NSG 250 FINAL REVIEW

The nurse is watching a new graduate nurse perform auscultation of a patient's abdomen. Which statement by the new graduate shows a correct understanding of the reason auscultation precedes percussion and palpation of the abdomen?

"It prevents distortion of bowel sounds that might occur after percussion and palpation."

During the history, the patient tells the nurse he has frequent nosebleeds and asks the best way to get them to stop. What would be the nurse's best response?

"Sit up with your head tilted forward and pinch your nose midway to the tip."

The mother of a 2-year-old is concerned because her son has had three ear infections in the past year. What would be the most appropriate response for the nurse to make?

"Your son's eustachian tube is shorter and wider than yours because of his age, which allows for infections to develop more easily."

A male patient presents with urinary frequency. The nurse suspects

All of the above

For older-adult postoperative patients, poorly controlled acute pain places them at higher risk for:

All of the above

The nurse is reviewing the blood supply to the arm. The major artery supplying the arm is the _____ artery.

Brachial

To enhance the physical environment of the interview the nurse:

Reduces noise by turning off televisions and radios

While conducting an ear examination, the nurse knows that the normal tympanic membrane would appear:

Shiny and translucent with a pearl-gray color.

The latest lab values indicate that the 26-year-old male patient has hepatitis C, a disease that causes inflammation of the liver. The patient's skin has a yellowish color as does both sclera. Which observation about the stool is consistent with the presence of jaundice?

Stool is clay-colored (light tan).

A client comes to the emergency department complaining of increasing eye pain, seeing halo's around lights and a decrease in peripheral vision. Which data would be essential to obtain for this patient?

The degree of intraocular eye pressure.

Stridor is a high-pitched, inspiratory crowing sound commonly associated with:

Upper airway obstruction.

When listening to a patient's breath sounds, the nurse is unsure of a sound that is heard. The nurse's next action should be to:

Validate the data by asking a coworker to listen to the breath sounds.

The nurse keeps in mind that a thorough skin assessment is very important because the skin holds information about a person's:

Circulatory status.

Assessment findings expected in a patient with pneumonia include:

Breath sounds diminished and dullness on percussion.

The patient who was just admitted is in acute pain, has not been sleeping well lately, and is having difficulty breathing. How should the nurse prioritize these problems?

Breathing, pain, sleep.

The two parts of the nervous system are the:

Central and peripheral.

A 30-year-old woman tells the nurse that she has been very unsteady and has had difficulty in maintaining her balance. Which area of the brain would the nurse be concerned about with these findings?

Cerebellum

During a nutritional assessment, why is it important for the nurse to ask a patient what medications he or she is taking?

Certain drugs can affect the metabolism of nutrients.

The 55-year-old client reports that her intake of calcium and vitamin D is minimal and her recent bone mineral density scan reveals that she has an increased fracture risk. The nurse bases her patient teaching for this client on the fact that this client is at a higher risk for developing complications related to:

Osteoporosis

Normal cervical lymph nodes are:

Palpated smaller than 1 cm

The primary muscles of respiration include the:

Diaphragm and intercostals.

The medical record indicates that a person has an injury to Broca's area. When meeting this person you expect:

Difficulty speaking

A patient is having difficulty in swallowing medications and food. The nurse would document that this patient has:

Dysphagia.

A nurse notices that a patient has ascites, which indicates the presence of:

Fluid.

After palpating an enlarged thyroid, the nurse should:

Request that the patient hold his breath while the nurse auscultates with the bell of the stethoscope over the enlarged lobe.

A 4-year-old boy is brought to the emergency department by his mother. She says he points to his stomach and says, "It hurts so bad." Which pain assessment tool would be the best choice when assessing this child's pain?

The Faces Pain Scale

One way to assess cognitive function and to detect dementia is with which of the following?

The Mini-Cog

Providing resistance while the patient shrugs the shoulders is a test of the status of cranial nerve:

XI

During the assessment of an 18-month-old, the mother expresses concern about the child's inability to toilet train. What would be the best response of the nurse?

" The nerves that will allow your baby to have control over urination and the passing of stools are not developed until at least 24 to 30 months of age."

The nurse is examining a patient's ears and notices cerumen in the external canal. Which of these statements about cerumen is correct?

The purpose of cerumen is to protect and lubricate the ear

The nurse is reviewing the components of the nursing process. Which statement about nursing diagnoses is true?

