Adaptive Quiz Chapter 12

When assessing the Glasgow Coma Scale (GCS) score in a patient, the nurse finds that the patient opens eyes in response to verbal stimuli. The nurse also finds that the patient is confused while interacting and responds to painful stimuli. What is the Glasgow Coma Scale (GCS) score for this patient? Record your answer as a whole number.

12

The nurse is assessing a patient using the Glasgow Coma Scale (GCS). The nurse documents and rates the patient's eye response as 3 and verbal as 3. Which motor response rating on the GCS scale would have made the nurse suspect brain injury in a patient?

2

The nurse is preparing to assess the hip extension movement in a patient in the prone position. What question should be most important question to be asked before the assessment?

"Do you have difficulty breathing?"

During an admission assessment and data collection interview, the nurse obtains both subjective and objective data. Which statement represents objective data documented by the nurse?

"Eyes downcast, flat effect."

The nurse is teaching a group of nursing students about the role of a licensed practical nurse (LPN) in caring for a patient with tuberculosis. Which statement by the nurse indicates effective teaching?

"The LPN should collect a sputum sample from the patient."

Which statement if made by the nurse could hinder the communication that takes place during the interview?

"Why did you let your problem get this bad?"

A patient arrives at the emergency center with severe pain in the lower abdomen. The patient reports pain of 9 on a scale of 1 to 10. The patient is crying and has assumed the fetal position. What type of assessment should be done?

Focused assessment

A patient's lower legs are noticeably edematous. When the nurse presses on the leg near the ankle with a finger, the imprint remains for 30 seconds before the leg returns to the original state. How would the nurse characterize the edema?

3+

While assessing a patient's lower extremities, the nurse notes edema around the feet and ankles. When the area is depressed, the depression lasts for more than 1 minute before the shape returns. How would the nurse document this edema?

3+ pitting edema

A nurse performs a neurologic assessment of a patient. The nurse finds that the patient's eyes open only with painful stimuli, the patient's speech is incomprehensible, and decorticate posture is noted. What score would this patient receive on the Glasgow Coma Scale? Record your answer using a whole number.

7

A student nurse is assessing a patient with a distended abdomen. The preceptor should intervene if the student nurse takes which action?

Gently pushes on the patient's abdomen and then documents it on the chart

The licensed practical nurse (LPN) assists a registered nurse (RN) during an admission assessment and data collection interview. The LPN considers the assessment of a patient complete at the end of the interview. Why does the LPN's thought about assessment indicate a need for further teaching?

Assessment is an ongoing process.

The process of listening to sounds produced by the body is which physical assessment technique?

Auscultation

The nurse has been assigned to auscultate the lungs of a patient. What instruction does the nurse provide to the patient?

Breath in and out through the mouth.

The nurse pinches and releases the skin on the sternum of a patient during a physical examination. The skin goes back to a flat position after 5 seconds. What is the likely inference a nurse may draw from this finding?

Dehydration

A licensed practical nurse (LPN) wants to know the weight of a patient who has been in the in-patient unit for the past three days. How does the LPN collect this data?

Check the patient database.

A nursing instructor is supervising a student nurse who is performing an assessment of a patient. During the assessment, the patient complains of pain, nausea, and vomiting. The instructor asks the student, "What is the term for the complaints made by patient?" The student correctly responds with what?

Clinical symptom

A patient with a history of gastrointestinal problems comes to the clinic for an appointment. The patient complains of abdominal discomfort, nausea, vomiting, and a feeling of fullness. The nurse auscultates each quadrant for 30 seconds and hears no bowel sounds. What should be the nurse's next step?

Continue to listen for bowel sounds.

The nurse is reviewing a patient's database record. Identify the data that reflects an interaction between the patient and the environment.

Cultural factors Lifestyle factors

A 70-year-old patient has been admitted to a unit. The nurse needs to conduct a detailed interview and complete a head-to-toe assessment. What is the best method for the nurse to use with this patient?

