NU660 Prep Week Practice Questions

The nurse is performing a neurological assessment of a patient in the emergency department. The patient does not open the eyes, utters incomprehensible sounds, and the best motor response is flexion withdrawal. Calculate the patient's score on the Glasgow Coma Scale

According to the Glasgow Coma Scale, not opening the eyes is given a score of 1. If the best verbal response is uttering incomprehensible sounds, the score given is 2. If the best motor response is flexion withdrawal, the score given is 4. The patient's total score on the Glasgow Coma Scale is 1 + 2 + 4 = 7

The nurse is assessing the neurological status of a patient admitted to the emergency department. The patient opens the eyes when the nurse calls the patient's name, follows commands, and is oriented to person only. Calculate the patient's score on the Glasgow Coma Scale.

According to the Glasgow Coma Scale, opening the eyes in response to speech is given a score of 3. If the patient's best motor response is obeying commands, the patient is given a score of 6. Being oriented to person only is given a score of 5. The patient's total score on the Glasgow Coma Scale is 3 + 6 + 5 = 14.

Which action would the nurse perform immediately after finding abnormal vital sign values in a patient who underwent abdominal surgery? a) Asking another nurse to repeat the measurement b) Informing the health care provider c) Documenting the finding in the patient record d) Reporting vital sign changes to nurses during hand-off communication

a) Asking another nurse to repeat the measurement; If the nurse finds abnormal vital signs in a patient, they should immediately ask another nurse or the health care provider to repeat the measurements to confirm the findings. After confirming the findings, the nurse should inform the health care provider, document the finding in the patient record, and report vital sign changes to nurses during hand-off communication.

Which statement if made by the nursing student indicates a need for further teaching regarding examination of the carotid arteries? a. "I should palpate the carotid artery vigorously." b. "I should examine one carotid artery at a time." c. "I should inspect the neck for pulsation of the carotid artery." d. "I should make the patient lie supine with the head elevated."

a. "I should palpate the carotid artery vigorously."; The nurse should not palpate the carotid artery vigorously because the carotid sinus is located at the bifurcation of the common carotid arteries in the upper third of the neck.

The registered nurse is teaching a nursing student about the assessment of vital signs in older adults. Which statement by the nursing student indicates the need for further teaching? a. "Use a large cuff to measure blood pressure." b. "Instruct the patient to slowly change his/her/their position." c. "Assess the skin while frequently monitoring the blood pressure." d. "Rotate the sites for measurement of blood pressure for frequent monitoring of blood pressure."

a. "Use a large cuff to measure blood pressure."; Older adults usually lose upper arm mass and require a smaller blood pressure cuff.

Which statement made by the nurse indicates a correct understanding of physical examination positioning? a. "While assessing a patient's heart, I'll ask the patient to assume the lateral recumbent position." b. "While assessing a patient's rectum and vagina, I'll ask the patient to assume the prone position." c. "While assessing a patient's abdomen, I'll ask the patient to assume the lithotomy position." d. "While assessing a patient's musculoskeletal system, I'll ask the patient to assume the Sims' position."

a. "While assessing a patient's heart, I'll ask the patient to assume the lateral recumbent position." While assessing a patient's heart, the nurse would ask the patient to assume the lateral recumbent position because this position facilitates easy detection of murmurs.

After assessing the strength of the pulse, the nurse documents "diminished pulse" in the patient's chart. Which scale rating signifies this condition? a. 1 b. 2 c. 3 d. 4

a. 1; When assessing the strength of a patient's pulse, a rating of 1 indicates a diminished or barely palpable pulse.

During a vascular system assessment, the nurse finds a blowing sound in the carotid artery of the patient. Which finding would the nurse include in the medical report? a. Bruit b. Thrill c. Syncope d. Murmurs

a. Bruit; When the blood passes through the narrowed section, it creates turbulence that causes a blowing or swishing sound called a bruit

While assessing the strength of a pulse in a patient, the nurse rates it as 3. Which statement is true regarding the rating? a. Full, increased b. Absent, not palpable c. Bounding, aneurysmal d. Pulse diminished, barely palpable

a. Full, increased; The strength of a pulse is a measurement of the force at which blood is ejected against the arterial wall.

