HealthTrust ENA: Patient Assessment

An obstetric patient is prone to which airway problem? A. Nosebleeds B. Occluded lower airway C. Airway obstruction by a foreign body D. Sleep apnea

A Capillary engorgement of airway mucosa predisposes obstetric patients to nosebleeds and airway obstruction. The upper and lower airways are smaller in pediatric patients and can easily become occluded. Loose partial plates or dentures may cause airway obstruction in geriatric patients. The large neck circumference of bariatric patients can cause obstructive sleep apnea.

Which abnormal finding can be detected during the secondary assessment? A. Friction rub B. Paradoxical chest wall motion C. Open wound of the chest D. Weak, thready pulse

A A friction rub may be noted when heart sounds are assessed during the secondary assessment. Paradoxical chest wall motion and an open wound of the chest indicate ineffective breathing and should be identified during the breathing evaluation in the primary assessment. A weak thready pulse indicates ineffective circulation and should be identified during the circulation evaluation in the primary assessment.

For which patients do baseline arterial blood gas levels (ABGs) reveal compensated respiratory alkalosis and hypocapnia? A. Obstetric B. Geriatric C. Middle-aged adult D. Pediatric

A Compensated respiratory alkalosis and hypocapnia normally appear in obstetric patients. The respiratory rate normally increases in pregnancy. This increased respiratory rate causes more carbon dioxide to be exhaled. The resulting decreased carbon dioxide level causes the carbonic acid level to fall, creating alkalosis. As a compensatory mechanism, the body combines bicarbonate with hydrogen ions to replace the carbonic acid. In a fully compensated blood gas abnormality, the body successfully brings the pH back to normal. Geriatric, pediatric, and middle-aged adult patients have normal ABG levels unless a disease develops.

Which finding indicates that a patient's respiratory compromise is improving? A. No extra effort is required to breathe. B. Auscultation reveals adventitious sounds. C. The chest wall moves asymmetrically. D. The mouth is clear of debris.

A If the patient demonstrates no increased work of breathing, respiratory compromise is improving. Adventitious sounds and asymmetrical chest wall movement indicate continued respiratory compromise. A mouth clear of debris is an assessment of airway patency, not respiratory compromise.

For a patient with severe sternal retractions, which intervention is the priority? A. Position the patient to maximize ventilation. B. Insert an airway adjunct. C. Suction the oropharynx. D. Initiate cardiac monitoring.

A Positioning to maximize ventilation is the priority for this patient. If you note severe sternal retractions during breathing evaluation, perform life-saving intervention to support ventilation. Because airway adjunct insertion and oropharynx suctioning are interventions to correct airway compromise, they should have been performed before breathing assessment and intervention. Cardiac monitoring should be performed during the circulation evaluation or the secondary assessment.

Which finding is evident during the circulation component of the primary assessment? A. Warm, dry skin B. Petechial rash C. Auscultation of crackles D. Decreased sensation on the left side

A Warm, dry skin reflects the circulation component. A petechial rash is noted during the exposure component, and auscultation of rales occurs during the breathing component of the primary assessment. Decreased sensation on the left side is assessed during the head-to-toe assessment.

Doppler ultrasonography can detect fetal heart tones beginning at about how many weeks' gestation? A. 8 Weeks B. 10 Weeks C. 14 Weeks D. 20 Weeks

A. Doppler ultrasonography can detect fetal heart tones beginning at around 10-12 weeks' gestation.

What does the M in the AMPLE mnemonic represent? A. Medications B. Movement of the extremities C. Meals eaten D. Monitor readings

A. In the AMPLE mnemonic, the M stands for medications. The L represents the last meal eaten. The other answer options are not part of the AMPLE mnemonic for taking a history.

The question, "Do you have any reactions to medications?" helps gather history data for which part of the AMPLE mnemonic? A. Medications B. Allergies C. Past health history D. Events leading to the illness or injury

B Asking about reactions to medications elicits information about allergies. Other questions to assess allergies include "Are you allergic to any medications?" and "Do you have any food or environmental allergies?" Questions to assess medications include "What medications do you currently take?" and "When did you last take the medication?" Questions to evaluate past health history include "Has this problem ever occurred before?" and "Have you ever had surgery?" Questions to investigate events leading to the illness or injury include "How and when did the illness or injury first occur?" and "Has anyone in your household been ill?"

