physical assessment #2

24. The nurse documents the patient's swollen lower extremities and measures the depth of a 4-mm indentation made 1 minute ago. Which is the best description for the nurse to use to describe the patient's lower extremities? a.4+ pitting edema b.Mild pitting edema c.4+ nonpitting edema d.Severe nonpitting edema

a.4+ pitting edema 4+ pitting edema is the best description of a lasting indentation of swollen legs at a depth of 4 mm. Mild and severe are subjective terms open to interpretation. Documentation must include that the edema is pitting because the indentation lingers for at least a minute.

1. The nurse admits the patient with mild chest pain from the emergency department. Which should the nurse implement first to gain patient cooperation during a physical assessment? a.Explain the procedure and its purpose. b.Perform assessment in stages over the day. c.Complete assessment within 3 to 5 minutes. d.Assess painful areas before nontender areas.

a.Explain the procedure and its purpose. First and foremost, the nurse should explain the procedure and its purpose. The patient is more likely to cooperate during a physical assessment if he or she knows what to expect and what the purpose of the procedure is. The nurse explains how the information is used to plan individualized nursing care. The information helps make the patient feel valued and important because the nurse engages him or her in the plan of care. In addition, the nurse reassures the patient about maintaining privacy. The nurse completes the assessment in as few stages as possible because he or she needs the assessment data to plan care. While the nurse will assesses painful and tender areas first because if pain is triggered, the nurse would want to stop the assessment and provide pain management, explaining the procedure should precede any assessment. Assessment data are vital to manage pain successfully.

5. The nurse is assessing a patient with a cast extending from just below the left knee to the toes. Which assessment contains a desirable patient outcome? a.The toes are pink bilaterally. b.The cast is warm at the ankle. c.Paresthesia is present in the left foot. d.The cast is snug at the knee.

a.The toes are pink bilaterally. Bilateral pink toes indicate adequate oxygenation to the periphery and support the outcome, "Patient has pink and warm toes bilaterally while wearing cast." This also implies that the cast fits properly without areas of constriction. An area of warmth on a cast potentially indicates an infection. Paresthesia indicates nerve compression or irritation; when this occurs with a cast in place on the affected extremity, it usually indicates swelling of the extremity, potentially leading to impaired perfusion. A tight cast potentially restricts blood flow and compresses nerves, leading to tissue damage and paresthesias.

15. The nurse assesses a patient with arterial occlusive disease in the lower extremities. Which activity should the nurse implement in the patient's plan of care? a.Use a Doppler device to locate pulses. b.Massage the feet and ankles twice daily. c.Elevate the legs slightly when in the chair. d.Measure the circumference of the thighs daily.

a.Use a Doppler device to locate pulses. The nurse uses a Doppler device to locate peripheral pulses for a patient with arterial occlusive disease because arteries in this health alteration are often difficult to locate as they slowly narrow and impair oxygenated blood flow. Additionally the nurse assesses skin temperature, color, and sensation to establish baseline information. Massaging areas of impaired arterial perfusion is contraindicated because the patient is already at risk for breakdown. Although massage potentially increases blood flow to tissue, it is contraindicated at the ankles and feet because this skin covers many bony prominences. The legs of the patient with arterial occlusive disease usually need to be dependent to allow gravity to help pull oxygenated blood to the periphery. Elevating the legs promotes venous return and increases the difficulty of oxygenating the tissue because the vessels need to deliver oxygenated blood through inadequate arteries. Thigh measurement is indicated for thromboembolic events, venous insufficiency, or other disorders that impair venous return.

16. A male patient with back pain asks why the nurse needs so many details about his history. What is the most effective response by the nurse? a."You seem reluctant to provide information." b."We need complete data to plan nursing care." c."It will take a short time to answer all questions." d."We need to determine contributors to your pain."

b."We need complete data to plan nursing care." The nurse explains that comprehensive data facilitate individualized patient care, lower patient risks of injury, and increase patient safety. Determining factors that contribute to the patient's pain is part of a pain assessment and one of the details that help the nurse plan individualized patient care. Stating that the patient seems reluctant to provide information is placing an interpretation on his motives and may be completely off base if the patient is just trying to understand the process. Commenting that not much time is needed to answer the questions is not responsive to the patient's question.

