N309 Exam 1 Quickie Quizzes

Mrs. Williams is an 89-year-old independent woman who lives alone and has severe arthritis in her hands. Over the last few months the arthritis has gotten worse and she is concerned because she can no longer clean her apartment. What question by the nurse would gain the most usable information to assist with this concern?

"Do you have family who visit you regularly?"

Considering the acronym OLD CART, the nurse is asking a newly admitted patient questions during the assessment process. The patient is a 35-year-old man who presents with pain in the upper arm since lifting weights 3 days ago. What question would be appropriate to ask that would give information for the "D" in the acronym?

"Does the pain come and go or is it constant?"

When trying to explore a patient's perspective on his or her illness, the question that would best determine the patient's thoughts on the cause of the problem would be:

"Why do you think you have (name the specific symptom)?"

When the nurse is performing a physical examination on admission of a patient to the medical unit, the patient says the doctor already did an exam. The best response by the nurse would be:

"the doctor focuses on the treatment of the disease process and the nursing assessment focuses more on the body's response to the disease."

A patient has a moderate risk for developing pressure ulcers. The nurse would expect the Braden score to be

13-14

The nurse is performing a Braden assessment on a 62-year old retired man. The nurse documents no impairment in sensory perception, skin usually dry, sitting in a chair most of the day with ambulation short distances outside the room three times a day, and making frequent changes in position. The nurse would record those portions of the Braden score as

15

When answering questions about health during a presentation at a women's club luncheon, the nurse emphasizes that prevention of disease is multifaceted but is connected directly to:

A healthy lifestyle

Which of the following patients would be classified as having chronic pain?

A patient with rheumatoid arthritis

A new RN tells her preceptor that she has always had trouble remembering all the steps of the nursing process. The preceptor tells the new grad that an easy way is to think about the anagram:

ADPIE

Acute shortness of breath is a medical emergency. Immediate assessments are necessary. What is the priority assessment the nurse would make with a patient who has acute shortness of breath?

Auscultate the lungs

Which of the following are considered an anthropometric measurement?

BMI, triceps skin fold, midarm muscle circumference

The nurse has completed an assessment on a new patient. After gathering the data, formulating a nursing diagnosis, and developing a plan of care, it is important for the nurse, before finalizing the plan, to:

Discuss the plan with the patient

The nurse percusses the lungs of a patient with pneumonia. What percussion note would the nurse expect to document?

Dullness

If the nurse who is conducting the interview feels uncomfortable asking about certain subjects, then it is okay to ignore those questions.

False

OLD CART is a mnemonic that will help the nurse remember the steps in the nursing process.

False

Smoking is a habit that only affect the individual who smokes.

False

To help with management of the patient's pain, a nurse should focus on the four A's to monitor a patient's outcome: analgesia, ADLs, adverse effects, and acceptable drug related behaviors.

False

The nurse is grouping subjective and objective data. Which data would the nurse list as subjective?

Headaches began 3 days ago

Staff are talking to the hospital educator and ask about "a government project that is meant to improve the health of people in the United States." The educator bases her response on the knowledge of:

Healthy People 2020

The nurse collects vital signs on a client with pain. Which of the following would indicate to the nurse that the client is experiencing pain?

Heart rate of 110 BPM

The nurse gathers the follow data: complaint of headache and sore throat, redness noted on pharynx with white exudates on tonsils, minimal cough, temperature 100.6%F orally. It was noted that the patient had another sore throat 2 weeks ago. The most appropriate nursing diagnosis for this data would be:

Impaired comfort related to headache and sore throat pain

The first technique in your physical assessment is

Inspection

When auscultating the lungs, the nurse listens over symmetrical lung fields for which of the following?

One deep inspiration and expiration through an open mouth.

A good tool to use to assess alcohol and drug use is the:

PAGE questionnaire

Which statement would demonstrate the correct method for writing an evaluation of patient progress after implementing the nursing process?

Patient ambulated 3/3 times during a planned 8-hour period

The nurse is developing goals after completing the assessment of a newly admitted medical patient. The nurse would document the goals under which part of the nursing process?

Planning

During a health class, the nurse is emphasizing exercise and healthy eating. The level of prevention being utilized by the nurse is:

Primary prevention

A patient in the Emergency Department is diagnosed with myocardial infarction (heart attack). The patient describes pain in his left arm and shoulder. What name is given to this type of pain?

Referred pain

The nurse discusses ear plugs for a patient with low tone deafness when working in a noisy environment. The nurse is utilizing:

Tertiary prevention

Which of the following would the nurse use as the primary assessment for a client's pain?