Which assessment is performed first while the nurse initiates the general survey? a. Inspecting appearance and behavior b. Taking measurement of vital signs c. Observing specific body systems d. Conducting a detailed health history

a. Inspecting appearance and behavior; The nurse inspects appearance and behavior first as part of the general survey. As the patient enters the room, the nurse can observe the patient's appearance and behavior, noting any unusual choices of clothing or hygiene or any signs of confusion, anxiety, or unhappiness.

Which action would the nurse take during inspection to get the best results? Select all that apply. One, some, or all responses may be correct. a. Make sure that adequate lighting is available. b. Use a penlight or lamp to inspect body cavities. c. Inspect each area for size, shape, color, symmetry, position, and abnormality. d. Expose the patient completely for an easy inspection. e. Check for side-to-side symmetry.

a. Make sure that adequate lighting is available. b. Use a penlight or lamp to inspect body cavities. c. Inspect each area for size, shape, color, symmetry, position, and abnormality. e. Check for side-to-side symmetry.

The nurse decides not to measure the temperature of an older adult using the oral site. Which patient factor is the likely reason for this decision? Select all that apply. One, some, or all responses may be correct. a. No teeth b. Rigid rib cage c. Poor muscle control d. Ribs are downward-slanted e. Sweat gland reactivity is decreased

a. No teeth c. Poor muscle control; The oral temperature for older adults may be inaccurate because of an inability to close the mouth completely, which may occur because of the absence of teeth and poor muscle control

Which physical examination technique(s) is/are required when assessing a patient? Select all that apply. One, some, or all responses may be correct. a. Palpation b. Evaluation c. Percussion d. Reflection e. Auscultation

a. Palpation c. Percussion e. Auscultation; Palpation, percussion, and auscultation are all techniques the nurse uses during a physical examination. Palpation refers to assessing by touch. Percussion involves assessment by tapping the skin with the fingertips to vibrate underlying tissues and organs. Auscultation involves listening to body sounds to detect variations from normal functioning

Which sound is considered an adventitious breath sound? Select all that apply. One, some, or all responses may be correct. a. Rhonchi b. Crackles c. Vesicular d. Wheezes e. Bronchial

a. Rhonchi b. Crackles d. Wheezes

Which parameter would the nurse use to assess whether the patient is oriented? Select all that apply. One, some, or all responses may be correct. a. Time b. Place c. Person d. Medical disorder e. Laboratory investigation

a. Time b. Place c. Person

When examining a patient from behind, which anatomic imaginary line extends down from the center of the neck and back? a. Vertebral b. Midaxillary c. Midsternal d. Scapular

a. Vertebral; When examining a patient from behind, the vertebral line is the chest wall imaginary line that extends down from the center of the neck

Which principle would the nurse remember when assessing skin turgor? Select all that apply. One, some, or all responses may be correct. a. When tenting occurs, skin turgor is poor. b. Body fluid levels regulate skin turgor. c. Dehydration diminishes skin turgor. d. Edema increases skin turgor. e. The most reliable site for assessment of skin turgor is the back of the hand.

a. When tenting occurs, skin turgor is poor. b. Body fluid levels regulate skin turgor. c. Dehydration diminishes skin turgor.: When tenting occurs, skin turgor is poor; body fluid levels regulate skin turgor; and dehydration diminishes skin turgor are principles the nurse would remember when assessing skin turgor.

The registered nurse is teaching a nursing student about the guidelines for measuring vital signs. Which statement by the nursing student indicates the need for further teaching? Select all that apply. One, some, or all responses may be correct. a. "Know the patient's medical history." b. "Analyze the results of vital signs compared with other patients." c. "Measure the body temperature in a humid environment." d. "Know the acceptable range for the patient before giving medications." e. "Use vital sign measurements to determine indications for giving medications."

b. "Analyze the results of vital signs compared with other patients." c. "Measure the body temperature in a humid environment." The nurse should analyze the results of vital sign measurements on the basis of the patient's condition and past medical history and not compared to other patients. The nurse should not measure vital signs in a humid environment because the humidity may affect the vital signs.