Which of these is a secondary assessment finding? A. Loose teeth are noted in mouth. B. Bruising is noted on the right occiput. C. The patient is unresponsive to verbal stimuli. D. Peripheral pulses are weak and thready.

B Bruising on the right occiput is a secondary assessment finding. This finding is identified on a head-to-toe assessment during the secondary assessment. The other answer options are assessed during the primary assessment.

Which disorder is a possible cause of a decreased level of consciousness? A. Deep vein thrombosis B. Infection C. Diverticulosis D. Peptic ulcer disease

B Infection can alter the level of consciousness. AEIOU-TIPPS is a helpful mnemonic for investigating potential causes of a decreased level of consciousness. The AEIOU-TIPPS stand for alcohol, epilepsy or electrolytes, insulin (hypoglycemia or hyperglycemia), opiates, uremia, trauma, infection, poison, psychosis, and syncope. The other answer options do not pose a threat to mental status unless the disorders progress and complications arise.

Which statement accurately characterizes pulse oximetry measurement? A. Hypotension does not affect the accuracy of the reading. B. The two light sources should be positioned directly opposite the photo detector. C. Pulse oximetry readily evaluates the pulse quality. D. Pulse oximetry accurately assesses respiratory status.

B To obtain an accurate pulse oximetry reading, proper placement of the two light sources directly opposite the photo detector is essential. Pulse oximetry may not provide accurate readings in patients with hypotension, anemia, and certain other disorders. Although some models provide an audible signal to indicate an irregular pulse, they cannot determine the pulse quality. You can evaluate pulse quality through palpation. Pulse oximetry does not accurately assess respiratory status in patients with hypotension, anemia, and certain other disorders.

Which action is a component of the primary assessment? A. Obtain an AMPLE history B. Apply a warm blanket C. Splint an extremity D. Assist a significant other to the bedside

B. Applying a warm blanket is a component of the primary assessment. The components of the primary assessment include: airway with simultaneous cervical spine protection, breathing effectiveness, circulatory effectiveness, disability, and exposure and environmental control. Blanket application is part of exposure and environmental control. The other answer options are components of the secondary assessment.

Which finding indicates airway compromise? A. Asymmetric rise and fall of the chest B. Nasal flaring C. Audible stridor D. Sucking chest wound

C Audible stridor indicates airway compromise. Detection of abnormal airway sounds, such as stridor, suggests airway compromise and requires immediate intervention. The other answer options are findings from the breathing component of the primary assessment.

A bariatric patient is prone to which circulatory finding? A. Hypovolemia B. Aortocaval compression C. Pulmonary embolism D. Slowed response to catecholamines

C Bariatric patients are at increased risk for pulmonary embolism as well as deep vein thrombosis. After 20 weeks' gestation, obstetric patients may experience aortocaval compression when in a supine position because the fetus, uterus, placenta, and amniotic fluid compress the aorta and vena cava. Pediatric patients are more prone to hypovolemia because their circulating volume is proportionally greater than that of adults (90 mL/kg in infants, 80 mL/kg in children, and 70 mL/kg in adults) and because volume losses can produce hypovolemia more quickly. Geriatric patients have a slowed response to catecholamines.

Which finding is considered subjective data? A. The patient's skin is warm to the touch. B. The results of a computed tomography scan are negative. C. A family member states that the patient has a history of seizures. D. The patient can speak full sentences clearly.

C Subjective data include all information that the patient, family members, significant others, or caregivers provide verbally. In this case, a family member states that the patient has a history of seizures, which is considered subjective data. The other answer options are objective data, which are factual findings that can be observed or measured.

Which interview question helps obtain information for the P portion of the AMPLE assessment? A. "When did you last urinate?" B. "When did you last take your medication?" C. "Have you ever been hospitalized?" D. "Have you been traveling recently?"

C The P portion of the AMPLE mnemonic assesses the past health history, such as hospitalization. "When did you last take your medication?" provides information on the M (medications) part of the mnemonic. "When did you last urinate?" gathers information on the L (last meal eaten) part of the mnemonic. "Have you been traveling recently?" obtains information on the E (events leading to the illness or injury) part of the mnemonic.

