 1 Material + EAQ Flashcards
Subjective VS Objective data
Subjective
-how is the patient __________ [pain level, symptoms, fatigue, etc]
-view from ___________
Objective
-What the _______________________
-I see the patient is breathing hard
-I gather info from labs
Subjective
-how is the patient feeling [pain level, symptoms, fatigue, etc]
-view from the patient
Objective
-What nurse observes and gathers
-I see the patient is breathing hard
-I gather info from labs
Sources of patient data
Client
Family/Sig. others
______________ team
___________ records
diagnostic data
Client
Family/Sig. others
Health care team
medical records
diagnostic data
Methods of assessment
__________ centered interview
_________ experience
Environment
Nursing ________ history
Patient centered interview
Nurse’s experience
Environment
Nursing health history
Nursing health history
-___________ info
-_________ for seeking care
-client __________
-Present illness (PQRST)
-Health and family history
-Pyschosocial history
-spiritual health
-review of systems
-behavior observation
-Biographical info
-Reason for seeking care
-client expectations
-Present illness (PQRST)
-Health and family history
-Pyschosocial history
-spiritual health
-review of systems
-behavior observation
Medical diagnosis VS Nursing diagnosis
Medical diagnosis:
The identification of a disease condition base on specific evaluation of _____________________
Nursing diagnosis:
A clinical _____________ about the client in response to an actual or potential __________ problem
Medical diagnosis:
The identification of a disease condition base on specific evaluation of signs and symptoms
Nursing diagnosis:
A clinical judgment about the client in response to an actual or potential health problem
Actual (Problem Focused) Nursing Diagnosis Describes:
undesirable human response to existing problems or concerns of a patient.
Risk Nursing Diagnosis Describes:
human responses to health conditions/life processes that ________________
Actual (Problem Focused) Nursing Diagnosis Describes:
undesirable human response to existing problems or concerns of a patient.
Risk Nursing Diagnosis Describes:
human responses to health conditions/life processes that may develop
ABC [priorities]
?
Airway
Breathing
Circulation
Expected outcomes need to be
SMAR
?
Specific
Measurable
Attainable
Realistic
Vital Signs
- Body ______________
- Pulse
- ___________/Oxygen Saturation
- _______ Pressure
- _______ (The 5th Vital Sign)
- Body Temperature
- Pulse
- Respiration/Oxygen Saturation
- Blood Pressure
- Pain (The 5th Vital Sign)
Normal temperature range
◦ ______________________
or
36* C to 38* C
96.8* F to 100.4* F
Factors Affecting Body Temperature
-Age
-Exercise
- _________ level
-Circadian rhythm
- Environment
- ___________ alterations
◦ Fever/Pyrexia/FUO
◦ Heatstroke
◦ ______ Exhaustion
-Age
-Exercise
- Hormonal level
-Circadian rhythm
- Environment
-Temperature alterations
◦ Fever/Pyrexia/FUO
◦ Heatstroke
◦ Heat Exhaustion
Pulse
-An indicator of _________ status
-Electrical impulses originate from the _______________
-Cardiac output = heart rate * stroke volume
-Mechanical, neural, and chemical factors regulate ventricular contraction and stroke volume
-An indicator of circulatory status
-Electrical impulses originate from the sinoatrial (SA) node
-Cardiac output = heart rate * stroke volume
-Mechanical, neural, and chemical factors regulate ventricular contraction and stroke volume
Arterial Blood Pressure:
Force exerted on __________________
Force exerted on walls of an artery
Factors Influencing Blood
- Age
- Stress
- Ethnicity/Genetics
- Gender
- Daily Variation
- Medications
- Activity, weight
-Smoking
- Age
- Stress
- Ethnicity/Genetics
- Gender
- Daily Variation
- Medications
- Activity, weight
-Smoking
Hypertension
-More ___________ than hypotension
- ___________ of walls
- Loss of elasticity
- Family history
- Risk factors
Hypotension
-90 mm Hg
- __________ of arteries
- ______ of blood volume
- __________ of blood flow to vital organs
- Orthostatic/postural
Hypertension
-More common than hypotension
- Thickening of walls
- Loss of elasticity
- Family history
- Risk factors
Hypotension
-90 mm Hg
- Dilation of arteries
- Loss of blood volume
- Decrease of blood flow to vital organs
- Orthostatic/postural
What is pain?
An _____________ ____________ and emotional experience associated with actual or potential tissue damage..
whatever the _________________________________ says it is
Nurses are ___________ and ___________ responsible to manage pain and relieve suffering
An unpleasant sensory and emotional experience associated with actual or potential tissue damage..
whatever the person experiencing pain says it is
Nurses are ethically and legally responsible to manage pain and relieve suffering
Pain Assessment
PQRST
?