The client's report of the pain

Your patient has multiple sclerosis (MS). Neuromuscular disorders such as MS may lead to decreased vital capacity. What does vital capacity measure?

The maximum volume of air exhaled from the point of maximum inspiration.

You are teaching a physiology class for pre-nursing students. A student asks what the purpose of the upper airway is in regard to the lower airway. What would be your best answer?

To warm inspired air

The patient is positioned in a recumbent position. Which approach should the nurse take to assess the patient's lung fields for a patient in this position?

Turn the patient to assess all lung fields so the dependent areas can be assessed for breath sounds.

A patient hospitalized 3 days ago has a normal albumin level. The patient is most likely to be

Well nourished 1 month ago, but prealbumin is a more current indicator

A young toddler is brought to the emergency room by his parents. The mother states that the child was playing on the floor with toys and suddenly began to wheeze. The mother reports no recent illnesses. The nurse suspects that the most likely cause of the wheezing is

a foreign body obstruction

When a nurse assesses a 78 y/o client with pneumonia, which finding should be evaluated first?

airway patency

If your patient has a skin rash, you should ask specific questions to determine whether either of the patient's parents a history of

allergies

The nurse caring for a patient diagnosed with a 2nd rib fracture should know the location of the sternal angle also called what?

angle of Louis

When listening to heart sounds, you can hear S1 best at the

apex of the heart

You are caring for a patient with COPD. During your shift assessment you find your patient is experiencing a change in his respiratory and mental status. You are aware the most accurate measurement of the concentration of O2 in the blood is what?

arterial blood gas

Skin temperature is best assessed with the

back of the hand

A 65y/o client comes in for a follow-up after having a basal cell lesion removed from his face. When teaching the client how to inspect his skin for signs of melanoma, the nurse should tell the client to look for

black or purple irregularly shaped nodules

False low blood pressure can occur with

cuff too large, pressing stethoscope too tightly against pulse, repeating assessment too quickly

What characteristic nail color should the nurse recognize as an indication of hypoxia?

cyanotic (blue)

During your physical examination of the patient, you gently pinch the back of her hand. The skin remain in a "tent" shape and slowly returns to its normal position. This is a sign of:

dehydration

Dyspnea is a general symptom of several different disease processes. Some factors that may aggravate it are:

exertion, lying down, inhaled irritants

When auscultating the anterior chest on a large-breasted women, the nurse should:

gently move the breast tissue to the side.

Vesicles in a unilateral dermatomal pattern are typical of

herpes zoster

As you assess your patient, you note clubbed fingers. This is a sign of

hypoxia

During a nutritional assessment, a patient's serum transferrin level helps you assess the patient for

liver damage

Asymmetric borders on a lesion suggest a

malignant lesion

During percussion, you hear a flat sound. The most likely source of this sound is:

muscle

The patient with psoriasis is admitted to a medical unit for unrelated reasons. When documenting the type of lesion represented by psoriasis, the nurse should document a

plaque

The serum albumin test assesses

protein levels in the body

When patients are unconscious, the most appropriate route for taking a temperature is:

rectal

Which of the following indicators would be most likely to signify to the nurse that the patient is having pain?

rubbing a body part

The nurse documents vesicular lung sounds upon auscultation. The nurse heard what type of sound?

sound heard throughout inspiration and two thirds expiration

A 76 y/o client is diagnosed with iron deficiency anemia. Which finding should the nurse expect when assessing this client's nails

spoon shape

A patient undergoes a biopsy to confirm a diagnosis of skin cancer. Immediately following the procedure, the nurse should observe the site for

swelling

An adult patient is assesses as having an apical pulse of 140. How would a nurse document this finding?

tachycardia

The nurse tells a newly admitted patient that she is going to do a health assessment to help in planning care and educational needs during the patient's hospital stay. Before the physical examination, the nurse should first:

take a complete health history

The nurse is going to take a blood pressure on a patient who has had a previous left mastectomy with lymph node dissection. What would be an appropriate action by the nurse?

take the blood pressure in the right arm

Functions of the skin include

temperature control, provides protection, sensory perception

What is the phrase that defines the volume of air inspired and expired with a normal breath?

tidal volume

The fingernails can provide important clues to the patient's respiratory system

true

A patient appears in the clinic with a cough that began 24 hours prior to coming to this visit. The nurse evaluates the patient based on the most common cause of an acute cough, which is

viral respiratory infection

The nurse is caring for a patient with malignant melanoma. She explains that the first and most important treatment for malignant melanoma is

wide excision