After measuring the degree of pitting edema in a patient, the nurse documents 2+ indicating which depth of pitting in millimeters? a. 2 b. 4 c. 6 d. 8

b. 4; The depth of pitting is 4mm. The depth of pitting is recorded in millimeters to determine the degree of edema. To assess the degree of pitting edema, the edematous area is firmly pressed with the thumb for several seconds and released

Where would the nurse palpate for the apical impulse? a. At the second intercostal space on the right side b. At the fourth intercostal space just medial to the left midclavicular line c. At the fourth or fifth intercostal space along the sternum d. At the left sternal border to the third intercostal space

b. At the fourth intercostal space just medial to the left midclavicular line; The apex of the heart touches the fourth to fifth intercostal space just medial to the left midclavicular line; the apical impulse is palpated best in this anatomical region

Which information would the nurse include in a teaching session to new orienting nurses about keeping a physical examination well organized? a. If the patient becomes fatigued, stop the assessment. b. Carry out painful procedures at the end of the examination. c. Complete all documentation at the end of the examination. d. Document assessments in specific terms solely in the electronic record.

b. Carry out painful procedures at the end of the examination.; To keep a physical examination well organized, the nurse would carry out painful procedures at the end of the examination.

In addition to cyanotic lips and nail beds, nasal flaring, and pursed lips, which sign would directly indicate that a patient is suffering from cardiac or pulmonary insufficiency? a. Graying of the hair b. Clubbing of the fingers c. Swollen toes and ankles d. Callus formation on heels

b. Clubbing of the fingers

When would the nurse evaluate pain in a patient who is on oral analgesics? a. Every 30 minutes b. Every 60 minutes c. Every 2 hours d. Once per nursing shift

b. Every 60 minutes; Oral analgesics peak in about 60 minutes. Therefore, the nurse should evaluate the pain levels in the patient every hour. Reassessing pain also depends on the severity and type of pain. Intravenous infusion should be evaluated between 15 and 45 minutes because pain peaks during this time period.

Which range is acceptable for the diastolic blood pressure in a healthy adult? a. Less than 120 mm Hg b. Less than 80 mm Hg c. 30 to 50 mm Hg d. 35 to 45 mm Hg

b. Less than 80 mm Hg; The acceptable range for diastolic blood pressure in a healthy adult is less than 80 mm Hg.

Which statement is true regarding nonpharmacological pain interventions? a. Nonpharmacological interventions should only be used alone. b. Nonpharmacological interventions are useful for patients who cannot tolerate pain medications. c. Nonpharmacological interventions have a clear set of guidelines regarding intensity and duration. d. Nonpharmacological interventions should be used in place of pharmacological therapies for acute pain.

b. Nonpharmacological interventions are useful for patients who cannot tolerate pain medications. ; Nonpharmacological pain relief can be useful for patients who cannot tolerate pain medications.

Which nursing intervention is appropriate when performing an abdominal examination and the patient's abdominal muscles have tightened? Select all that apply. One, some, or all responses may be correct. a. Asking the patient to drink a lot of water b. Placing a small pillow beneath the patient's knees c. Asking the patient to move the arms from under the head d. Warming the hands and stethoscope used in the examination e. Placing the patient in the dorsal recumbent position with knees slightly bent

b. Placing a small pillow beneath the patient's knees c. Asking the patient to move the arms from under the head d. Warming the hands and stethoscope used in the examination e. Placing the patient in the dorsal recumbent position with knees slightly bent