◦ Provokes/Pallaiative
◦ Quality
◦ Region/Radiation
◦ Severity
◦ Timing
Pulse (Acceptable range)
60 to 100 beats/min, strong and regular
Pulse oximetry (SpO2) Acceptable range
Normal: SpO2 ≥95%
Respirations acceptable range
12 to 20 breaths/min, deep and regular
Blood pressure acceptable range
Systolic <120 mm Hg
Diastolic <80 mm Hg
Pulse pressure: 30 to 50 mm Hg
Capnography (EtCO2) acceptable range
Normal: 35-45 mm Hg
Which assessing technique involves tapping a client’s skin with the fingertips to cause vibrations in the underlying tissues?
1 Palpation
2 Inspection
3 Percussion
4 Auscultation
3 Percussion
Percussion is the process of tapping the body parts with the fingers or hands to determine the consistency and borders of the body organs. Palpation is the act of feeling with the hand by applying pressure to the body surface to determine the condition of the skin and underlying tissues. Inspection is the process of visual observation of the body during physical examination. Auscultation means to listen to the internal sounds of the body.
Components of a Nursing Diagnosis
-__________ Label (NANDA-I)
-________ Factors (r/t=related to)
- Definition (NANDA-I)
- ____________ Condition
-Support of the Diagnostic Statement
-Diagnostic Label (NANDA-I)
-Related Factors (r/t=related to)
- Definition (NANDA-I)
- Associated Condition
-Support of the Diagnostic Statement
__________ Diagnosis Examples
- Impaired comfort r/t itching.
- Risk for electrolyte imbalance r/t renal dysfunction.
- Disturbed body image r/t lesions on body.
- Deficient fluid volume r/t active fluid loss as evidenced by (aeb) excessive diuresis.
Nursing
Peripheral resistance.
The BP depends on peripheral vascular resistance.
Peripheral vascular resistance is the _________________________ determined by the tone of vascular musculature and diameter of blood vessels.
The smaller the lumen of a vessel, the greater is the peripheral vascular resistance to blood flow.
As resistance rises, arterial BP rises. When vessels dilate and resistance falls, arterial BP falls.
resistance to blood flow
The nurse assessed a client’s pulse rate and recorded the score as 3+. Which describes the strength of the pulse?
1 Strong
2 Bounding
3 Expected
4 Diminished
1 Strong
Which physical skin finding would the nurse associate with opioid abuse?
Needle markings
Which relatable site would the nurse utilize to assess a client for jaundice?
Sclera
Which part of the client’s body would the nurse assess to confirm a diagnosis of frostbite?
fingertips, earlobes
Which condition would the nurse suspect when a client, who underwent a physical examination two days ago, reports itching?
Contact dermatitis
After assessing the muscle functionality of a client, the nurse assigns a grade of F(fair) on the Lovett scale,=. Which statement describes the muscle functionality of this client?
Full range of motion with gravity.
When interpreting findings from a pain assessment, which factors would the nurse consider the most significant influences on a client’s perception of pain?
Previous experience and cultural values
When assessing a client’s blood pressure, obtained via the client’s unsupported left arm, which reading error would the nurse expect?
False high reading
In which situation would the nurse consider family members as the primary source of information?
The client is an infant or child.
The client is brought in as an emergency.
The client is critically ill and disoriented.
To prevent an adverse outcome while providing care for a client experiencing diarrhea, which client data would the nurse closely monitor?
Fluid and electrolyte balance
For which age group would the nurse expect the occurrence of chronic illness to be the highest?
older adults
When assessing a patient for malnutrition, the nurse would monitor for an increase in liver enzymes and a decrease in which water soluble vitamin?
Biotin
Niacin
Folic Acid
Riboflavin
Vitamin C
When gathering data fro a client’s health history, which intellectual factor would the nurse consider as a dimension?
attention span
Which factor would the nurse assess for a client reporting constipation?
Diet
Fluid intake
Use of laxatives
Date of last BM
Use of opioid pain meds
oranges and other citrus fruits contain:
potassium
Which physical change would the nurse observe in a client with malnutrition?
Hypotension
Dry, dull hair
Abdominal edema
Delayed wound healing
Depletion of muscle mass
Hypotension
Dry, dull hair
Abdominal edema
Delayed wound healing
Depletion of muscle mass
all of the above
Which clinical finding would the nurse associate with hypokalemia?
Muscle weakness
Which pulse site would the nurse use to preform the Allen test?
Ulnar
The nurse providing primary preventive care at a community health care center focuses on which type of activity?
