UNIT III TEST ONE
The nurse is performing a respiratory assessment and is auscultating the client's breath sounds. On auscultation, the nurse hears a grating and creaking type of sound. The nurse interprets this to mean that client has which type of sounds? 1.Wheezes 2.Rhonchi 3.Crackles 4.Pleural friction rube
Pleural friction rub A pleural friction rub is characterized by sounds that are described as creaking, groaning, or grating. The sounds are localized over an area of inflammation on the pleura and may be heard in both the inspiratory and the expiratory phases of the respiratory cycle. Wheezes are musical noises heard on inspiration, expiration, or both and are the result of narrowed airway passages. Rhonchi are usually heard on expiration when there is an excessive production of mucus that accumulates in the air passages. Crackles have the sound that is heard when a few strands of hair are rubbed together and indicate fluid in the alveoli.
The nurse notes documentation that a client is exhibiting Cheyne-Stokes respirations. On assessment of the client, the nurse should expect to note which finding? 1.Rhythmic respirations with periods of apnea 2.Regular rapid and deep, sustained respirations 3.Totally irregular respiration in rhythm and depth 4.Irregular respirations with pauses at the end of inspiration and expiration
1.Rhythmic respirations with periods of apnea Cheyne-Stokes respirations are rhythmic respirations with periods of apnea and can indicate a metabolic dysfunction in the cerebral hemisphere or basal ganglia. Neurogenic hyperventilation is a regular, rapid and deep, sustained respiration that can indicate a dysfunction in the low midbrain and middle pons. Ataxic respirations are totally irregular in rhythm and depth and indicate a dysfunction in the medulla. Apneustic respirations are irregular respirations with pauses at the end of inspiration and expiration and can indicate a dysfunction in the middle or caudal pons.
While performing a cardiac assessment on a client with an incompetent heart valve, the nurse auscultates a murmur. The nurse documents the finding and describes the sound as which? 1.Lub-dub sounds 2.Scratchy, leathery heart noise 3.A blowing or swooshing noise 4.Abrupt, high-pitched snapping noise
A blowing or swooshing noise A heart murmur is an abnormal heart sound and is described as a faint or loud blowing, swooshing sound with a high, medium, or low pitch. Lub-dub sounds are normal and represent the S1 (first) heart sound and S2 (second) heart sound, respectively. A pericardial friction rub is described as a scratchy, leathery heart sound. A click is described as an abrupt, high-pitched snapping sound.
What is the appropriate initial action that the nurse should direct the client to perform? Nurse Ejay is assigned to a telephone triage. A client called who was stung by a honeybee and is asking for help. The client reports of pain and localized swelling but has no respiratory distress or other symptoms of anaphylactic shock. A.) Removing the stinger by scraping it. B.) Applying a cold compress. C.) Taking an oral antihistamine. D.) Calling the 911.
A.) Removing the stinger by scraping it. The stinger will continue to release venom into the skin. removing the stinger should be the first action that the nurse should direct to the client.Options B and C: After removing the stinger. Antihistamine and cold compress follow.Option D: The caller should be further advised about symptoms that require 911 assistance.
The nurse is performing a neurological assessment on a client and notes a positive Romberg's test. The nurse makes this determination based on which observation? 1.An involuntary rhythmic, rapid, twitching of the eyeballs 2.A dorsiflexion of the great toe with fanning of the other toes 3.A significant sway when the client stands erect with feet together, arms at the side, and the eyes closed 4.A lack of normal sense of position when the client is unable to return extended fingers to a point of reference
A significant sway when the client stands erect with feet together, arms at the side, and the eyes closed In Romberg's test, the client is asked to stand with the feet together and the arms at the sides, and to close the eyes and hold the position; normally the client can maintain posture and balance. A positive Romberg's sign is a vestibular neurological sign that is found when a client exhibits a loss of balance when closing the eyes. This may occur with cerebellar ataxia, loss of proprioception, and loss of vestibular function. A lack of normal sense of position coupled with an inability to return extended fingers to a point of reference is a finding that indicates a problem with coordination. A positive gaze nystagmus evaluation results in an involuntary rhythmic, rapid twitching of the eyeballs. A positive Babinski's test results in dorsiflexion of the great toe with fanning of the other toes; if this occurs in anyone older than 2 years it indicates the presence of central nervous system disease.