10. A patient has the following intake: a cup of oatmeal, a half cup of ice, 3 ounces of apple juice, and 6 ounces of coffee. What is the total intake the nurse should document on the intake portion? a.210 mL b.390 mL c.600 mL d.630 mL

b.390 mL The oatmeal is not counted because it is not fluid. A half cup of ice = 120 mL because it equals 50% of the measured volume. The juice is 3 ounces = 90 mL 6 ounces of coffee = 180 mL. Therefore the total is 120 + 90 + 180 = 390 mL. 1 cup = 240 mL 1 oz = 30 mL

17. The nurse assesses an adult patient with a cardiopulmonary illness and hears a grating sound over the lower lateral lung during inspiration that does not clear with coughing. What would the nurse most likely document as a result of the assessment findings? a.Rhonchi b.A pleural friction rub c.Wheezes d.Crackles

b.A pleural friction rub A pleural friction rub is heard over the anterior lateral lung field if the patient is sitting upright. It has a grating quality that is best heard during inspiration. It does not clear with coughing. It indicates inflamed parietal pleura rubbing against visceral pleura. Rhonchi indicate fluid or mucus in larger airways causing turbulence in the airways. Rhonchi can sometimes be cleared by coughing. Wheezes are heard all over the lung fields and indicate a narrowed or obstructed bronchus. Crackles, formerly called rales, are most common in dependent lobes and indicate fluid in the small airways.

4. How often should the nurse perform a general assessment of the patient? a.At least every 4 hours b.As often as it is needed c.When the patient requests it d.At the rate set by agency policy

b.As often as it is needed The nurse performs a general assessment at the beginning of the shift and as often as needed afterward; however, the nurse frequently performs a focused assessment to make clinical judgments and problem solve. Every 4 hours is time consuming unless indicated by patient condition. Patients do not determine when to perform an assessment, but the nurse is responsive to patient concerns and resolves the problem to the patient's satisfaction. Agency policy generally requires an assessment at the beginning of the shift and supports the nurse's decision to reassess the patient as needed at the nurse's discretion.

9. The nurse is instructing a patient how to breathe during auscultation of the lungs. Instruction by the nurse has been effective if the patient breathes in which manner? a.Takes rapid shallow breaths b.Breathes with the mouth open c.Coughs and then takes a deep breath d.Takes a deep breath and holds it

b.Breathes with the mouth open The nurse instructs the patient to breathe with the mouth open because this facilitates air movement and amplifies patient lung sounds. In addition, the nurse instructs the patient to take slow deep breaths. Rapid shallow breaths quickly induce hypocarbia, leading to lightheadedness and fatigue, and impair auscultation of breath sounds because the sounds are too faint to assess. Coughing and deep breathing are instructions to facilitate the mobilization of pulmonary secretions. Holding the breath impairs the nurse's ability to auscultate air movement for a respiratory assessment.

28. The nurse assesses the oral mucosa for pathological color changes. Which finding does the nurse expect to see in the patient's mouth, and why does the nurse expect to find it? a.Ecchymosis, because it often is bluish green b.Cyanosis, because it can occur as an ashen tongue c.Petechiae, because they are easily visible in all patients d.Erythema, because the gums should be pink and moist

b.Cyanosis, because it can occur as an ashen tongue The nurse can assess cyanosis, a late sign of hypoxia, in the mouth of a dark-skinned patient by examining the tongue for an ashen gray appearance. In fair-skinned patients, cyanosis is usually observed with pallor or a bluish-gray cast. The nurse expects to find ecchymosis in a fair-skinned patient, but it appears as yellowish green to purple. Petechiae are usually invisible in patients' mouths. It is possible to observe erythema in the mouth, keeping in mind that the tongue can be beefy red in color.