They are clinical judgments about a person's response to an actual or potential health state.

During examination of genitalia of a 80 year old female, the nurse would expect:

Thin and sparse pubic hair

What problems are associated with smoking and the use of oral contraceptives?

Thrombophlebitis and pulmonary emboli.

While conducting an admission assessment, the nurse notes a draining ulceration on the patient's lower leg. Which intervention is appropriate?

Wash hands, put on gloves, continue with the examination of the ulceration and then proceed with the remainder of the exam.

The nurse is performing a nutritional assessment on a 15-year-old girl, who tells the nurse that she is "so fat." Assessment reveals that she is 5 feet 4 inches and weighs 110 pounds. The nurse's appropriate response would be:

"How much do you think you should weigh?"

During the interview the patient reveals that she has some vaginal discharge. She is worried that it may be a sexually transmitted disease. The most appropriate response to this would be:

"I'd like additional information about the discharge. Please describe the appearance of the discharge and the amount."

A 17-year-old single mother is describing how difficult it is to raise a 2-year-old by herself. During the course of the interview she states, "I can't believe my boyfriend left me to do this by myself! What a terrible thing to do to me!" Which of the following responses of the nurse is the best example of expressing empathy?

"It must be so hard to face this all alone."

The visiting home health nurse has been assigned to care for a patient on a ongoing basis and is making an initial home visit with the patient who has many chronic medical problems. Which type of database is most appropriate to collect in this setting?

A complete health database because the nurse will be responsible for monitoring the patient's health over time.

When performing a respiratory assessment on a patient, the nurse notices a costal angle of approximately 85degrees. This characteristic is :

A normal finding in a healthy adult.

A 6-month-old infant has been brought to the well-child clinic for a routine check-up. The child is currently sleeping. What should the nurse do first?

Auscultate the lungs and heart while the infant is still sleeping.

The reason for performing a palpated pressure prior to auscultating is to:

Avoid missing the auscultatory gap during auscultation and obtaining a false low blood pressure.

The Emergency Department nurse is assessing a 16-year-old patient with head injuries from a recent motor vehicle accident that occurred three hours ago. Which of the following statements indicate the most important reason for assessing for any drainage from the ear canal?

Bloody or clear watery drainage can indicate a basal skull fracture.

A woman has just been diagnosed with HPV, or genital warts. The nurse should counsel her to receive regular examinations because this virus makes her at a higher risk for _____ cancer.

Cervical

The nurse is examining a 2-year-old child and asks, "May I listen to your heart now?" Which critique of her technique is most accurate?

Children at this age like to say "no." The examiner should not offer a choice when there is none.

The nurse is performing a focused neurological assessment on a patient within the immediate postoperative period following abdominal surgery. Assessments to be included in this exam include all of the following except:

Cognition through "new learning" assessment

The patient tells the nurse that he notices one of his moles has started to burn and bleed. While assessing the patient's skin, the nurse would pay special attention to any possible danger signs of skin cancer. If it was cancerous, which of the following findings would mostly likely be of concern?

Color variation and asymmetry.

The nurse should measure rectal temperatures in which of these patients?

Comatose adult

A patient with a middle ear infection asks the nurse, "What does the middle ear do?" The nurse responds by telling the patient that the middle ear functions to:

Conducts vibrations of sound to the inner ear

The pediatric nurse realizes the importance of noting the first meconium stool passed within 24 to 48 hours of birth in order to:

Confirm a patent rectum and anus.

A patient states, "I can hear a crunching or grating sound when I kneel." She also states that "it is very difficult to get out of bed in the morning because of stiffness and pain in my joints." The nurse should assess for signs of what problem?

Crepitation.

When considering the use of alcohol by older adults, the nurse recognizes that older adults have several age related changes that can increase the risk of alcohol use. Which would increase the bioavailability of alcohol in the blood for longer periods of time in the older adult?

Decreased liver functioning

A 68-year-old woman is in the eye clinic for an evaluation of her macular degeneration. Which of the following objective and subjective data does the nurse expect to find?

Difficulty with reading the paper, sewing and seeing the faces of her grandchildren. Examination findings indicate a loss of central vision with normal peripheral vision.

When performing a cultural assessment on a client, which of these questions would not be appropriate for the nurse to ask?

Does the patient require government assistance for health care expenses?