In caring for a victim of sexual assault, which task is most appropriate for an LPN/LVN? A.) Provide emotional support and supportive communication. B.) Assess immediate emotional state and physical injuries. C.) Ensure that the "chain of custody" is maintained. D.) Collect hair samples, saliva swabs, and scrapings beneath fingernails.
A.) Provide emotional support and supportive communication. The LPN/LVN is able to listen and provide emotional support for her patients. Options B, C, and D: The other tasks are the responsibility of an RN or, if available, a SANE (sexual assault nurse examiner) who has received training to assess, collect and safeguard evidence, and care for these victims.
Which of the following nursing action should take priority? Nurse Kelly. a triage nurse encountered a client who complaints of mid-sternal chest pain. dizziness. and diaphoresis. A. Complete history taking. B. Put the client on ECG monitoring. C. Notify the physician. D. Administer oxygen therapy via nasal cannula.
Administer oxygen therapy via nasal cannula. The priority goal is to increase myocardial oxygenation.Options A. B. and C: These actions are also appropriate and should be performed immediately.
A 26-year-old woman is brought to the emergency department after fainting while visiting her mother in ICU. There is no seizure activity or head trauma. In triage, her fingerstick glucose is 76 mg/dL and partial pressure of oxygen is 99% room air. The patient denies drug and alcohol use, pregnancy, or other medical conditions. Which information is now a priority for the triage nurse to obtain? 1.What she felt just before she fainted. 2.Her stress related to her mother's hospitalization. 3.What food she had eaten that day. 4.How much sleep she has been getting.
Answer: A The most important clue in a loss of consciousness is the patient's recollection of the event just before it happened or the "onset." When there is a true loss of consciousness, or syncope, patients will say that "everything went black" with a rapid recovery (compared with postictal). It is important to rule out a cardiac origin when "fainting" occurs without warning; ask about palpitations and check for pulse irregularity. Vasovagal syncope, in comparison, often has premonitory symptoms that make the patient dizzy, nauseated, or diaphoretic.1 The fact that it is a younger woman, rather than an older obese man with a pacemaker, might tempt a triage nurse to focus initially on emotional distress instead of a cardiac etiology. Food intake, while appropriate in some circumstances, is not that significant for her since it is already known that the glucose level is adequate. In this true case, the woman had a previously undiagnosed cardiac condition and anemia and did well with treatment.
An 80-year-old woman presents with a noticeable left-sided facial droop, complaining of facial pain. What is most important for the triage nurse to do next? 1.Evaluate cranial nerve III (oculomotor). 2.Determine the presence of the palmar drift. 3.Ask the patient to squeeze the nurse's hands. 4.Assess if there is a history of facial trauma.
Answer: B Rule out a systemic neurological cause, such as a brain attack (stroke), by first checking for extremity movement and strength. Most nurses do this by evaluating bilateral hand grasps for extremity strength, but this finding can be affected by forearm or hand afflictions, such as arthritis. Use the palmar drift instead. Have patients close their eyes and stretch their arms out straight (palm side up) for 15 seconds. A weak side will drift down and turn medially. An alternative version is determining if the patients can hold their arms straight up (palm side forward) for 15 seconds (without drifting) and then resist against the nurse's efforts to push the arms down. Alternative causes for this patient's symptoms, such as Bell's palsy (peripheral facial paralysis) or local trauma, can be considered afterwards (options A and D).
A 64-year-old man presents complaining that his leg "is not working right" after he fell 4 days ago. He cut his knee but did not seek medical care. The triage nurse notes a scabbed, wide, jagged area on the right knee, without red streaks, warmth, or drainage. The nurse should next: 1.verify his tetanus immunization status. 2.teach the time frame for suturing and signs of infection. 3.clarify what is meant by "not working right." 4.assess his pain level.
Answer: C The patient implies this is just a minor case of an old local injury, with a possible lingering infection or musculoskeletal injury. However, the atypical description and lack of infection should prompt further questioning. In this case, the nurse elicited that there was weakness in the patient's leg and, incidentally, his arm on that side was a little weak, too. In the end, it was discovered that this man had actually experienced a minor stroke that caused his fall.