30. The nurse is assessing the temperature of the lower legs. Which method should the nurse use to best assess the patient's skin temperature subjectively? a.Oral thermometer b.Dorsum of the hand c.Tympanic thermometer d.Thumb and index finger

b.Dorsum of the hand To evaluate the patient's skin temperature according to the nurse's opinion, the nurse uses the dorsal aspect of the hand because this skin is thin and more sensitive to temperature changes. An oral or tympanic thermometer evaluates temperature objectively. Thumb and index finger are not used to evaluate the skin temperature subjectively because these are the most frequently used fingers and the skin is likely to be thicker and less sensitive to slight temperature fluctuations.

21. The nurse observes yellow sclerae while assessing the patient's eyes. What does the nurse look for to validate this finding? a.A history of pallor b.Jaundice c.Cyanosis d.Ecchymosis

b.Jaundice The nurse concludes that the yellow sclerae are indicators of jaundice, an accumulation of bilirubin in the skin. Pallor is skin without a pink cast. Skin with a bluish or dusky cast is an indicator of cyanosis. Ecchymosis is purplish to yellow green and results from subcutaneous bleeding.

27. The nurse assesses a possible melanoma on the patient's skin. Which characteristic does the lesion have that is consistent with a melanoma? a.Regular borders b.Larger than 6 mm c.Symmetrical borders d.Reddened coloration

b.Larger than 6 mm Melanomas are usually larger than 6 mm in diameter. In addition, melanomas are usually asymmetrical lesions with irregular borders and blue, black, or variegated coloring.

8. The nurse is listening to the patient's lungs. Which information should the nurse use to document normal patient lung sounds? a.Rales in the right lower lobe b.No adventitious breath sounds c.Pleural friction rub in the left lung d.Inspiratory wheezing in the upper lobes

b.No adventitious breath sounds A clinical indicator of normal lung sounds is a lack of adventitious breath sounds, meaning that the patient does not exhibit crackles, rhonchi, rubs, stridor, or wheezing. Rales are the same as crackles and indicate fluid or atelectasis in the alveoli. Pleural friction rubs are not normal and indicate inflammation of the pleural lining. Wheezing indicates constriction of the airway as heard during an asthma attack.

23. The nurse is performing a cardiovascular assessment at the fifth intercostal space at the midclavicular line. What would the nurse be attempting to check? a.S3 b.Point of maximal impulse (PMI) c.Murmur d.Visible pulsations

b.Point of maximal impulse (PMI) The nurse expects to find the PMI at the fifth intercostal space at the midclavicular line because this is where the left ventricle is the closest to the chest wall. The nurse follows palpation of the PMI with auscultation of the apical pulse. If the patient's heart is dilated or hypertrophic, the PMI shifts to the left toward the anterior axillary line. S3 or murmur auscultated near any heart valve is generally abnormal along with visible pulsations (called a lift or heave) coming from the heart.

26. The nurse assesses the adult patient's spine. Which expected finding does the nurse identify about the patient's alignment and posture? a.Upper spine bent slightly b.Spine in straight alignment c.Slumping to nondominant side d.Dominant side of patient favored

b.Spine in straight alignment The anterior-posterior alignment of the spine should be a straight line from the skull to the sacrum. The other findings would be unexpected. An excessive thoracic curvature is kyphosis, which is common with vertebral compression fractures of the thoracic spine. Slumping to the nondominant side and favoring the dominant side are abnormal findings, indicating muscular weakness or abnormal spine alignment.