Promoting health in healthy individuals
Which position would the nurse utilize to assess the musculoskeletal system, but contraindicated for clients experiencing chronic respiratory disease?
prone position
__________ refers to circulation of the skin
Vascularity
During a physical examination, which assessment would the nurse anticipate when a client is placed in the lithotomy position?
female genitalia
__________ refers to circulation of the skin
Vascularity
________ indicates fluid build up in the tissues
Edema
Which assessment finding of the skin refers to elasticity?
Turgor
Which physical assessment technique involves listening to the sounds of the body?
Auscultation
Which statement describes the percussion technique?
Tapping the skin with the fingertips to vibrate underlying tissues.
In which order would the nurse apply the nursing process while providing care for clients ?
diagnosis,
implementation,
Assessment,
evaluation
planning,
Assessment,
diagnosis,
planning,
implementation,
evaluation
Which degree of edema will result in a 6-mm deep indentation upon pressure application?
a. 4+
b. 3+
c. 2+
d. 1+
b. 3+
The nurse noticed the respiratory rate a regular and slow while assessing a client. Which would be the condition of the client?
a. apnea
b. bradypnea
c. tachypnea
d. hyperpnea
b. bradypnea
A client complains of pain in the ear. While examining the client, a nurse finds swelling in front of the left ear. Which lymph node does the nurse expect to be involved?
- Mastoid
- Occipital
- Submental
- Pre-auricular
- Pre-auricular
The nurse is assessing a client who underwent abdominal surgery 10 days ago. The client complains of pain in the abdomen. Which type of pain would the client experience?
1 Visceral pain
2 Somatic pain
3 Referred pain
4 Intractable pain
- Visceral pain arises from visceral organs such as the pancreas, which results from the stimulation of pain receptors in the abdominal cavity.
Koilonychia is the concave ________ on the nail.
curves
Paronychia is the ____________ of the skin at the base of nail.
inflammation
In clubbing, there is a change in the angle between the nail and the nail base that is larger than ____ degrees.
180
A nurse is assessing a client’s nails and finds a slight convex curve at the angle from the skin to nail base of about 160 degrees. Which condition does the nurse suspect?
a. clubbing
b. paronychia
c. koilonychia
d. normal finding
d. normal finding
The nurse finds that the client’s fever spikes and falls without a return to a normal level. Which pattern of fever is this a characteristic of?
Remittent
Which would the nurse document for a client with drooping of the eyelid over the pupil?
Ptosis
Which term refers to a blowing sound created by turbulence caused by narrowing of arteries while assessing for carotid pulse?
a. bruit
b. ectropion
c. entropion
d. borborygmi
a. bruit
A bruit is an audible vascular blowing sound associated with turbulent blood flow through a carotid artery. Ectropion is a condition in which the eyelid is turned outwards away from the eyeball. Entropion is a malposition resulting in an inversion of the eyelid margin. Borborygmi are rumbling or gurgling noises made by the movement of fluid and gas in the intestines
Which characteristic would the nurse associate with collaborative problems experienced by a client?
A. they are the identification of a disease condition
B. they include problems treated primarily by nurses
C. they are identified by the primary health care provider
D. they are identified by the nurse during the nursing diagnosis stage
d) ID by nurse during diagnostic process
The nurse assesses the client to gather information to reach diagnostic conclusions. Collaborative problems are identified by the nurse during this process. If the client’s health problem requires treatment by other disciplines such as medical or physical therapy, the client has a collaborative problem. A medical diagnosis is the identification of a disease condition. Problems that require treatment by the nurse are referred to as nursing diagnoses. A medical diagnosis is identified by the primary healthcare provider based on the results of diagnostic tests.
The nurse is developing a nursing diagnosis for a client after surgery. The nurse documents the “related to” factor as first time surgery. Which assessment activity enabled the nurse to derive this conclusion?
1 The nurse notes nonverbal signs of discomfort.
2 The nurse observes the client’s position in bed.
3 The nurse asks the client to explain the surgery.
4 The nurse asks the client to rate the severity of pain
3 The nurse asks the client to explain the surgery.
The nurse must assess the client’s knowledge about the surgery to determine if the client is aware of the outcome of surgery. The nurse observes for nonverbal signs of discomfort because some clients may not state that they are in pain. The nurse observes the client’s positioning in bed to determine any abnormal signs such as discomfort or pain. The nurse asks the client to rate the severity of pain to determine a nursing diagnosis of pain related to a surgical wound.
The nurse is assessing a client after surgery. Which assessment finding would the nurse obtain from the primary source?
a. X Ray reports
b. severity of pain
c. results of blood work
d. family caregiver interview
Severity of pain [from client]
what definition does the WHO use to define health?
a state of complete physical, mental and social well-being
The nurse assessed a client’s pulse rate and recorded the score as 3+. Which describes the strength of the pulse?