The nurse performs triage in the emergency department for a patient with a bee sting. The family reports a history of allergic reactions to bee stings, and the patient complains of difficulty breathing and swelling in his mouth. Which of the following is the priority of the nurse? A.) Maintain an open airway. B.) Contact the physician. C.) Administer oral diphenhydramine. D.) Obtain a full patient history. E.) Administer subcutaneous epinephrine.
Maintain an open airway.
A 70-year-old woman has a known history of Alzheimer's disease, hypertension, and diabetes. She is brought to the emergency department by her son because of new, nonstop verbal rambling and pacing today. What is the best response for the triage nurse to do next? 1.Ask about her other typical dementia-related behavior. 2.Assess the caregiver's stress and ability to cope. 3.Inquire if anything upset the patient emotionally today. 4.Classify this as a "change in mental status."
Answer: D A sudden change in behavior is a change in mental status, regardless of the patient's baseline cognitive status. It is an adage that can be forgotten when patients are elderly, have dementia, or have a history of a psychiatric disorder. Start further assessment by obtaining a pulse oximeter and fingerstick glucose reading. Sudden cognitive changes are the most common manifestation of illness in the elderly (with or without dementia). As much credence and attention should be given to the geriatric caregiver who recognizes a change in this patient's "normal" conditon as is traditionally given to the parents' evaluation of their children.2
The nurse performing a neurological examination is assessing eye movement to evaluate cranial nerves III, IV, and VI. Using a flashlight, the nurse would perform which action to obtain the assessment data? 1.Turn the flashlight on directly in front of the eye and watch for a response. 2.Ask the client to follow the flashlight through the 6 cardinal positions of gaze. 3.Instruct the client to look straight ahead, and then shine the flashlight from the temporal area to the eye. 4.Check pupil size, and then ask the client to alternate looking at the flashlight and the examiner's finger.
Ask the client to follow the flashlight through the 6 cardinal positions of gaze. The nurse asks the client to follow the flashlight through the 6 cardinal positions of gaze to assess for eye movement related to cranial nerves III, IV, and VI. Options 1 and 3 relate to pupillary response to light. Also, shining the light directly into the client's eye without asking the client to focus on a distant object is not an appropriate technique. Option 4 assesses accommodation of the eye.
Michael works as a triage nurse, and four clients arrive at the emergency department at the same time. List the order in which he will assess these clients from first to last. 1. A 50-year-old female with moderate abdominal pain and occasional vomiting. 2. A 35-year-old jogger with a twisted ankle, having a pedal pulse and no deformity. 3. An ambulatory dazed 25-year-old male with a bandaged head wound. 4. An irritable infant with a fever, petechiae, and nuchal rigidity. A.) 1, 2, 3, 4 B.) 2, 1, 3, 4 C.) 4, 3, 1, 2 D.) 3, 4, 2, 1
C.) 4, 3, 1, 2 An irritable infant with fever and petechiae should be further assessed for other meningeal signs. The patient with the head wound needs additional history and assessment for intracranial pressure. The patient with moderate abdominal pain is uncomfortable, but not unstable at this point. For the ankle injury, a medical evaluation can be delayed 24 - 48 hours if necessary.
A 65-year-old patient arrived at the triage area with complaints of diaphoresis, dizziness, and left-sided chest pain. This patient should be prioritized into which category? A.) Non-urgent. B.) Urgent. C.) Emergent. D.) High urgent.
C.) Emergent. Chest pain is considered an emergent priority, which is defined as potentially life-threatening. Option B: Clients with urgent priority need treatment within 2 hours of triage (e.g. kidney stones). Option A: Non-urgent conditions can wait for hours or even days. Option D: High urgent is not commonly used; however, in 5-tier triage systems, High urgent patients fall between emergent and urgent in terms of the time elapsing prior to treatment.
Which of the following triage assessments in a toddler would indicate the need for immediate treatment? A.) temperature of 102ºF (38.8ºC) B.) sinus arrhythmia of 160/min C.) respirations of 60/min D.) systolic blood pressure of 90 mm Hg
C.) respirations of 60/min A respiratory rate of 60/min is a triage red flag. Children have a decreased pulmonary reserve. A child breathing this fast for any extended period of time without intervention with decompensate very quickly into respiratory failure.