Divide the assessment into several short sessions

A patient reports pain in his knee during a routine office visit. How does the nurse examine this patient?

Examine the joint's range of motion

A student nurse is performing a physical assessment of a patient. What action should the student nurse take to decrease anxiety in the patient?

Explaining what will occur before touching the patient

A nurse is taking care of a patient with a leg wound. The nurse notices redness, swelling, and purulent drainage while completing the assessment and recognizes that these are cardinal signs of what process?

Infection

During an assessment of the lungs, the nurse is unsure of the sounds that are auscultated. What is the first action the nurse should take to determine if the sounds are adventitious?

Instruct the patient to cough

In performing a physical assessment, which findings would indicate a deviation from normal?

Jaundice Apical heart rate of 110 Erythema of lower extremities Cyanosis of the fingers and toes

The nurse is performing physical examination of a patient with cardiac disorder. Which position would be best to assess the presence of cardiac murmurs?

Lateral recumbent position

The nurse is gathering supplies in preparation to perform a physical examination. Identify the uses of a stethoscope during a physical examination.

Listening to lung sounds Assessing heart sounds Listening to bowel sounds

While assessing a newly admitted patient, the registered nurse (RN) delegates the task of collecting patient data to a practical nurse (PN). Which task belongs to the data collection step of the assessment phase?

Measuring the height of the patient.

Which term is described as an abnormal growth of new tissue, either malignant or benign?

Neoplastic disease

If a light is shined in the eyes of the patient during the physical assessment and the pupils are noted to be equal, round, and reactive to light and accommodation, which system is being tested?

Neurologic system

While assessing the six cardinal fields, the nurse notes the presence of jerky eye movements. What does the nurse document this finding as?

Nystagmus

The licensed practical nurse (LPN) is assisting a registered nurse (RN) during a patient's physical examination. What are the tasks performed by the LPN during this examination?

Obtain vital signs. Record history of drug and drug allergies. Take a brief medical history.

The nurse is palpating the patient's lymph nodes. Which part of hand should the nurse use to perform this assessment?

Pads of fingers

What information documented in the nurse's notes would be of concern?

Patient's leg is red, swollen, and warm to touch.

A student nurse is instructed to measure the pulse rate of a patient. The student nurse is doing this for the first time. What step should the student nurse follow?

Place two or three fingers lightly over the radial artery.

After auscultating the heart sounds of a 50-year-old patient, the nurse infers that the patient may have cardiomyopathy. Based on which finding did the nurse make this conclusion?

Presence of S 4 heartbeat

A patient who was involved in a motor vehicle accident and sustained a brain injury is found to have dilated pupils upon examination in the emergency department (ED). What could be the reason for dilated pupils in this patient?

Raised intracranial pressure

In documenting assessment findings, which are examples of objective data?

Redness and swelling of feet

While a nurse is performing a physical assessment, the patient complains of dyspnea. This symptom indicates a problem with which body system?

Respiratory

A patient comes to the clinic complaining of swelling of the feet. The nurse assesses the extremities and notes pitting edema of the feet. The nurse also notes that the jugular vein is distended, and a vibration is felt on palpation. What disease process should the nurse suspect?

Right-sided heart failure

A child reports severe itching. The nurse finds that the rashes are raised from the surface of the neck. The nurse also finds that the patient has fever, and the blood pressure is 130/85 mm Hg. Which is the subjective data in this assessment?

Severe itching

The nurse is concluding a head-to-toe assessment of a young patient. The rectum is the final area to be assessed. What is the best position in which to place this patient with no mobility limitations for inspection of the rectal area?

Sims position

Mr. S. is complaining of pain in his chest, difficulty breathing, and a cough. What are these reports by the patient considered?

Subjective data

A nurse performing an examination pinches the tips of the patient's fingers for 5 seconds, monitors the blood return, and estimates the speed at which the blood returns. The blanching of the fingers is less than 3 seconds. What can the nurse conclude from this test?