1 Strong
2 Bounding
3 Expected
4 Diminished
1 Strong
Body temperature is regulated by the ______________ , a small endocrine gland in the center of the brain.
hypothalamus
Blood pressure is a peripheral measure of function of the cardiac system.
More specifically, it is the _____________________ against the artery wall during contraction and relaxation of the ventricles.
force of the blood
Blood pressure is measured using two pressure readings—systolic (top number) and diastolic (bottom number).
Systolic pressure is the force exerted when the ventricles __________. This measure depends on the cardiac output, blood volume, and arterial compliance.
The diastolic pressure is the force exerted by peripheral vascular resistance when the ventricles are ____________ and the heart is filling.
Systolic pressure is the force exerted when the ventricles contracts. This measure depends on the cardiac output, blood volume, and arterial compliance.
The diastolic pressure is the force exerted by peripheral vascular resistance when the ventricles are relaxed and the heart is filling.
_____________________ : systematic observation, measurement, experiment, formulation, testing, and modification of hypothesis
Scientific method
___________________ : defining a problem, determining cause of problems, identifying, prioritizing and selecing alternatives for a solution; implementing solution
Problem solving
_____________________ : making choices by identifying a decision, gathering information, and assessing alternative resolutions
Decision making
______________________ and inference: dynamic thinking process that leads to identification of a hypothesis that best explaiins the clinical evidence
Diagnostic reasoning
__________________________: best practice (the evidence, the research), awareness of the current situation and environment, and knowledge of the patient
Clinical decision making
Critical thinking: always think in the context of the ___________, NOT just the norms
______________ there is a problem
___________ the clinical data
___________ the data and review assumptions and evidence
_____________: draw a conclusion
Critical thinking: always think in the context of the patient, NOT just the norms
Recognize there is a problem
Analyze the clinical data
Evaluate the data and review assumptions and evidence
Explanation: draw a conclusion
ADPIE:
Assessment
diagnosis
Planning
Implementation
Evaluating
_______________ : the collection, verification, and analysis of data
Tools:
Interview (subjectiver data)
Nursing health history: reason for seeking care, hisory
Physical examination (objective data) labs, observation, nursing judgements
Documentation: last component of assessment, legal requirement
Concept mapping: visually represents connection between client’s health problems
Assessment
_________________________ : a clinical judgement about the client in response to an actual or potential health problem
Actual: existing
At risk: potential
Components:
Diagnostic label (NANDA-I)
R/T
Definition (NANDA-I)
Risk factors
Support of diagnostic statement
Nursing diagnosis
________: a broad statement that describes the desired change in a client’s condition or behavior
Guideleines: ________ centered, singular, observable. measurable, time limited, realistic
Goal: a broad statement that describes the desired change in a client’s condition or behavior
Guideleines: client centered, singular, observable. measurable, time limited, realistic
______________________: measurable criteria to evaluate goal achievement
Determine when a specific, client centered goal has been met
Expected outcome
Implementation process
__________!
___________ client
review care plan
organize resources
Anticipate/prvent complications
Implementation process
REASSESS!
Reassess client
review care plan
organize resources
Anticipate/prvent complications
Significance of vital signs
help establish Pt’s baseline + Detect overall changes in their health
__________- on-going process
Positive evaluation: outcomes are met, understand that interventions were successful
5 elements of evaluation:
Identify evaluative criteria and standards
collect _______
interpret/ summarize ___________
Document findings and clinical judgements
Terminate, continue, or revise care plan
Evaluation
Identify evaluative criteria and standards
collect data
interpret/ summarize results
Document findings and clinical judgements
Terminate, continue, or revise care plan
What is the major health problem resulting from a pulse deficit?
A. Bradycardia
B. Activity intolerance
C. Decreased cardiac output
D. Impaired tissue perfusion
C. Decreased cardiac output
What should the nurse do when a pulse deficit is suspected?
A. Measure the radial pulse for 1 minute, and then measure the apical pulse for 1 minute.
B. Measure the radial pulse for 30 seconds, and then measure the apical pulse for 30 seconds.
C. Measure the radial pulse for 1 minute, wait 5 minutes, and then measure the apical pulse for 1 minute.
D. Ask another health care provider to count the radial pulse while the nurse counts the apical pulse.
D. Ask another health care provider to count the radial pulse while the nurse counts the apical pulse.
Which action should the nurse perform after identifying a pulse deficit?
A. Reassess the apical-radial pulse in 5 minutes.
B. Assess the patient for signs of decreased cardiac output.
C. Notify the primary health care provider of the pulse deficit.
D. Initiate interventions directed toward managing the patient’s symptoms.
B. Assess the patient for signs of decreased cardiac output.
You have the following information:
Oral temperature–36.8°C.