A nurse's primary goal in emergency department triage is A.) the rapid admission of patients to the treatment area. B..) to develop a plan of care for each patient seen. C.) the immediate and brief assessment to determine acuity level. D.) to assist with rapid registration to expedite electronic documentation.
C.) the immediate and brief assessment to determine acuity level. During triage, the nurse's primary role is the assessment to determine acuity level. Once that is done, the sorting, rapid admission, and physician consultation can occur in a manner which matches the patient's needs to available resources.
A triage nurse in a busy emergency department assesses a patient who complains of 6/10 abdominal pain and states, "I had a temperature of 104.6º F (40.3º C) at home." The nurse's first action should be to? A.) tell the patient that it may be several hours before being seen by the doctor. B.) assess the patient's current vital signs. C.) obtain a clean-catch urine for urinalysis. D.) ask the health care provider to order a nonopioid analgesic medication for the patient.
Correct Answer: B Rationale: The patient's pain and statement about an elevated temperature indicate that the nurse should obtain vital signs before deciding how rapidly the patient should be seen by the health care provider. A urinalysis may be needed, but vital signs will provide the nurse with more useful data for triage. The health care provider will not order a medication before assessing the patient.
A 24-year-old is brought to the emergency department with multiple lacerations and tissue avulsion of the right hand after catching the hand in a produce conveyor belt. When asked about tetanus immunization, the patient says, "I've never had any vaccinations." The nurse will anticipate administration of what medication and/or vaccine? A.) immunoglobulin. B.) and diphtheria toxoid. C.) immunoglobulin, tetanus-diphtheria toxoid, and pertussis vaccine. D.) immunoglobulin and tetanus-diphtheria toxoid.
Correct Answer: C Rationale: For a patient with unknown immunization status, the tetanus immune globulin is administered along with the Tdap (since the patient has not had pertussis vaccine previously). The other immunizations are not sufficient for this patient.
You respond to a call for help from the ED waiting room. There is an elderly patient lying on the floor. List the order for the actions that you must perform. 1. Call for help and activate the code team. 2. Instruct a nursing assistant to get the emergency cart. 3. Initiate cardiopulmonary resuscitation (CPR). 4. Perform the chin lift or jaw thrust maneuver. 5. Establish unresponsiveness. A) 5, 2, 4, 3, 1 B.) 1, 5, 2, 4, 3 C.) 1, 2, 5, 4, 3 D.) 5, 1, 4, 3, 2
D.) 5, 1, 4, 3, 2 Establish unresponsiveness first. (The patient may have fallen and sustained a minor injury.) If the patient is unresponsive, get help and have someone initiate the code. Performing the chin lift or jaw thrust maneuver opens the airway. The nurse is then responsible for starting CPR. CPR should not be interrupted until the patient recovers or it is determined that heroic efforts have been exhausted. A crash cart should be at the site when the code team arrives; however, basic CPR can be effectively performed until the team arrives.
A 15-year-old male client was sent to the emergency unit following a small laceration on the forehead. The client says that he can't move his legs. Upon assessment, respiratory rate of 20, strong pulses, and capillary refill time of less than 2 seconds. Which triage category would this client be assigned to? A.) Black. B.) Green. C.) Red. D.) Yellow.
D.) Yellow. The client is possibly suffering from a spinal injury but otherwise, has a stable status and can communicate so the appropriate tag is YELLOW.
The emergency department nurse is performing an assessment on a child suspected of being sexually abused. Which assessment data obtained by the nurse most likely support this suspicion? 1.Poor hygiene 2.Difficulty walking 3.Fear of the parents 4.Bald spots on the scalp
Difficulty walking Abuse is the nonaccidental physical injury or the nonaccidental act of omission of care by a parent or person responsible for a child. It includes neglect and physical, sexual, or emotional maltreatment. Sexual abuse can involve incest, molestation, exhibitionism, pornography, prostitution, or pedophilia. Many times the findings associated with sexual abuse may not be easily apparent in the child. The most likely assessment findings in sexual abuse include difficulty walking or sitting; torn, stained, or bloody underclothing; pain, swelling, or itching of the genitals; and bruises, bleeding, or lacerations in the genital or anal area. Poor hygiene may indicate physical neglect. Fear of the parents and bald spots on the scalp most likely are associated with physical abuse.