The nurse is assessing a patient's skin during an office visit. What is the best technique to use to best assess the patient's skin temperature? Use the:

Dorsal surface of the hand because the skin is thinner than on the palms

A Positive Babinski sign is:

Dorsiflexion of the big toe and fanning of all toes

A 56-year-old male patient is being examined for possible BPH (benign prostatic hypertrophy). Which assessment finding would indicate that he may be experiencing urinary retention?

Dullness heard on percussion below the umbilicus.

The nurse is percussing over the lungs of a patient with pneumonia. The nurse knows that percussion over an area of pneumonia in the lungs would reveal:

Dullness.

The Glasgow Coma Scale (GCS) is divided into three areas. They include:

Eye opening, motor response to stimuli and verbal response

During an interview, the nurse states, "You mentioned shortness of breath. Tell me about that." Which verbal skill is used with this statement?

Facilitation

During an examination of a female patient, the nurse notes lymphadenopathy and suspects an acute infection. Acutely infected lymph nodes would be:

Firm but freely movable

A patient tells the nurse that she is having a hard time bringing her hand to her mouth when she eats or tries to brush her teeth. The nurse knows that for her to move her hand to her mouth, she must perform which movement?

Flexion

A full mental status examination should be completed if the patient:

Has a change in behavior and the family is concerned

After completing a diet assessment on a 30-year-old woman, the nurse suspects that she may be deficient in iron. Laboratory studies to obtain to verify this condition would be:

Hemoglobin and hematocrit.

The nurse examines a patient who has been diagnosed with atherosclerosis and a higher than normal blood viscosity. Based on this information, the nurse can expect the blood pressure reading on this patient to be:

Higher than normal.

The nurse suspects that a patient has carpal tunnel syndrome and wants to perform the Phalen test. To perform this test, the nurse should instruct the patient to:

Hold both hands back to back while flexing the writs 90 degrees for 60 seconds.

While performing diaphragmatic excursion, the nurse measures a distance of 1.5 cm. This finding suggests:

Hypoventilation.

The six muscles that control eye movement are innervated by cranial nerves:

III, IV, VI.

The nurse is assessing an older adult's functional ability. Which definition correctly describes one's functional ability?

It refers to one's ability to perform activities necessary to live in modern society.

Which of the following statements is true regarding the expression of pain?

Just as the perception of pain varies within the patient population, so does the expression of pain.

A patient is complaining of a sharp pain along the costovertebral angles. The nurse knows that this symptom is most often indicative of:

Kidney inflammation.

A woman who is 8 months pregnant comments that she has noticed a change in posture and is having lower back pain. The nurse tells her that during pregnancy women have a posture shift to compensate for the enlarging fetus. This shift in posture is known as:

Lordosis

A patient has been diagnosed with osteoporosis and asks the nurse, "What is osteoporosis?" The nurse explains to the patient that osteoporosis is defined as:

Loss of bone density

During a session on substance abuse, the nurse is reviewing statistics with the class. For persons aged 12 years and older, which of these illicit substances was the one most commonly used?

Marijuana

The nurse is testing the function of CN XI. Which statement best describes the response the nurse should expect I f this nerve is intact? The patient:

Moves the head and shoulders against resistance with equal strength

The nurse is reviewing 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 caring for geriatric patients knows that a normal physiologic change associated with the aging process is:

Peripheral blood vessels growing more rigid with age producing a rise in systolic blood pressure. Narrowing of the inferior vena cava causing low blood flow and increases in venous pressure resulting in varicosities.

A nurse in a clinic is caring for an older adult client who reports dry, flaky skin on her upper back. Which of the following is an intervention should the nurse complete?

Pinch up a fold of skin to check for turgor.

To perform an otoscopic examination on a 2 year old child, the nurse should:

Pull the pinna down and back.

The nurse is testing a patient's visual accommodation, which refers to which action?

Pupillary constriction when looking at a near object

When assessing a 45-year-old asthmatic patient with COPD, the nurse notes that the patient assumes a tripod position, leaning forward with arms braced on the chair. Based on this observation the nurse would:

Recognize that a tripod position is often used when a patient is experiencing respiratory difficulties.

A mother brings her 3-month-old infant to the clinical for evaluation of a cold. The mother tells the nurse that the child has had "a runny nose for a week". The nurse notes nasal flaring and sternal and intercostal retractions. The nurse should:

Recognize that these are serious signs and refer the child immediately.