Radial Pulse–112 weak, thready
Apical pulse–117 regular
Respirations–24 regular
Blood Pressure–104/56 right arm
–102/50 left arm
What is the pulse deficit?
A. 2
B. 5
C. 6
D. 48
B. 5
What is the purpose of performing hand hygiene?
A. To prevent the spread of infection
B. To prevent staff contact with infections
C. To keep patients from exposure to bacteria or viruses
D. To eliminate the need to wear gloves when providing care
A. To prevent the spread of infection
Which of the following is an early manifestation of decreased cardiac output?
A. Fatigue
B. Substernal pain
C. Nail bed cyanosis
D. Shortness of breath
A. Fatigue
When is it appropriate to use an alcohol-based hand rub to perform hand hygiene?
A. If exposure to anthrax spores is suspected
B. If gloves were worn during patient contact
C. If the hands are not visibly soiled
D. If the hands are dry or chapped
C. If the hands are not visibly soiled
When washing the hands with soap and water, which procedure should the nurse follow?
A. Turn on and adjust the water until it feels cool.
B. Keep your hands above your elbows while washing.
C. Turn off the faucet with your clean dry hand.
D. Use plenty of lather and friction and wash for at least 15 to 20 seconds.
D. Use plenty of lather and friction and wash for at least 15 to 20 seconds.
When using soap and water to perform hand hygiene, how much soap should the nursing assistant use?
A. About one drop
B. About two pumps
C. About 1 teaspoon
D. About 1 tablespoon
C. About 1 teaspoon
As part of performing hand hygiene, how should the nursing assistant dry the hands?
A. Let the hands air dry.
B. Use clean, dry paper towels.
C. Use a clean, dry cloth.
D. Place the hands under a hot-air hand dryer.
B. Use clean, dry paper towels.
During the admissions process, the nurse initially assesses the patient’s radial pulse primarily for what purpose?
A. Assessment of peripheral blood perfusion
B. Establishment of a baseline as part of the patient’s vital signs
C. Assessment of the patient’s cardiovascular disease risk
D. Determination of oxygen saturation
B. Establishment of a baseline as part of the patient’s vital signs
What will the nurse instruct nursing assistive personal (NAP) to do when measuring an adult patient’s radial pulse?
A. Place the patient in the lateral (side-lying) position before measuring the pulse.
B. Apply gloves with each patient before measuring the pulse.
C. Document whether the patient’s pulse is bounding or has diminished.
D. Palpate the patient’s inner wrist on the thumb side with the fingertips of your two middle fingers.
D. Palpate the patient’s inner wrist on the thumb side with the fingertips of your two middle fingers.
What is the nurse’s priority action if a patient’s radial pulse has an irregular rhythm?
A. Reassess the pulse for 1 full minute.
B. Assess the patient for a pulse deficit.
C. Wait 5 minutes, and then reassess the pulse.
D. Review documentation regarding an irregular rhythm.
B. Assess the patient for a pulse deficit.
Inadequate oxygenation to the body will cause the radial pulse to become:
A. Tachycardic
B. Bradycardic
C. Irregular
D. Bounding
A. Tachycardic
Which action would best assess the effect of exercise on a patient’s radial pulse measurement?
A. Measuring the patient’s radial pulse before and after exercise.
B. Assessing the patient’s radial pulse 30 minutes after exercise.
C. Comparing the patient’s radial and apical pulses after exercise.
D. Comparing the patient’s pre-exercise radial and post-exercise apical pulses.
Submit Test
A. Measuring the patient’s radial pulse before and after exercise.
What is the major health problem resulting from a pulse deficit?
A. Bradycardia
B. Activity intolerance
C. Decreased cardiac output
D. Impaired tissue perfusion
C. Decreased cardiac output
During an examination of a pediatric patient who was admitted for postoperative pain management, the nurse assesses a decreased respiratory rate. What should the nurse consider as the most likely cause for a decrease in the rate?
A. Fever
B. Anxiety
C. Opioid analgesic
D. Fear
C. Opioid analgesic
Which statement by the patient’s parent indicates the family needs further education about accurate respiratory rate measurement?
A. “My child is breathing fine; the monitor numbers have been good all day.”
B. “Whenever my child needs pain medicine, my child’s breathing is very shallow and fast.”
C. “I’ve noticed that when my child has a fever, my child’s breathing is faster.”
D. “I will hold my child and give the pacifier so that you can listen to the breathing.”
A. “My child is breathing fine; the monitor numbers have been good all day.”
When assessing an accurate respiratory rate for a 3-month-old patient, what should the nurse directly observe?