The nurse is performing a neurological assessment on a client who had a stroke. The nurse checks for proprioception using which assessment technique? 1.Tapping the Achilles tendon using the reflex hammer 2.Gently pricking the client's skin on the dorsum of the foot in 2 places 3.Firmly stroking the lateral sole of the foot and under the toes with a blunt instrument 4.Holding the sides of the client's great toe and, while moving it, asking what position it is in
Holding the sides of the client's great toe and, while moving it, asking what position it is in A method of testing for proprioception is to hold the sides of the client's great toe and, while moving it, asking the client what position it is in. Tapping the Achilles tendon with a reflex hammer describes gastrocnemius muscle contraction. Pricking the skin on the dorsum of the foot in 2 different places describes 2-point discrimination. The plantar reflex is tested when the sole of the foot is stroked with a blunt instrument.
The nurse is assessing a client's muscle strength. The nurse asks the client to hold the arms up and supinated, as if holding a tray, and then asks the client to close the eyes. The client's left hand turns and moves downward slightly. The nurse interprets this to mean that the client has which condition? 1.Ataxia 2.Nystagmus 3.Pronator drift 4.Hyperreflexia
Pronator drift Pronator drift occurs when a client cannot maintain the hands in a supinated position with the arms extended and the eyes closed. This assessment may be done to detect small changes in muscle strength that might not otherwise be noted. Ataxia is a disturbance in gait. Nystagmus is characterized by fine, involuntary eye movements. Hyperreflexia is an excessive reflex action.
A client is diagnosed with external otitis. Which finding would the nurse expect to note on assessment of the client? 1.A wider than normal ear canal 2.A pearly gray tympanic membrane 3.Redness and swelling in the ear canal 4.An excessive amount of cerumen lodged in the ear canal
Redness and swelling in the ear canal
The nurse in the health care clinic is performing a neurological assessment and is testing the motor function of cranial nerve V (trigeminal nerve). Which technique should the nurse implement to test the motor function of this nerve? 1.Ask the client to puff out the cheeks. 2.Separate the client's jaw by pushing down on the chin. 3.Place a small amount of sugar on the client's tongue and ask him or her to identify the taste. 4.Ask the client to rotate the head forcibly against resistance applied to the side of his or her chin.
Separate the client's jaw by pushing down on the chin. The motor function (muscles of mastication) of cranial nerve V (trigeminal nerve) is assessed by palpating the temporal and masseter muscles as the person clenches the teeth. The muscles should feel equally strong on both sides. The nurse should try to separate the client's jaws by pushing down on the chin; normally, the jaws cannot be separated. Asking the client to puff out the cheeks tests the facial nerve. Placing an object on the client's tongue tests sense of taste and the sensory function of the facial nerve. Checking for equal strength by asking the person to rotate the head forcibly against resistance applied to the side of the client's chin assesses cranial nerve XI, the spinal accessory nerve.
The nurse is performing a neurological assessment on a client with a head injury. The nurse should use which technique to assess the plantar reflex? 1.Stroking the foot from the heel to the toe 2.Gently inserting a gloved finger in the rectum 3.Directing a flashlight onto the pupils of the eyes 4.Using a tongue depressor and stimulating the back of the throat
Stroking the foot from the heel to the toe The plantar reflex is assessed by stroking the outer plantar surface of the foot from the heel to the toe. The anal reflex is assessed by stimulating the perianal area or gently inserting a gloved finger in the rectum. Pupillary response is tested using a flashlight. The pharyngeal (gag) reflex is tested by touching the back of the throat with an object such as a tongue depressor. A positive response to each of these reflexes is considered normal.