11. Nursing assistive personnel (NAP) are part of the patient care team. Which aspect of obtaining health information can the nurse delegate to NAP? a.Auscultate apical pulse of a patient with acute angina. b.Take vital signs of a patient who might be discharged. c.Complete lung assessment of a patient with pneumonia. d.Clarify effects of antihypertensive therapy for a patient.

b.Take vital signs of a patient who might be discharged. The task of taking vital signs of a patient who may be discharged may be delegated to NAP. The patient with acute angina needs a nursing assessment to avert complications of impaired coronary artery blood flow. The nurse evaluates the patient to complete a nursing assessment and implement indicated therapy without delay. The nurse assesses the patient with pneumonia to auscultate breath sounds and evaluate the airway and oxygenation because the lungs fill with infectious exudate, impairing ventilation and increasing the risk of airway occlusion. The nurse evaluates the patient's antihypertensive therapy as part of the patient's plan of care and the nursing process.

6. The patient has an irregular, elevated, localized area of edema on the left forearm. Which term should the nurse use when documenting? a.Tumor b.Wheal c.Macule d.Vesicle

b.Wheal An irregular, elevated, localized area of edema is a wheal. The nurse documents the approximate size of the wheal. A tumor is a solid mass of abnormal growth larger than 1 to 2 cm (0.4 to 0.8 in). A macule is a flat change in skin pigmentation such as a freckle or petechiae. A vesicle is a round elevation of skin filled with serous fluid.

22. The nurse assesses the patient's lungs to find high-pitched musical sounds on inspiration and expiration. Which description does the nurse use to document the findings? a.Rhonchi b.Wheezes c.Crackles d.Friction rub

b.Wheezes High-pitched musical breath sounds are wheezes that result from bronchospasm; the smaller the constricted airways, the higher the pitch of the wheeze. Rhonchi are low-pitched rumblings indicative of fluid in larger airways; rhonchi are potentially cleared with coughing. Crackles are higher pitched and sharper sounding than rhonchi, indicating fluid or atelectasis in dependent lobes of the lungs. A friction rub is heard on inspiration and expiration but characteristically is a grating sound. A friction rub is frequently accompanied by pain and fever.

39. The nurse is performing a neuromuscular assessment. Which method should the nurse use to evaluate muscle strength? a.Measure the muscle size. b.Perform range of motion. c.Apply pressure against resistance. d.Observe the patient's gait and transfers.

c.Apply pressure against resistance. The nurse applies pressure against the patient's resistance to measure muscle strength to make the subjective evaluation safe. Muscle size usually is an indication of muscle strength in a patient who is conscious and cooperative. Range of motion indicates flexibility of joints. Observing a patient's gait is a valuable measure of the patient's muscle strength but is not used initially because it increases the risk of patient injury.

2. The nurse assesses a patient with light skin and observes normally shaped nail beds exhibiting pallor and a slight bluish color. Which should the nurse implement? a.Provide a warm heating pad. b.Collaborate with the healthcare provider. c.Assess patient oxygen saturation. d.Check for restricted venous return.

c.Assess patient oxygen saturation. Capillary refill less than 3 secs Nail beds in a patient with light skin are a view of the patient's capillary bed at the periphery. Pallor and a bluish color in the capillary bed indicate inadequate oxygenation because oxygenated blood is dark red resulting in pink nail beds. Generally application of heat and cold requires a prescription from a healthcare provider; moreover, the nurse needs to assess the patient and gather related data before being able to decide that warmth is indicated. The nurse needs to complete the assessment first, as long as the patient is in no immediate danger or experiencing distress, and to think critically before collaboration. If collaboration with the provider becomes necessary, the nurse presents a complete patient assessment. Restricted venous return usually leads to edema; severe peripheral edema leads to pallor; and cyanosis potentially occurs but is not common.

40. The nurse has been assessing the patient's bowel sounds. Which action should the nurse implement before notifying the healthcare provider if the bowel sounds are absent? a.Obtain an abdominal radiograph. b.Ambulate the patient. c.Assess related factors. d.Use an amplifying instrument.

c.Assess related factors. If the patient has inaudible bowel sounds, the nurse assesses the patient for distention, the last bowel movement, and patient comfort to obtain a more complete assessment. The nurse needs an order for an abdominal x-ray film. Ambulating the patient can help in some situations, but further assessment is indicated at this time. Doppler devices are not useful to detect bowel sounds.