A. Abdominal movement for 1 minute
B. Chest movement for 1 minute
C. Abdominal movement for 30 seconds
D. Chest movement for 30 seconds
A. Abdominal movement for 1 minute
A nurse is caring for a 2-year-old patient with respiratory distress. The patient’s respiratory rate has been 50 breaths per minute, with intercostal retractions and nasal flaring for the past 45 minutes. The nurse now observes that the patient is sleepy, with a respiratory rate of 16 breaths per minute. The patient has received no pain medication. What must the nurse consider in performing a respiratory assessment of this patient?
A. The patient’s condition has improved.
B. The patient’s respiratory rate is normal for the patient’s age.
C. The patient’s respiratory rate indicates hyperpnea.
D. The patient may be in imminent respiratory failure.
D. The patient may be in imminent respiratory failure.
A 2-week-old infant is displaying an irregular breathing pattern, with periodic increases in respiratory rate that return to normal. The patient is otherwise eating well and has no other signs of respiratory distress. What should the nurse tell the family about this breathing pattern during family teaching?
A. This is an indication of moderate respiratory distress.
B. The patient has signs of impending respiratory failure.
C. This breathing pattern is normal for the patient’s age.
D. The patient has an upper respiratory infection.
C. This breathing pattern is normal for the patient’s age.
What must the pediatric nurse know about accurate respiratory measurements when monitoring for signs of changes in the work of breathing in an infant or child?
A. Infants and children have higher metabolic rates than adults.
B. Normal respiratory patterns in infants can be irregular.
C. Children have more areas for gas exchange in the lungs than adults.
D. Infants are less prone to respiratory infections than adults.
B. Normal respiratory patterns in infants can be irregular.
What is the altered respiratory pattern that can be described as unpredictable, ataxic, irregular breathing?
A. Kussmaul
B. Hyperpnea
C. Tachypnea
D. Biot
D. Biot
What is the median respiratory rate (breaths per minute) for an 8-year old patient?
A. 19
B. 20
C. 16
D. 24
B. 20
The nurse is preparing to auscultate breath sounds for an infant. What is the first step taken?
A. Warm the bell of the stethoscope with the hand.
B. Place the stethoscope on the left side of the chest.
C. Position the infant with the head slightly elevated.
D. Place the stethoscope on the right upper chest.
A. Warm the bell of the stethoscope with the hand.
The nurse is preparing to assess a patient’s blood pressure. What would cause the blood pressure reading to be inaccurately high?
A. Blood pressure cuff is too wide
B. Blood pressure cuff is too loose around the arm
C. Taking the blood pressure in an arm into which intravenous fluids are infusing
D. Arm is positioned above the level of the heart
B. Blood pressure cuff is too loose around the arm
What would cause the nurse to delay the assessment of a patient’s blood pressure?
A. Patient is resting in bed, reading a book
B. Patient received medication within the last 10 minutes
C. Patient is visiting with family
D. Patient has just finished having a cigarette
D. Patient has just finished having a cigarette
The nurse has just measured a patient’s blood pressure and is waiting 2 minutes to measure the pressure again. What is the purpose of taking two measurements?
A. Minimize the effect of anxiety
B. Distract the patient
C. Listen for the second and third Korotkoff sounds
D. Confirm that the cuff was applied correctly
A. Minimize the effect of anxiety
The nurse is teaching a patient about ways to reduce blood pressure. What will the nurse include in these instructions?
A. Follow your regular healthy diet.
B. Limit physical activity.
C. Ensure an adequate daily intake of sodium and fat.
D. Ensure that your diet has an adequate daily intake of calcium.
D. Ensure that your diet has an adequate daily intake of calcium.
Where should the nurse measure the blood pressure of a patient recovering from a left-sided mastectomy?
A. Use the left arm to take the blood pressure.
B. Use the right arm to take the blood pressure.
C. Do not take the blood pressure.
D. Use a lower extremity to take the blood pressure.
B. Use the right arm to take the blood pressure.
A patient who was rescued from a pond is hypothermic and has been intubated. The patient’s blood pressure cannot be auscultated. Which technique using the probe is the best for measuring the patient’s blood pressure by Doppler ultrasound?
A. Apply 2 to 10 lb of pressure to the probe, depending on the depth of the vessel.
B. Use alcohol to moisten the area where the probe will be placed.
C. Place the probe at a 45-degree angle along the length of the vessel.
D. Place the probe directly over the femoral pulse.
C. Place the probe at a 45-degree angle along the length of the vessel.
A systolic blood pressure measurement of 100 mm Hg is obtained from a patient with diabetes by using Doppler ultrasound. Which statement is correct regarding this blood pressure measurement?
A. Indicates a need for a vasodilator
B. May be erroneously low
C. Indicates the most accurate blood pressure
D. May be erroneously elevated
D. May be erroneously elevated
During assessment of peripheral pulses in the left leg via a Doppler instrument, the dorsalis pedis pulse cannot be located. What is the most appropriate next step?