A client with a diagnosis of asthma is admitted to the hospital with respiratory distress. Which type of adventitious lung sounds should the nurse expect to hear when performing a respiratory assessment on this client? 1.Stridor 2.Crackles 3.Wheezes 4.Diminished
Wheezes Asthma is a respiratory disorder characterized by recurring episodes of dyspnea, constriction of the bronchi, and wheezing. Wheezes are described as high-pitched musical sounds heard when air passes through an obstructed or narrowed lumen of a respiratory passageway. Stridor is a harsh sound noted with an upper airway obstruction and often signals a life-threatening emergency. Crackles are produced by air passing over retained airway secretions or fluid, or the sudden opening of collapsed airways. Diminished lung sounds are heard over lung tissue where poor oxygen exchange is occurring.
The nurse is testing the extraocular movements in a client to assess for muscle weakness in the eyes. The nurse should implement which assessment technique to assess for muscle weakness in the eye? 1.Test the corneal reflexes. 2.Test the 6 cardinal positions of gaze. 3.Test visual acuity, using a Snellen eye chart. 4.Test sensory function by asking the client to close the eyes and then lightly touching the forehead, cheeks, and chin.
Test the 6 cardinal positions of gaze. Testing the 6 cardinal positions of gaze (diagnostic positions test) is done to assess for muscle weakness in the eyes. The client is asked to hold the head steady, and then to follow movement of an object through the positions of gaze. The client should follow the object in a parallel manner with the 2 eyes. A Snellen eye chart assesses visual acuity and cranial nerve II (optic). Testing sensory function by having the client close his or her eyes and then lightly touching areas of the face and testing the corneal reflexes assess cranial nerve V (trigeminal).
The nurse is assessing a client suspected of having meningitis for meningeal irritation and elicits a positive Brudzinski's sign. Which finding did the nurse observe? 1.The client rigidly extends the arms with pronated forearms and plantar flexion of the feet. 2.The client flexes a leg at the hip and knee and reports pain in the vertebral column when the leg is extended. 3.The client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column. 4.The client's upper arms are flexed and held tightly to the sides of the body and the legs are extended and internally rotated.
The client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column. Brudzinski's sign is tested with the client in the supine position. The nurse flexes the client's head (gently moves the head to the chest), and there should be no reports of pain or resistance to the neck flexion. A positive Brudzinski's sign is observed if the client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column. Kernig's sign also tests for meningeal irritation and is positive when the client flexes the legs at the hip and knee and complains of pain along the vertebral column when the leg is extended. Decorticate posturing is abnormal flexion and is noted when the client's upper arms are flexed and held tightly to the sides of the body and the legs are extended and internally rotated. Decerebrate posturing is abnormal extension and occurs when the arms are fully extended, forearms pronated, wrists and fingers flexed, jaws clenched, neck extended, and feet plantar-flexed.
After performing an initial abdominal assessment on a client with nausea and vomiting, the nurse should expect to note which finding? 1.Waves of loud gurgles auscultated in all 4 quadrants 2.Low-pitched swishing auscultated in 1 or 2 quadrants 3.Relatively high-pitched clicks or gurgles auscultated in all 4 quadrants 4.Very high-pitched, loud rushes auscultated especially in 1 or 2 quadrants
Waves of loud gurgles auscultated in all 4 quadrants Although frequency and intensity of bowel sounds vary depending on the phase of digestion, normal bowel sounds are relatively high-pitched clicks or gurgles. Loud gurgles (borborygmi) indicate hyperperistalsis and are commonly associated with nausea and vomiting. A swishing or buzzing sound represents turbulent blood flow associated with a bruit. Bruits are not normal sounds. Bowel sounds are very high-pitched and loud (hyper-resonance) when the intestines are under tension, such as in intestinal obstruction. Therefore, options 2, 3, and 4 are incorrect.
The patient is brought to the ED with an anterior ST-elevation myocardial infarction (STEMI). You are assessing him for possible administration of fibrinolytics. An absolute contraindication for this treatment is: a. The patient's pain is not relieved by medications. b. Symptoms began 36 hours before arrival. c. The patient has received aspirin in the last 2 hours. d. The patient had a previous MI 6 years ago.
b. Symptoms began 36 hours before arrival. Fibrinolytic therapy is generally NOT recommended for patients whose symptoms began more than 12 hours before arrival. Fibrinolytics should not be given if the onset of symptoms was more than 24 hours before arrival UNLESS a posterior MI is diagnosed. In this case, the MI was anterior.
