Assessment & Promotion Exam

Tertiary

A patient with diabetes is administering insulin as directed by their physician. This is an example of what type of disease prevention? Tertiary Secondary Primary

Every 5 years

A 35-year old female patient is scheduling a Pap smear. She has never had an abnormal result. What is the recommended timeline for this type of screening? 3 years 1 year 2 years 5 years

aggressive

A nurse comes into a patient's room to perform an assessment and administer medication. When asked if they would like to take their medication with water or juice, the patient starts yelling at the nurse and tells her to get out of the room. How should the nurse document this patient's response? -flat affect confused impulsive aggressive

Increased heart rate increased blood pressure increased respiratory rate

A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply.) -Increased heart rate -increased hematocrit -increased temperature -increased blood pressure -increased respiratory rate

Assess the apical pulse for a full minute.

A nurse is assessing a client's radial pulse and determines that the pulse is irregular. Which of the following actions should the nurse take? -Assess the apical pulse for a full minute. -Assess the pedal pulses for a full minute. -Assess the pedal pulses with a Doppler device. -Assess the apical pulse with a Doppler device.

focused

A patient comes to the emergency room with a suspected fracture of their lower leg. Which of the following assessments would the nurse complete? basic focused comprehensive

Secondary

A patient has made an appointment for a physical exam. This is an example of which of the following types of disease prevention? Primary Secondary Tertiary

Damage to the trigeminal nerve

A patient is unable to differentiate between sharp and dull stimulation to both sides of her face. The nurse suspects: Frostbite with paresthesia to the cheeks Damage to the trigeminal nerve Scleroderma Bells palsy

Ibuprofen 800 mg by mouth every 4 hours as needed for pain

A patient with a history of kidney disease is admitted with acute shoulder pain. Which order should the nurse question? -Digoxin 0.125 mg by mouth daily -Pan cultures for a temperature >38.5º C -Ibuprofen 800 mg by mouth every 4 hours as needed for pain -Metoprolol 50 mg by mouth twice daily

9

A patient with cerebral edema after a motor vehicle accident opens their eyes to noise, grunts when the nurse asks questions and withdraws from painful stimuli. When documenting these findings, what is the associated Glascow Coma Scale score? 9 11 13 5

Administer oxygen by nasal cannula.

A patient with kidney failure reports dyspnea. The patient's pulse oximeter reading is 95% on room air, but is visibly distressed with a respiratory rate of 32 breaths/min. What is the priority intervention? -Administer lorazepam as the patient's tachypnea is related to anxiety. -Notify the respiratory therapist. -Administer a respiratory nebulizing treatment. -Administer oxygen by nasal cannula.

Assessing the inguinal lymph nodes first, then moving to the upper lymphatics (pre-auricular, post-auricular, etc.).

A student nurse is documenting their lymphatic assessment of a patient admitted for fever of unknown origin. Which of the following actions by the student nurse would cause the instructor to intervene? -Using the pads of their fingers in a circular motion to assess the lower lymph nodes. -Assessing the inguinal lymph nodes first, then moving to the upper lymphatics (pre-auricular, post-auricular, etc.). -Documenting lymph nodes as enlarged and fixed. -Palpating the epitrochlear lymph nodes on the medial side by the bend of the arm.

older adults

Falls can lead to complications including fractures and soft tissue injury. Which of the following patient populations are most at risk for these types of complications? older adults toddlers middle-aged adults adolescants

extension flexion

Knowing the intended range of motion for joints, which of the following would the nurse anticipate the patient being able to perform using their elbow? Select all that apply. abduction circumduction extension supination flexion

"Tell me what this fable means to you."

The emergency department nurse is caring for a 78-year old patient whose daughter reports a decrease in cognition. Which nursing statement directed to the patient helps the nurse to assess cognition? -"Tell me what this fable means to you." -"Please count backward from 100 by 7s." -"Tell me how you were transported to the hospital today." -"I will write a word on this paper, and you copy it."

vii

The nurse asks the patient to close their eyes tightly. By doing so, the patient is demonstrating that which of their cranial nerves is intact? iv vi iii vii

Notify the physician.

The nurse is assessing a patient's AV fistula and notes there is not a thrill present. What is the priority action? -Administer dialysis via the AV fistula. -Reschedule dialysis for tomorrow. -Reassess in 1 hour. -Notify the physician.

Enable the bed alarm safety system.