While obtaining a history of a 3-month-old infant from the mother, the nurse asks about the infant's ability to suck and grasp the mother's finger. What is the nurse assessing?

Reflexes

A nurse is caring for a client who has contact dermatitis of the neck and upper chest. Which of the following is an expected finding?

Report of exposure to a skin irritant.

The nurse reads the following documentation of her patient's respiratory status: "Respirations are relaxed and regular. AP: transverse diameter is 1:2. No accessory muscle use. No tenderness or crepitus. Chest expands symmetrically. Tactile fremitus equal bilaterally. Lungs fields resonant throughout. No adventitious sounds heard." Which of the following has been omitted from this documentation?

Respiratory rate.

A patient is complaining of pain in his joints that is worse in the morning, is better after he has moved around for awhile, and then gets worse again if he sits for long periods of time. The nurse should assess for other signs of what problem?

Rheumatoid arthritis

After being asked to stand with feet together, arms at the side and eyes closed, the 68-year-old patient starts to sway and moves his feet further apart to catch his balance. The nurse would document this as a positive __________.

Romberg.

The nurse has completed her computer documentation of her assessment of her patient. What data is missing from the following nursing assessment? "Patient grimacing and having difficulty concentrating. Breathing is shallow. Arms guarding upper abdominal area. Abdomen distended. Patient reports acute pain in left upper quadrant that is localized and does not radiate to other regions. Patient reports that pain started at approximately 9 p.m. yesterday evening and has not felt any improvement in pain since onset. Bowel sounds hyperactive in all four quadrants."

Severity of the pain

A 78 year old male who is bedridden is evaluated for a sacral pressure sore. You note a lesion measuring 4 cm x 7 cm that is oval in nature and has enhanced pigmentation. The epidermis is intact. This is an example of a:

Stage 1 pressure sore

The nurse observes the physician assessing the patient's scrotum. It is noted that the scrotal contents transilluminate and show a red glow. Based on this finding, it would be important to:

Suspect the presence of serous fluid in the scrotum.

As a mandatory reporter of elder abuse, which must be present before a nurse should notify the authorities?

Suspicion of abuse and/or neglect.

The nurse has completed the musculoskeletal examination of a patient's knee and has found a positive bulge sign. The nurse interprets this finding to indicate:

Swelling from fluid in the suprapatellar pouch

Which of the following patients does the nurse identify as needing further evaluation?

The 22-year old woman complaining of vaginal pain and dysuria.

The nurse is preparing to check the blood pressure of an obese patient using a standard-sized blood pressure cuff. The nurse would expect the reading to:

Yield a falsely high blood pressure.

During an assessment of the spine, the patient would be asked to:

Flex, extend, abduct and rotate.

The nurse interprets a Snellen score of 20/60 as:

The patient can read at 20 feet what a person with normal vision can read at 60 feet.

The nurse hears bilateral hyperresonant tones when percussing over the thorax of a 3-year-old child. The nurse would:

Consider this a normal finding for a child this age and proceed with the examination.

To determine the seriousness of a client's suicide attempt, which question would be the most important for the nurse to ask?

"Do you have a plan?"

A school nurse is assessing a child for pediculosis capitis. Which of the following manifestations should the nurse recognize as an indication of this the condition?

Firmly attached white particles on the hair.

The nurse is performing a nasal assessment on a 12 year-old male. The nurse notes that his nasal mucosa appears pale, gray, and swollen with clear watery discharge. What would be the most appropriate question to ask the patient?

"Do you have any allergies?"

The nurse is describing how to perform a testicular self-examination to a patient. Which of the following statements is most appropriate?

"If you notice an enlarged testicle or a painless lump, it is important for you to have your care provider evaluate further."

The nurse knows that the findings of palpated lymph node that are indicative of a systemic infection are:

Enlarged, tender, or painful nodes that are matted together.

Acute otitis externa is a common infection among children and adults. Which describes a typical exam finding of otitis externa?

Erythema and edema of the EAC.

A 60-year old male patient asks the nurse about risk factors for prostate cancer. The nurse should explain to the patient that the greatest risk factor(s) for developing this cancer is (are):

Ethnicity, heredity and advanced age.

For a patient with significant shortness of breath, the nurse should:

Examine body areas appropriate to the problem and then complete the assessment after the problem has been resolved.