The arterial blood flow is normal

Which statement is true regarding the initial physical assessment and the ongoing physical assessment of a patient?

The initial assessment identifies problems, and the ongoing assessment determines the effectiveness of the care.

A patient comes into the clinic for an appointment. What data if collected by the nurse can indicate the patient is experiencing problems with the cardiovascular system?

The jugular vein in the neck is swollen.

One of the first steps in gathering data about a patient is to establish the nurse-patient relationship. What are appropriate ways to establish this relationship?

The nurse communicates trust and confidentiality to patients. The nurse shows professionalism and competence to patients. The nurse introduces herself or himself to patients and answers questions the patients may have.

The LPN/LVN is working on a medical floor and assisting the registered nurse (RN) with patient assessments. A new patient is admitted to the floor, and the RN takes a health history and performs an assessment. What is this considered the first step of?

The nursing process

During an assessment of a new clinic patient, a pulse oximetry sensor is applied to the patient's finger. Which results would be of greatest concern to the nurse?

The oximeter registers an Sao 2 of 89%.

The nurse is caring for a patient who is a chronic alcoholic. The nurse finds that the patient's vomitus is "coffee-ground." What would the nurse infer from this?

The patient has a bleeding stomach.

While interviewing a patient with hypertension, the nurse holds the patient's hand and applies mild pressure. Following this the nurse observes a notch on the patient's hand after letting go of the hand. What does the nurse infer from this?

The patient has edema.

While auscultating the carotid artery of the patient, the nurse hears swishing sounds. What would the nurse infer from this observation?

The patient has hyperlipidemia.

The nurse finds that the jugular vein of a patient is distended. What does the nurse conclude from this observation?

The patient has improper heart function.

Following an assessment and interview, the nurse suggests that the patient place two pillows below the head while sleeping to help elevate the head. What would be the probable reason for giving such advice?

The patient has orthopnea.

A nurse is called into the room of a newly admitted patient who has vomited. When emptying the basin the nurse notes that the emesis resembles coffee grounds. What should the nurse suspect?

The patient may be bleeding in the stomach.

A patient who was in a motorcycle accident is brought into the emergency room. The police report states that the patient was not wearing a helmet. A Glasgow Coma Scale assessment is performed. The patient's total score is 6. What does this score indicate?

The patient may be in a coma.

The nurse finds that a patient has reduced muscle tone and absence of pupillary reflex. The primary health care provider instructs the nurse to place the patient on ventilation. What can the nurse infer about the health status of the patient?

The patient may be in stage IV coma.

On reviewing the laboratory reports of a patient with diarrhea, the nurse finds that the patient has dark black stool. What does the nurse infer from this finding?

The patient may have bleeding in the ileum.

The nurse observes that a patient has difficulty in breathing while sleeping. The patient tells the nurse, "I don't have this difficulty when I sit or stand for a long time." What does the nurse interpret from the assessment?

The patient may have orthopnea.

What data are essential to collect before the primary health care provider begins the medical assessment?

The patient's vital signs

A nurse is performing an assessment of an oncology patient. Which systems are essential for the nurse to auscultate while performing the physical assessment?

The respiratory system The cardiovascular system The gastrointestinal system

A patient arrives at the clinic for a scheduled appointment. The patient is complaining of pain in the right leg. When assessed, the pulse is absent and the leg is hairless, blue in color, and cool to touch. What should the nurse suspect based on these findings?

There may be a problem with circulation in the right leg.

The nurse is interviewing a patient who has just been admitted to the nursing unit. What is the main purpose of this interview?

To find out the patient's major complaints

A nurse is performing a physical assessment of an elderly patient. Which question(s) might the nurse ask to assess the patient's level of orientation?

What is today's date?" "Can you state your name?" "Where you are right now?"

An adult female patient has a scheduled appointment for an assessment. During the interview it is found that the patient does not perform a monthly breast self-examination. What is the best intervention in response to this finding?

While assessing the lungs, perform and teach the patient about monthly breast self-examination.