The nurse is caring for a 30-year-old patient who experienced a frontal lobe infarction after a motorcycle accident. What is the appropriate nursing intervention? -Place all items directly in front of the patient. -Use a picture board to assist with communication. -Instruct the patient to use a call light prior to getting out of bed. -Enable the bed alarm safety system.

weber whisper rinne

The nurse is caring for a patient with an acoustic neuroma. When preparing to assess the patient further which of the following tests should the nurse anticipate doing? Select all that apply. romberg test whisper test snellen test rinne test weber test

oxygen insufficiency

The nurse is caring for an older adult who is usually alert and oriented. When the patient exhibits a change in mental status, which cause does the nurse assess for first? oxygen insufficiency use of sedatives infection electrolyte imbalance

39 y/o caucasian american

The nurse is caring for four female patients. Which patient is identified as being at greatest risk for low bone density? 39 y/o Caucasian American 50 y/o African American 44 y/o Native American 22 y/o Asian American

OD

What is the abbreviation for the right eye when documenting its score on the Snellen chart? OD OU OS

Close monitoring is needed because toxic levels may develop.

When administering a new GI medication to an older patient, the nurse anticipates what? -Nausea and vomiting may develop rapidly and are common side effects in older adults. -Close monitoring is needed because toxic levels may develop. -Older adults always require a lower-than-normal dose than younger patients. -A higher-than-normal dose may be needed.

Severe dehydration

When assessing a patient with an indwelling catheter the nurse notes the color as brown. Which of the following is most likely the cause of this finding? -Severe dehydration -Old urinary tract bleed -10-year history of diabetes mellitus -Congestive heart failure

Document as a diminished response/1.

When assessing a patient's deep tendon reflexes, the nurse does not get a strong response with their patellar reflex. What is the most appropriate action? -Notify the physician of the unexpected finding. -Have the patient tighten their quadriceps to aid in a response. -Try again and have the patient use a distraction technique -Document as a diminished response/1.

step throat

When assessing a patient's tonsils, the nurse notes many red spots. The cause of this is most likely tonsilitis fungal infection strep throat post nasal drip

Anosmia present bilaterally.

When assessing a patient, the nurse notes that they cannot identify the scent as coffee. How should the nurse document this? - Cranial nerve III is not intact. - Anosmia present bilaterally. - Olfactory nerve is intact. - Ptosis of nares bilaterally.

drainage

When assessing the pediatric patient's ears with an otoscope the nurse notes an excess of wax. Another way to document is excess -tinnitus -furuncle -drainage -cerumen

inflammation

When assessing your patient you notice their knee joint is red, swollen and warm to the touch. Which of the following would best describe your findings? atrophy effusion inflammation crepitus

arterial insufficiency

When checking a client's capillary refill, the nurse finds that the color returns in 10 seconds. The nurse should understand that this finding indicates which of the following? -venous insufficiency -thrombus forming in vein -arterial insufficiency -within expected range

A new inability to hold urine Urinating 10 times daily although fluid intake remains unchanged A burning sensation occurring on urination A foul odor from the urine

When obtaining a health history from a 22-year-old female client who has new-onset urinary incontinence, which finding or factors does the nurse consider significant? Select all that apply. -A new inability to hold urine -Chemical exposure in the workplace -Urinating 10 times daily although fluid intake remains unchanged -A recent change in the client's oral contraceptive prescription -A burning sensation occurring on urination -A foul odor from the urine

ocular misalignment

When the nurse performs the corneal light reflex, the light reflects on different parts of each eye and not directly in the center of each pupil. This finding is documented as: - hyperopia anisocoria occular deviation ocular misalignment

Patient with +2 on the right, 0 on the left

Which of the following patients would you prioritize first? - Patient with SBP of 130 -Patient with +2 on the right, 0 on the left -Patient with a pedal pulse of +1 bilaterally -Patient with bilaterally cool feet

"I take ibuprofen three times daily for arthritis."

Which patient statement alerts the nurse to perform a thorough GI history and focused assessment? "I don't like the taste of spicy foods" "I got dentures four years ago." "I experience occasional constipation." "I take ibuprofen three times daily for arthritis."

comprehensive

You are caring for a newly admitted patient with congestive heart failure. Which of the following assessments would you complete? basic focused comprehensive

walking

You are educating a patient with osteoporosis. They are interested in learning more about weight-bearing activities. Which of the following would you suggest? walking using resistance bands while seated swimming biking

basic

You are starting your shift and begin to see your patients. One of which has been on the unit for two days with Covid. Which of the following assessments would be most appropriate? basic focused comprehensive