The nurse is preparing to examine a patient who has been complaining of right lower quadrant pain. Which technique is correct during the assessment? The nurse should:

Examine the tender area last.

A patient drifts off to sleep when she is not being stimulated. The nurse can easily arouse her by calling her name, but the patient remains drowsy during the conversation. The best description of this patient's level of consciousness would be:

Lethargic.

The nurse is assessing the vital signs of a 24-year-old marathon runner. The following vital signs have been documented: temperature: 97.8º F oral; pulse: 46 bpm; respirations: 12 breaths/minute; blood pressure: 100/70 (right upper arm). Which of the following statements is true?

These are within the range of normal vital signs for a healthy athletic adult.

During an abdominal assessment, the nurse is unable to hear bowel sounds in a patient's abdomen. Before reporting this finding as "silent bowel sounds" the nurse should listen for at least:

5 minutes.

During report, the student nurse hears that a patient has "hepatomegaly" and recognizes that this term refers to:

An enlarged liver.

When assessing a newborn infant's genitalia, the nurse notes that the genitalia are somewhat engorged. The labia majora are swollen, the clitoris looks large and the hymen is thick. The vaginal opening is difficult to visualize. The infant's mother states that she is worried about the labia being swollen. The best response the nurse could provide is:

"This is a normal finding in newborns due to the maternal estrogen effect and should resolve within a few weeks."

A woman is discussing the problems she is having with her 2-year-old son. "He won't go to sleep at night and during the day he has several fits. I get so upset when that happens." An appropriate response by the nurse would be:

"You say that your son has several fits during the day. Tell me what you mean by this."

The nurse is assessing the joints of a woman who has stated, "I have a long family history of arthritis, and my joints hurt." The nurse suspects that she has osteoarthritis. Which of these are symptoms of osteoarthritis? Select all that apply.

-Asymmetrical joint movement -Pain with motion of affected joints -Affected joints are swollen with hard, bony protuberances

The nurse is assessing the abilities of an older adult. Which activities are considered IADLs?

-Preparing a meal -Balancing a checkbook -Grocery shopping

When assessing muscle strength, the nurse observes that a patient has complete range of motion against gravity with full resistance. What Grade should the nurse record using a 0 to 5 point scale?

5

One aspect of a culture's value orientation concerns the dimension of time. This specific cultural understanding may assist with discharge planning for the patient. An example of a person with "present time" value orientation would be:

A patient with a total hip replacement who has been unwilling to discuss or plan for needs at home or for getting prescriptions filled after discharge from the hospital.

A 22-year-old man comes to the clinic for an examination after falling off his motorcycle and landing on his left side on the handlebars. The nurse suspects that he may have injured his spleen. Which of these statements is true regarding assessment of the spleen in this situation?

An enlarged spleen should not be palpated because it can rupture easily

The nurse determines that the patient's condition is one of a "second-level' priority problem. Based on this determination this situation could be which of the following?

Abnormal laboratory values.

A 40-year-old man has come into the clinic with complaints of "extreme tenderness in my toes." The nurse notices that his toes are slightly swollen, reddened, and warm to the touch. His complaints would suggest:

Acute gout

Which type of sweat gland is primarily found in the axillae, genital and rectal areas, nipples, and naval?

Apocrine glands

Although a full mental status examination may not be required for every patient, the health care provider must address the four main components during a health history and physical examination. The four components are:

Appearance, behavior, cognition, and thought processes

When examining the aging adult the nurse should:

Arrange the sequence to allow as few position changes as possible.

The nurse is aware that intimate partner violence (IPV) screening should occur with which situation?

As a routine part of each health care encounter.

A dark-skinned patient is in the intensive care unit because of impending shock after an accident. How would the skin appear as the nurse assesses the patient?

Ashen, gray, or dull.

During a follow-up visit, the nurse discovers that the patient has not been taking his insulin on a regular basis. The nurse asks, "Why haven't you taken your insulin as instructed?" Which statement is an appropriate evaluation of the nurse's response to the patient?

Asking "why" may put the patient on the defensive and harm any therapeutic relationship between the nurse and patient.

A 75-year-old male client has a history of hypertension and was recently changed to a new antihypertensive medication by his health care provider. He reports feeling dizzy at times. What is the best means to evaluate the client's blood pressure in this situation?