Which condition could cause a widening pulse pressure? A. Anemia B. Hypotension C. Vasodilation D. Bounding pulses

C Vasodilation widens the pulse pressure. A widening pulse pressure may indicate an increase in stroke volume and lower peripheral vascular resistance (vasodilation). A patient with hypotension has a decreased cardiac output, which would cause a narrowed pulse pressure. Anemia and bounding pulses have no direct effect on pulse pressure.

Which patients can usually maintain cardiac output by increasing the heart rate because the heart cannot increase contractility? A. Obstetric B. Geriatric C. Bariatric D. Pediatric

D Because pediatric patients have less contractile mass and less compliant ventricles, they cannot increase contractility (stroke volume or SV). They maintain cardiac output (CO) by increasing their heart rate (HR) and vasoconstriction. Other patients maintain cardiac output by increasing stroke volume and heart rate (CO = HR x SV).

Which finding requires priority intervention? A. The skin is cold and clammy. B. The patient is unresponsive to painful stimuli. C. Respirations are slow and shallow. D. Blood is noted in the oropharynx.

D Blood in the oropharynx requires emergency intervention. Primary assessment requires the nurse to ensure the patient's airway patency first. After addressing airway concerns, the nurse assesses and addresses issues related to breathing, circulation, and disability to complete the ABCDs of the primary assessment.

Which patients are more prone to cyanosis or ruddiness of the face and neck? A. Obstetric B. Geriatric C. Pediatric D. Bariatric

D In bariatric patients, this change in skin color results from changes in body habitus. It does not normally occur in pediatric, geriatric, or obstetric patients.

Which technique is appropriate for neurovascular assessment of an extremity? A. Splint the extremity to promote accurate initial assessment. B. Evaluate pulse quality proximal to the injury site. C. Assess for sensation at the joint above the injury site. D. Assess capillary refill distal to the injury site.

D Neurovascular assessment requires evaluation of capillary refill, pulse quality, skin temperature, sensation, and movement. This assessment occurs distal to the injury site. You should perform the initial assessment before splinting the extremity and should reassess neurovascular status after splinting has been completed.

Which of the following assessments would result in you scoring the patient as a "P" using the AVPU mnemonic? A. The pupils are equal and reactive to light. B. Pain occurs when the patient lifts his left arm. C. Painful stimuli elicit no patient response. D. The patient exhibits abnormal flexion in response to a sternal rub.

D The P component in the AVPU mnemonic stands for pain, which means the patient does not respond to voice, but does respond to a painful stimulus, such as a sternal rub. Pain occurs when the patient lifts his left arm reflects the A component (for alert), in which the patient is awake, alert, and responsive. Painful stimulus elicits no patient response reflects the U component (for unresponsive), in which the patient does not respond to voice or a painful stimulus. The pupils are equal and reactive to light reflects pupillary assessment. This is not part of the AVPU mnemonic, which determines the gross level of consciousness.

In an adult, which finding is an emergent threat? A. The patient rates pain as a 10 on a 0-10 scale. B. The blood pressure is 100/60 mm Hg. C. The heart rate is 52 beats per minute and regular. D. The patient cannot speak in complete sentences.

D. A patient who cannot speak in complete sentences has an emergent threat. Such a patient has compromised breathing effectiveness, which is identified during the primary assessment and is a life-threatening problem.

A patient with which finding requires a focused neurologic assessment? A. Rapid heart rate B. Subcutaneous emphysema C. Jugular vein distention D. Dizziness

D. Any patient who presents with a neurologic complaint or deficit (such as dizziness, headache, seizure, altered mental status, loss of consciousness, or syncope) requires a focused neurologic assessment.

Which statement is the best example of a chief complaint? A. Patient exhibits symptoms of possible food poisoning. B. Rule out appendicitis. C. Skin is hot to the touch. D. Patient reports sudden onset of severe right lower abdominal pain.

D. The chief complaint is the reason for the patient's visit and should be recorded exactly as the patient describes the reason for the emergency department visit.