A. Attempt to find the dorsalis pedis pulse in the right leg.
B. Attempt to locate the posterior tibial pulse.
C. Attempt to locate the popliteal pulse.
D. Reattempt to locate the pulse after applying additional transmission gel.
B. Attempt to locate the posterior tibial pulse.
Vascular sounds are not audible with the Doppler probe over the site where the brachial artery is palpable. What is the best way to assess the sensitivity of the instrument?
A. Use the probe to check own pulse.
B. Use bleach and hot water to clean the probe.
C. Change probes.
D. Press harder with the probe.
A. Use the probe to check own pulse.
During assessment of a patient’s brachial pulse, a high-pitched sound is heard. The sound resembles a rushing wind and is cyclic with respirations. What is the best next step?
A. Reposition the probe until loud, pulsatile sounds are heard.
B. Increase the angle of the probe to 90 degrees.
C. Clean the probe and the skin thoroughly with alcohol.
D. Switch to the 2.25-MHz probe.
A. Reposition the probe until loud, pulsatile sounds are heard.
What is a possible explanation for an artificially high reading obtained from an obese patient’s arm?
A. The cuff is too large for the extremity.
B. The cuff is too small for the extremity.
C. Resistance to pressure is generated by the heart.
D. The cuff is too snug for the extremity.
B. The cuff is too small for the extremity.
Which is correct regarding Korotkoff phase 1 sounds?
A. Last sound heard after deflation of the cuff begins
B. Reflect the diastolic pressure
C. Sound muffled
D. First sound heard after slow deflation of the cuff begins
D. First sound heard after slow deflation of the cuff begins
What instruction should be given to the patient before using Doppler ultrasound to obtain peripheral pulses?
A. “There is no pressure applied to the site when using the probe.”
B. “You need to remain still for the procedure.”
C. “You will be expected to move during the procedure.”
D. “Gel will be used to reduce transmission of the sound.”
B. “You need to remain still for the procedure.”
Which is correct regarding size of a pediatric blood pressure cuff?
A. The length of the cuff bladder should be 40% of arm circumference.
B. The width of the bladder should be at least 80% of arm circumference.
C. The length of the cuff bladder should be 80% of arm circumference.
D. The width of the bladder should be at least 20% of arm circumference.
C. The length of the cuff bladder should be 80% of arm circumference.
Which is a characteristic of arterial sounds?
A. Arterial sounds are loud and pulsatile.
B. Arterial sounds are muffled and pulsatile.
C. Arterial sounds resemble the sound of rushing wind.
D. Arterial sounds are high pitched.
A. Arterial sounds are loud and pulsatile.
A nurse is caring for a patient who has just had major abdominal surgery to resect a portion of his colon. What is the most reliable sign that the patient has significant postoperative pain?
A. The patient rates his pain a 7 on a scale of 0 to 10.
B. The patient winces and guards the area as the nurse gently palpates the abdomen.
C. The patient is having trouble sleeping and has become irritable.
D. The patient is moaning softly and frowning, with a pinched expression on his face.
A. The patient rates his pain a 7 on a scale of 0 to 10.
What will the nurse instruct nursing assistive personnel (NAP) to do regarding the management of a patient’s pain?
A. “Let me know at least 30 minutes before you transport her so I can administer her analgesics.”
B. “Be sure to keep the room temperature high and the TV on at all times.”
C. “Be sure to tell me if you notice grimacing, guarding, or any unusual behavior.”
D. “I’ve given her some medication; please report to me whether it seems to have relieved her pain within an hour or so.”
A. “Let me know at least 30 minutes before you transport her so I can administer her analgesics.”
Which observation indicates that a patient’s 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 is seen quietly reading a magazine.
B. The patient rates her current pain as 3 out of 10 on the pain rating scale.
C. The patient is overheard telling her family that she is “feeling better today.”
D. The patient is observed sleeping, with a respiratory rate assessed at 18/minute, compared with 22/minute before the intervention.
B. The patient rates her current pain as 3 out of 10 on the pain rating scale.
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. Repainting her new apartment
B. Lifting moving boxes on and off of a truck
C. Performing neck, back, and shoulder exercises prescribed by a physical therapist
D. Performing yoga exercises from the patient’s favorite set of videotapes
C. Performing neck, back, and shoulder exercises prescribed by a physical therapist
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. It is likely the patient is a drug seeker and has little or no pain.
B. The patient’s problem is more mental than physical.
C. The absence of physiological signs and symptoms is associated with chronic pain.
D. The patient’s pain cannot be accurately assessed until the patient has been treated for anxiety.
C. The absence of physiological signs and symptoms is associated with chronic pain.
What will the nurse instruct nursing assistive personnel (NAP) to do when measuring a patient’s rectal temperature using an electronic thermometer?