29. The patient has iron deficiency anemia. Which is the nurse's priority for prevention with suitably planned nursing care? a.Pallor b.Jaundice c.Cyanosis d.Erythema

c.Cyanosis The nurse's priority is to prevent cyanosis because it is a late sign of hypoxia. The patient is most likely pale already, so the nurse cannot prevent pallor. Because the patient has a narrow margin between adequate oxygenation and hypoxia, the nurse's priority is to prevent hypoxia until the patient's iron stores and erythrocyte counts increase to restore pinkness to the skin.

20. The nurse assesses the patient with altered musculoskeletal function. Which is the best reason supporting the nurse's motive for asking probing questions? a.Explore how the patient's family reacts to the disability. b.Evaluate patient concerns about the problem at this time. c.Determine how the alteration affects the patient's lifestyle. d.Validate the amount of physical rehabilitation completed.

c.Determine how the alteration affects the patient's lifestyle. Determining how the altered musculoskeletal function affects the patient's lifestyle is the best reason for the nurse to ask probing questions. With skillful follow-up questioning, the nurse learns the most comprehensive information about the patient, including family reactions, patient concerns, and rehabilitation issues.

14. An older patient is being assessed by the nurse. Which finding does the nurse consider abnormal when assessing the patient's risk for fall? a.Use of an assistive device b.Wearing glasses c.Failure of the Get Up and Go test d.Negative Romberg's test

c.Failure of the Get Up and Go test The Get Up and Go test is an assessment that should be conducted as part of a routine evaluation of older adults. The test detects people at risk for falling. The Romberg's reflex is normally negative, meaning that when the patient stands with feet together, arms down at sides, and eyes open (20-30 seconds) or closed (20-30 seconds), there is minimal to no swaying. Using an assistive device or wearing glasses does not put the patient at risk for falling unless they are not using their devices.

32. The patient is being assessed for a possible respiratory problem. In which position should the patient be placed to facilitate chest expansion during a thoracic assessment? a.Prone b.Side-lying c.High-Fowler's d.Dorsal recumbent

c.High-Fowler's The nurse helps the patient assume high-Fowler's position to facilitate lung expansion during a thoracic assessment. The prone position would place the patient face down on the bed, making it impossible to see the chest expansion. The dorsal recumbent position is potentially contraindicated for some patients. Side-lying is a position used by the nurse to assess the posterior thorax of a patient who cannot cooperate with the examination.

18. The nurse is assessing an older patient and finds the heart rate to be 62 and irregular. Suddenly the patient complains of dizziness and "feeling faint." Which action should the nurse take next? a.Ask the patient about valve replacement surgery. b.Apply 3 L of oxygen via nasal cannula. c.Notify the healthcare provider. d.Explain that this is a normal finding in older adults.

c.Notify the healthcare provider. An irregular heart rate and dizziness are abnormal findings and symptoms, and the healthcare provider must be notified immediately for follow-up. An electrocardiogram (ECG) will be ordered along with other studies. History is important, but the current status is the priority. The usual amount of oxygen to be applied without an order is 2 L/min.

36. The nurse is performing an abdominal assessment. The technique is appropriate if the nurse uses which method? a.Assesses the painful areas first b.Auscultates each quadrant for 5 minutes c.Palpates lightly to locate painful and tender areas d.Positions the patient with the arms behind the head

c.Palpates lightly to locate painful and tender areas The nurse lightly palpates the abdomen to determine any painful or tender areas so the patient does not worry about the nurse aggravating the pain and the nurse can conduct a comprehensive abdominal assessment. Assessing painful areas first can terminate the assessment if the assessment exacerbates patient pain. Auscultating for 5 minutes is excessive. The nurse positions the patient with arms at the side and knees flexed to facilitate relaxation of the abdominal wall.