Assess blood pressure and pulse when the patient changes from the supine position to that of sitting and standing positions.

The nurse is performing a neurological assessment on a 41-year-old woman with a history of diabetes and uncontrolled blood sugar. When testing her ability to feel the vibrations of a tuning fork, the nurse notes the following: the patient is unable to feel vibrations on the great toe or ankle bilaterally, but is able to feel vibrations on both patellae. Given this information what would be an appropriate nursing action?

Assess for further indications of peripheral circulatory problems.

During a routine physical examination, a nurse observes a 1-cm (0.4-in) lesion on a client's chest. The lesion is raised and fresh-colored with pearly white borders. The nurse should recognize that this finding is suggestive of which of the following types of skin cancer.

Basal cell carcinoma

When taking a history from a newly admitted patient, the nurse notices that he is pausing often and looking at the nurse expectantly. What would be the nurse's best response to this behavior?

Be silent and allow him to continue when he is ready

The patient with presbyopia may complain of:

Inability to read the newspaper print up close.

A patient states that the pain medication is "not working" and rates his postoperative pain at a 10 on a 1-to-10 scale. Which of these assessment findings indicates an acute pain response to poorly controlled pain?

Increased pulse.

Prolonged heavy drinking can lead to all of the following except:

Increased resistance to pneumonia and other infectious disease

Which respiratory assessment finding is abnormal?

Increased tactile fremitus towards the base of the lungs.

The nurse's assessment of a client with acute bronchitis reveals the following: copious secretions, dyspnea, cough and fatigue. The client's oxygen saturation reading is 88%. Which nursing diagnosis is appropriate?

Ineffective airway clearance.

Which of the following assessment findings would the nurse most likely expect to find when assessing a child diagnosed with asthma?

Inspiratory or expiratory wheezing

Following total hip joint replacement, the patient is instructed to avoid turning his affected leg and hip inward toward midline, or crossing the affected leg over the nonaffected leg. These movements are documented as:

Internal rotation, adduction

The nurse is performing the Denver II screening test on a 12-month-old infant during a routine well-child visit. The nurse should tell the infant's parents that the Denver II:

Is a screening instrument designed to detect children who are slow in development

The nurse is preparing to use a stethoscope for auscultation. Which statement is true regarding the bell of the stethoscope? The bell:

Is used to listen for low-pitched sounds

The nurse is providing nutrition information to the mother of a 1-year-old child. Which of these statements represents accurate information for this age group?

It is important to maintain adequate fat and caloric intake.

When evaluating the temperature of older adults, the nurse remembers which aspect about an older adult's body temperature?

It is lower than that of younger adults

The nurse is preparing to do a mental status examination. Which statement is true regarding the mental status examination?

It is usually sufficient to gather mental status information during the health history interview

The general survey includes:

Observing the patient's stature and nutritional status

The nurse notices that the patient has a solid, elevated, circumscribed lesion that is less than 1 cm in diameter. When documenting this finding, the nurse would report this lesion as a:

Papule.

A nurse is assessing a patient who states, "I have this spot in front of my ear lobe on my cheek that seems to be getting bigger and is tender. What do you think it is?" The nurse notes swelling below the angle of the jaw and suspects that it could be an inflammation of his:

Parotid gland.

A physical examination can be considered to be complete, focused or a recheck (a re-evaluation). Which situation would warrant a focused physical examination?

Patient admitted with chest pain

To palpate the temporomandibular joint, the nurse palpates below the temporal artery and anterior to the:

Tragus

A female client is admitted to the hospital with a medical history of Parkinson's Disease. Which findings associated with Parkinson's Disease would the nurse expect to assess?

Tremor, rigidity, akinesia (impaired body movement), slower monotonous speech, facial expression that is flat, staring, expressionless and reduced eye blinking.

The nurse begins to care for a patient who is unable to speak or understand English. The best approach for overcoming the language barrier would be to:

Use a medically trained and culturally sensitive interpreter.

The nurse suspects abuse when a 10-year-old child is taken to the urgent care center for a leg injury. The best way to document the history and physical findings is to:

Use the words the child has said to describe how the injury occurred.

During the taking of the health history, a patient tells the nurse that "it feels like the room is spinning around me." The nurse knows the medical term for this is:

Vertigo.

Which technique is correct when the nurse is assessing the radial pulse of a patient? Count the:

pulse for 1 minute if the rhythm is irregular