A. Place the patient in the Fowler’s position.
B. Wear sterile gloves during the process.
C. Insert the probe in the direction of the knees.
D. Use the probe with the red tip.
D. Use the probe with the red tip.
Which of the following is contraindicated with taking a rectal temperature measurement?
A. Patient requires assistance to move to a side-lying position.
B. Patient has painful and swollen hemorrhoids.
C. Patient is incontinent of urine.
D. The last temperature recorded was 0.2° F above baseline.
B. Patient has painful and swollen hemorrhoids.
Which nursing action best evaluates the effectiveness of an antipyretic medication in a patient with an oral temperature of 101.6° F?
A. Assess for physical aches.
B. Assess skin temperature by touching the forehead.
C. Assess oral temperature 30 minutes after the agent is administered.
D. Assess skin color for signs of fever-related flushing.
C. Assess oral temperature 30 minutes after the agent is administered.
Which instruction might the nurse give to nursing assistive personal (NAP) that is applicable only to tympanic temperature assessment?
A. Leave the probe in place until the reading is complete.
B. Put on a new disposable probe cover for each patient.
C. Gently tug the pinna backward, up, and out before inserting the probe.
D. Check for any impacted cerumen in the ear.
C. Gently tug the pinna backward, up, and out before inserting the probe.
Which instruction might the nurse give to nursing assistive personnel (NAP) that is applicable only to temporal artery temperature assessment?
A. An accurate temperature reading is obtained with moisture on the forehead.
B. Put on a disposable sensor cover before taking the temporal artery temperature.
C. Place the sensor flush on the patient’s forehead.
D. Obtain the temperature reading on the lower neck.
C. Place the sensor flush on the patient’s forehead.
The general assessment of a 6-month-old patient who appears malnourished reveals uncleanliness and a flat, balding occiput. What do these findings indicate about this infant?
A. Physical abuse
B. Prematurity
C. Neglect
D. A congenital abnormality
C. Neglect
During the general assessment of a 2-year-old patient, a foul odor emanating from the right naris is noted. What is the most likely cause of this odor?
A. A foreign body
B. An upper respiratory infection
C. Epistaxis
D. Allergies
A. A foreign body
What is the best way to gain the cooperation of a 5-year-old patient during a physical examination?
A. Engage in a conversation with the patient to encourage relaxation.
B. Give the patient a treat before beginning the examination in exchange for cooperation.
C. Use a stuffed animal to demonstrate the examination.
D. Have the patient draw a picture as a distraction technique during the examination.
C. Use a stuffed animal to demonstrate the examination.
A 4-year-old patient recognizes the parent, says “tree” when looking out the window, and states, “I am four,” when asked about age. How should the nurse document orientation for this patient?
A. Unable to determine
B. Oriented × 3
C. Awake and alert
D. Appropriate for developmental level
D. Appropriate for developmental level
During the physical assessment of a patient with diabetes mellitus, the nurse palpates nonpainful localized areas of hardness in the midepigastric area of the patient’s abdomen. What instruction should the nurse provide the family regarding this finding?
A. Rotate injection sites
B. Increase fiber intake
C. Increase fluid intake
D. Use smaller-gauge needles
A. Rotate injection sites
While counting a patient’s respirations, the nurse recognizes respiratory distress. Which assessment should the nurse conduct next?
A. Circulatory system
B. Remaining vital signs
C. Respiratory system
D. Head and neck
C. Respiratory system
In which order should the nurse assess an infant’s vital signs?
A. Respiration, temperature, heart rate
B. Heart rate, respiration, temperature
C. Temperature, heart rate, respiration
D. Respiration, heart rate, temperature
D. Respiration, heart rate, temperature
Which approach to physical examination is appropriate when assessing a school-age patient?
A. Gain cooperation through distraction.
B. Teach about body function and care.
C. Make up a story about procedure.
D. Allow equipment inspection.
B. Teach about body function and care.
Which condition should the nurse include in a list of common causes of hearing loss in school-age patients when providing patient and family education?
A. Impacted cerumen
B. Foreign body in the ear canal
C. Repeated inner ear infection
D. Noise-induced loss
A. Impacted cerumen
Which approach should the nurse use during the physical examination of an adolescent patient?
A. Emphasize normalcy of development.
B. Suggest family presence.
C. Ask the parent to voice any concerns.
D. Use prone positioning.
A. Emphasize normalcy of development.
Pulse strengths
0- _______
1- diminished/ barely palpable
2- ________________
3- full/strong
4- _________ / very strong
0- absent
1- diminished/ barely palpable
2- normal/ expected
3- full/strong
4- bounding/ very strong