13. The nurse is preparing to assess the patient's abdomen. Nursing care is appropriate if which maneuver is seen? a.The abdomen is auscultated after percussion. b.The nurse instructs the patient to extend the legs. c.The nurse inspects the abdomen before auscultation. d.The assessment begins with palpation, followed by auscultation.

c.The nurse inspects the abdomen before auscultation. For an abdominal assessment, the nurse begins with inspection followed by auscultation to prevent accidental stimulation of movement, potentially leading to inaccurate assessment data. With inspection the nurse observes the abdominal surface for movement, scars, and pulsations; then he or she auscultates bowel sounds before potentially stimulating the bowels with palpation or percussion. The nurse has the patient bend at the knees to relax the abdominal wall, making abdominal palpation easier. Palpation never precedes auscultation of the abdomen.

25. The nurse assesses the pupils of an older patient. What unexpected finding might the nurse identify about the patient's pupils? a.They are 3 mm in size. b.Both of them are round. c.There is a slight opacity. d.They respond to light spontaneously.

c.There is a slight opacity. Normal pupils are round, clear, and equal in size and shape. Mild opacity in an older patient's eyes is abnormal and potentially indicates cataract formation. A 3-mm size, roundness, and responsiveness to light are expected findings of an eye assessment, indicating that the oculomotor cranial nerve (III) is intact.

19. The nurse assesses the patient admitted with constipation. Which assessment finding warrants further investigation? a.No aortic bruit b.Firm liver edge c.Bowel sounds audible d.Abdomen distended and taut

d.Abdomen distended and taut A distended abdomen that is round and taut is a significant finding for a patient with constipation because it potentially indicates the accumulation of fluid, gas, tumor, or other material. This warrants the nurse's attention because, if the accumulation of fluid or gas is caused by a bowel obstruction, the patient may need emergency care to prevent the bowel from rupturing and spilling intestinal contents into the peritoneum. No aortic bruits, a firm liver edge, and audible bowel sounds are normal findings.

37. The nurse admitted a patient with clear lungs and 2 days later determines that the patient has fluid in the left lung. Which should the nurse implement next? a.Place the patient in high-Fowler's position. b.Obtain a stat portable chest x-ray film. c.Notify the healthcare provider immediately. d.Complete a full respiratory assessment

d.Complete a full respiratory assessment Because this is a new finding for the patient, the nurse facilitates suitable patient care by obtaining a comprehensive patient assessment to communicate to the healthcare provider. There are no data indicating that the patient is in respiratory distress. The nurse needs an order for a chest x-ray film. The nurse should notify the healthcare provider promptly, but he or she needs to finish the complete respiratory examination first as long as the patient is not in acute distress.

33. The nurse is preparing to begin the thoracic assessment of a patient. What is the initial step of the thoracic assessment? a.Percussion of the lateral thorax b.Palpation of the anterior thorax c.Measurement of the respiratory rate d.Inspection of the posterior thorax

d.Inspection of the posterior thorax The nurse begins a thoracic assessment by inspecting the posterior thorax to identify any factors that can impair chest expansion or cause respiratory distress. Lateral percussion is not used in a respiratory assessment because the biggest lung fields are across the patient's back. Palpation of the anterior thorax follows assessment of the posterior thorax. Measuring the respiratory rate follows the posterior thoracic inspection.

12. The nurse is teaching a nursing student the correct technique for assessing an apical pulse. Which method when used by the student demonstrates she knows the correct location to take an adult patient's apical pulse? a.Percusses the left ventricular wall b.Palpates along the left sternal border c.Directs the patient to lie in a supine position d.Listens at the fifth intercostal space at the point of maximal impulse (PMI)

d.Listens at the fifth intercostal space at the point of maximal impulse (PMI) To locate the apical pulse, the nurse locates the fifth intercostal space on the left midclavicular line; this point should coincide with the patient's PMI. Evaluation of the heart rarely includes percussion. Palpation along the left sternal border reveals cardiac thrusts and thrills; however, the apical pulse is not proximate to the sternal border. The nurse positions the patient with the head of the bed at 30 degrees for patient comfort and to facilitate cardiac assessment.