Which body part is the best site for the nurse to inspect for jaundice? a. Lips b. Sclera c. Mouth d. Tongue

b. Sclera

The patient rates his pain as a 6 on a scale of 0 to 10. The patient's wife says that he cannot be in that much pain because he has been sleeping for 30 minutes. Which resource is most accurate for assessing the pain? a. The patient's wife is the best resource for determining the level of pain because she has been with him continually for the entire day. b. The patient's report of pain is the best method for assessing the pain. c. The patient's health care provider has the best knowledge of the level of pain that the patient should be experiencing. d. The nurse is the most experienced at assessing pain.

b. The patient's report of pain is the best method for assessing the pain; A patient's self-report of pain is the single most reliable indicator of the existence and intensity of pain. Pain is a subjective experience of the patient only, so the patient's wife, health care provider, and the nurse cannot give as accurate of an assessment of the patient's experience of pain.

The nurse is evaluating the statements made by the nursing student about pain. Which statement by the nursing student is true? a. "Psychogenic pain is not real." b. "Drug abusers overreact to pain." c. "Intensity of the pain does not accurately indicate the tissue damage." d. "Patients with minor illness have less pain than patients with major trauma."

c. "Intensity of the pain does not accurately indicate the tissue damage."; There are many misconceptions about pain, such as that psychogenic pain is not real, drug abusers overreact to pain, and patients with minor illnesses have less pain than patients with major trauma.

Which rectal temperature is average for a 35-year-old adult? a. 36.5° C (97.7° F) b. 37° C (98.6° F) c. 37.5° C (99.5° F) d. 38° C (100.4° F)

c. 37.5° C (99.5° F)

Which patient does the nurse suspect to have an increased anteroposterior diameter of the chest? a. A 25-year-old patient who has throat cancer b. A 34-year-old patient who has a throat infection c. A 50-year-old patient who has chronic lung disease d. A 30-year-old patient who has acute allergic asthma

c. A 50-year-old patient who has chronic lung disease; An increase in the anteroposterior diameter of the chest indicates a barrel-shaped chest. A barrel-shaped chest is usually found in older adults and patients who have chronic lung disease.

The nurse is assessing a patient who complains of pain in the abdomen. Which method is most appropriate to assess the intensity of pain? a. Asking the patient to describe the pain b. Asking the patient about the location of the pain c. Asking the patient to describe the pain using a pain scale d. Asking the patient about the precipitating factors of the pain

c. Asking the patient to describe the pain using a pain scale; Pain intensity is identified by asking the patient to choose a facial expression illustrated in the Oucher or Wong-Baker FACES pain scales or by asking the patient to quantify pain using a numeric scale. Description of pain may include characteristics, but not intensity, of pain. Asking about the location of the pain would help identify the organs involved. Asking the patient about what precipitates his or her pain would help plan the therapy.

A patient has been transferred to the unit from the respiratory intensive care unit, where they have been for the past 2 weeks recovering from pneumonia. They are receiving oxygen through a 4 L nasal cannula. Their respiratory rate is 26 breaths/min, and oxygen saturation is 92%. In planning his care, which information is most helpful in determining the priority nursing interventions? a. Activity order b. Medication list c. Baseline vital signs d. Patient's perception of dyspnea

c. Baseline vital signs

Which examination technique is the nurse using when pressing the hand inward about 4 cm (2 inches) into the patient's abdomen? a. Percussion b. Auscultation c. Deep palpation d. Light palpation

c. Deep palpation; Hand inward about 4cm (2 in) into the patient's abdomen to examine the condition of organs.

Which sign or symptom is associated with pyrexia? a. Cyanosis b. Chest pain c. Diaphoresis d. Dyspnea

c. Diaphoresis; Elevated body temperature (pyrexia) results in diaphoresis (sweating). Cyanosis is associated with hypoxemia. Chest pain has many potential causes but not generally associated with fever. Abnormal respirations result in dyspnea.

