Lab 21 Need To Know

The nurse is assessing a patient's headache pain. Which questions reflect one or more of the critical characteristics of symptoms that should be assess? select all that apply

"How often do the headache occur?" "Where is the headache pain?" "On a scale of 1 to 10, how bad is the pain?" "What makes the headache feel better?"

During the examination, offering some brief teaching about the patient's body or the examiner's findings is often appropriate. Which one of these statements by the nurse is most appropriate?

"your pulse is 80 beats per minute, which is within the normal range

While the nurse is taking the history of a 68 year old patient who sustained a head injury 3 days earlier, he tells the nurse that he is on a cruise ship and is 30 years old. The nurse knows that his finding is indicative of an:

Decreased level of consciousness

When the examiner asks the person to repeat a series of unrelated numbers, what is being evaluated?

memory

The nurse is preparing to perform a musculoskeletal examination on an adult patient. The patient tells you, the nurse, that he has a limitation in ROM of his left elbow. To further assess you should do which of the following?

Anchor the joint with one hand while the other slowly moves it to its limit.

With a normal Babinski response (plantar reflex) the adult individual

Flexes toes when the outer border of the sole of the foot is stroked

In a person with an upper motor neuron lesion such as a cerebrovascular accident, which of these physical assessment findings should the nurse expect?

Hyperreflexia

When you ask the patient to push his feet against your hands, you are assessing which of the following?

Muscle strength

The nurse is caring for a patient who has just had neurosurgery. To assess for increased intracranial pressure, what would the nurse include in the assessment?

Level of consciousness, motor function, pupillary response, and vital signs

The nurse is assessing a 75 year old man. As the nurse begins the mental status portion of the assessment, the nurse expects that this patient:

May take a little longer to respond, but his general knowledge and abilities should have not declined

The acronym PERRLA is used to document the assessment of the eyes. Match what the other letters to the corresponding assessment technique.

P - pupils E - Pupillary size ranges 3-7 mm, and are equal in size R - inspect the iris and pupil for shape and color R to L - constrict briskly/sluggishly when light is directed to the eye, both directly and consensual A - pupils dilate when looking at distant objects, and constrict when looking at nearer objects

During the musculoskeletal examination, the person is asked to bend forward at the waist to evaluate which condition?

Scoliosis

Looking up at the ceiling

extension

movement of a body part away from the midline

abduction

When asking the patient "A rolling stone catches no moss.", you are assessing which of the following?

abstract reasoning

The Romberg test evaluates

equilibrium

The nurse is preparing to interview a client knows it is important to do which of the following first:

establish rapport

A normal response to striking the triceps tendon with the reflex hammer is

forearm extends slightly at elbow

To test for back and leg pain, you should do which of the following:

in supine position with leg raised to point of pain, dorsiflex the foot

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 blood pressure and pain

A person who is drowsy or asleep most of the time, capable of making spontaneous movements, can be aroused with gentle shaking, and responds to their name, is described as

lethargic

When testing shoulder abduction, ask the patient to:

lift both arms out to the side

How do you test for stereognosis? With patient's eyes closed

place a familiar object in hand and ask patient to identify it

A patient visits the clinic and complains of wrist pain. To perform Phalen's test for carpal tunnel syndrome, the nurse should ask the client to

place the backs of both hands against each other

Movement when pointing the toe to the ground

plantar flexion

When performing the Romberg test, it is important to place your arms around the person without touching in order to

prevent a fall

Thrusting the jaw forward

protraction

The patient is admitted with right-sided hemiparesis. Which of the following would be the most appropriate episodic assessment?

testing the strength of hands

The nurse is providing instructions to newly hired graduates for the mini-mental state examination (MMSE). Which statement best describes this examination?

this examination is a good tool to detect delirium and dementia and to differentiate these from psychiatric mental illness.