35. The nurse is preparing to auscultate the pulmonic area. At which site should the nurse place the stethoscope? a.At the costovertebral angle b.Over the costochondral junction c.At Erb's point d.On the left side at the second intercostal space

d.On the left side at the second intercostal space The nurse locates the pulmonic area at the second intercostal space, on the left side at the midclavicular line. This location is useful for assessing the pulmonic valve. The costovertebral angle is at the inferior aspect of the sternum. The costochondral junction is the point where a bony rib meets the cartilage connecting the rib to the sternum. The third intercostal space, Erb's point, is a useless location for cardiac or respiratory assessments.

38. The nurse assesses peripheral perfusion. Which does the nurse find in a patient with arterial insufficiency? a.Edema b.Warm skin c.Palpable pulses d.Pain with exercise

d.Pain with exercise The patient with arterial insufficiency usually reports pain with exercise because the arteries to the lower extremities are insufficient to meet tissue oxygen demands. The tissue reverts to anaerobic metabolism with increased accumulation of carbon dioxide and lactic acid, precipitating pain in the tissues. The pain often improves with rest and dependent positioning. Edema is consistent with venous insufficiency. Warm skin and palpable pulses are consistent with adequate arterial perfusion of tissues.

34. The nurse begins to assess the patient's respiratory system. Which assessment by the nurse best determines the patient's diaphragmatic excursion? a.Observation of respiratory effort b.Percussion over air-filled regions c.Auscultation of thorax symmetrically d.Palpation of chest inspiratory movement

d.Palpation of chest inspiratory movement The nurse palpates the patient's thoracic movement by placing hands on each side of the spine with thumbs adjacent to one another and instructs the patient to breathe deeply. On inspiration the nurse observes or measures the respiratory excursion, a reflection of the patient's inspiratory volume. Observing respiratory effort reveals data on the work of breathing. The nurse percusses over areas of suspected fluid accumulation to determine the size of the fluid from consolidation from pneumonia or a pleural effusion. The nurse symmetrically auscultates the thorax to compare bilateral breath sounds.

3. The nurse is performing a neurological assessment. Which patient behaviors demonstrate a level of consciousness within normal limits? a.States name, age, and date but not location b.Is lethargic; responds logically to questions c.Responds verbally, but words are unintelligible d.Responds to questions spontaneously; is alert and oriented

d.Responds to questions spontaneously; is alert and oriented The patient who responds to questions spontaneously and is alert and oriented exhibits neurological findings that are within normal limits. *Orientated to · 1: person · 2: person, place · 3: person, place, and time · 4: person, place, time and purpose The patient is conscious, responds to the environment, and has congruent thought processes. The patient who does not know the location is disoriented to place. Lethargy is not a normal finding despite correct responses. Unintelligible speech is abnormal.

7. The nurse is concerned with possible impaired peripheral perfusion after performing a patient's assessment. Which assessment datum about the patient's lower extremities supports the nurse's suspicion? a.The ankle bones are prominent. b.The skin is warm and pink bilaterally. c.The legs ache when in a dependent position. d.The peripheral pulses are absent on both legs.

d.The peripheral pulses are absent on both legs. Clinical indicators of impaired perfusion to a lower extremity include absent or diminished pulses, cool and dusky skin, and pain on exertion; if the disease is advanced, the patient potentially has pain at rest. Prominent ankle bones are normal. Warm pink skin is a clinical indicator of adequate tissue oxygenation. Aching in the lower extremities when in the dependent position is characteristic of venous insufficiency.

31. The school nurse alerts parents to observe for chickenpox. Which clinical indicator does the nurse instruct the parents to observe for chickenpox? a.Wheals b.Nodules c.Pustules d.Vesicles

d.Vesicles When chickenpox first erupts, the lesions are small, fluid-filled skin elevations called vesicles. Wheals are irregular elevated areas found with mosquito bites. Nodules are an elevated but solid mass. The vesicles of chickenpox change to pustules as the illness wanes.