Which condition alters pupillary reactions? Select all that apply. One, some, or all responses may be correct. a. Presence of arcus senilis b. Direct trauma to the eye c. Inflammation of the orbit d. Changes in intracranial pressure e. Lesions along the nerve pathways

c. Direct trauma to the eye d. Changes in intracranial pressure e. Lesions along the nerve pathways; Direct trauma to the eye, changes in intracranial pressure, and lesions along the nerve pathways alter pupillary reactions

Which action is most appropriate when a nurse learns that the patient who needs a physical examination is elderly and very weak? a. Postpone the examination. b. Perform the examination calmly. c. Pace the examination, pausing at intervals. d. Allow a family member in the examination room.

c. Pace the examination, pausing at intervals.; The nurse's best action would be to pace the examination, pausing at intervals to ask how the patient is feeling

Which physical assessment technique is the nurse using when tapping a patient's skin with the fingertips to vibrate underlying tissues and organs? a. Palpation b. Inspection c. Percussion d. Auscultation

c. Percussion; Percussion is the tapping of a patient's skin with fingertips to vibrate underlying tissues and organs.

Which pupil finding would the nurse observe in a patient intoxicated with opioids? a. Cloudy b. Dilated c. Pinpoint d. Constricted

c. Pinpoint; Pinpoint pupils are common signs of opioid intoxication

Which position would the nurse instruct the patient with a cough to assume for a proper physical examination? a. Sims' b. Prone c. Sitting d. Supine

c. Sitting; The nurse would ask the patient to assume a sitting position. The upright position provides better visualization of the symmetry of the upper body, thorax, and lungs.

After assessment, the nurse immediately reports an unstable vital sign to the health care provider. Which finding alerts the nurse to a deviation from the normal range? a) Pulse pressure of 50 mm Hg b) Rectal temperature of 37.5° C (99.5° F) c) Pulse rate of 62 beats per minute d) Respiratory rate of 11 breaths per min

d) Respiratory rate of 11 breaths per min. The normal acceptable range of respiratory rate is between 12 and 20 breaths per min; hence the patient has a reduced respiratory rate (bradypnea)

Which physical examination technique is the nurse performing when listening to heart sounds? a. Palpation b. Inspection c. Percussion d. Auscultation

d. Auscultation; The nurse is performing auscultation. Auscultation involves listening to the sounds of the body to detect abnormalities

The nursing student is performing an assessment of the anterior thorax of a patient placed in a supine position. Which condition is most likely to result, requiring correcting the position of the patient? a. Pain in joints b. Embarrassment c. Elevated blood pressure d. Difficulty breathing

d. Difficulty breathing; A supine position may cause a patient to experience shortness of breath or difficulty in breathing easily if the patient has a respiratory disorder like asthma

While palpating the patient's pulse, the nurse places the fingertips between the first and second toes and slowly moves up the dorsum of the foot. Which pulse is the nurse palpating? a. Ulnar pulse b. Radial pulse c. Popliteal pulse d. Dorsalis pedis pulse

d. Dorsalis pedis pulse; The dorsalis pedis pulse is located in the top of the foot. While palpating this pulse, the nurse places the fingertips between the first and second toes and slowly moves up the dorsum of the foot.

The nurse is assessing the pain for an adult patient who has cognitive impairment. Which nursing action is most appropriate? a. Asking the patient to rate the pain on a scale of 1 to 10 b. Using the pain face scale to determine the pain intensity c. Assessing the vital signs twice per shift to detect a pain response d. Observing the facial expressions and body movements for any pain behavior

d. Observing the facial expressions and body movements for any pain behavior; For patients who have cognitive impairment, the nurse should look for any facial expressions or body movements that indicate pain. The patient who has cognitive impairment may not be able to rate pain on a scale of 1 to 10 and also may be unable to determine the facial expressions on a pain face scale.

Which patient with a respiratory disorder requires immediate nursing intervention? Patient A: Asthma: RR 12 Patient B: Bronchitis: RR 15 Patient C: Emphysema: RR 20 Patient D: COPD: RR 10 a. Patient A b. Patient B c. Patient C d. Patient D

d. Patient D; Patient D with chronic obstructive pulmonary disease and a respiratory rate of 10 breaths/min requires immediate nursing intervention because the condition is critical.