267 Study Guide Final
Which are appropriate health promotion questions to ask during a review of symptoms? 1) "Do you use sunscreen while outside?" 2) "I need to see if your skin is warm and dry." 3) "Have you had any dizziness or headaches?" 4) "When you cough, what color is the sputum you bring up?"
"Do you use sunscreen while outside?"
The most important observation you should make when palpating for chest expansion is? 1) palpable vibration 2) chest symmetry 3) crepitus 4) tenderness, masses, and skin moisture
chest symmetry
If the CNA fails to chart in the box on the flow sheet next to the word "Breakfast" then it may be presumed that: 1) The resident was not given breakfast. 2) The resident only ate 50% of his breakfast. 3) The resident received breakfast but ate nothing. 4) The resident refused breakfast.
The resident was not given breakfast.
The nurse is assessing a patient's pain. The nurse knows that the most reliable indicator of pain is (are) which of the following? 1) Vital signs 2) The physical examination 3) MRI findings 4) The subjective report
The subjective report
A patient has finished giving the nurse information about the reason he is seeking care. When reviewing the data, the nurse finds that some information about past hospitalizations is missing. Which statement by the nurse would be most appropriate to gather these data? 1) "Mr. Y., at your age, surely have been hospitalized before!" 2) "Mr. Y., I just need permission to get your medical records from County Medical." 3) "Mr. Y., you mentioned that you have been hospitalized on several occasions. Please tell me more about that." 4) "Mr. Y., I just need to get some additional information about the past hospitalizations. When was the last time you were admitted for chest pain?"
"Mr. Y., you mentioned that you have been hospitalized on several occasions. Please tell me more about that."
A 63 year-old male comes to the clinical with an exacerbation of asthma. Which of the following findings indicate worsening status of his asthma? 1) Increased wheezing 2) Bloody sputum 3) Increased tympany 4) Flushed red skin
1) Increased wheezing
When inspecting the oral cavity and oropharynx, the client is asked to say "ah" in order for the examiner to observe: 1) the rise of the soft palate and uvula. 2) the size of the tonsils. 3) the sublingual ridge. 4) Wharton's ducts.
1) the rise of the soft palate and uvula.
During the physical exam, a patient tells the nurse that "it feels like the room is spinning around me." The nurse would document this as: 1) vertigo. 2) syncope. 3) dizziness. 4) seizure activity
1) vertigo.
Normal capillary beds should refill after being depressed in: 1) < 1 second. 2) > 3 seconds. 3) 1-2 seconds. 4) Time is not significant as long as color returns.
1-2 seconds.
You are completing a cardiac health history on a patient. Which patient would need more education to decrease their risk for a myocardial infarction (heart attack)? 1) A 63 year-old female who smokes, is a diabetic, and has a BP of 155/95. 2) A 45 year-old male who is the CEO of a Fortune 500 company. 3) An 83 year-old female who has significant multi-system disease. 4) A 54 year-old female who is overweight with a blood pressure of 135/88.
1) A 63 year-old female who smokes, is a diabetic, and has a BP of 155/95.
Which of the following are you most likely to observe in a client with scoliosis? 1) A difference in the level of the scapulae and/or iliac crests. 2) An abnormal curve in vertebral column when viewed from the side. 3) Decreased ability to flex forward and laterally. 4) Greater muscle development of right trapezius.
1) A difference in the level of the scapulae and/or iliac crests.
Which of the following assess the sensory component of the nervous system? 1) Assessing for temperature, pain, and light touch. 2) Assessing pain sensation, position sensation, and muscle tone. 3) Examining cranial nerves X (vagus), XI (spinal accessory), and XII (hypoglossal). 4) Watching the client tandem walk.
1) Assessing for temperature, pain, and light touch.
Recommended protective measures to avoid skin cancer include which of the following? 1) Avoiding sun exposure 2) Knowing signs of skin cancer 3) Performing monthly skin self-examinations 4) Seeking biannual examination by a clinician after age 40 years
1) Avoiding sun exposure
When auscultating the heart, the following technique is helpful: 1) Close your eyes briefly to tune out distractions. 2) Listen to only one location. 3) Listen to the patient's heart sounds with only the bell of your stethoscope. 4) Listen to the patient's heart sounds in only one position.
1) Close your eyes briefly to tune out distractions.
Asking the patient to "smile and squeeze your eyes shut" tests which cranial nerve? 1) Cranial Nerve VII 2) Spinal Accessory Nerve 3) Glossopharyngeal Nerve 4) Cranial Nerve IX
1) Cranial Nerve VII
A 17 year-old boy is in the emergency department with stridor, intercostal and supraclavicular retractions, and a respiratory rate of 40. What type of situation is this? 1) Emergency 2) Stable 3) Acute 4) Urgent
1) Emergency
Which of the following statements is true of physical assessment? 1) It is best carried out in a systematic fashion. 2) The approach is the same regardless of the age of the client. 3) The approach to the client should be most invasive to least invasive. 4) The results are part of the subjective database.
1) It is best carried out in a systematic fashion.
While assessing the inguinal lymph nodes of a patient, a 1-cm soft and freely movable node is palpated. What action should the examiner take next? 1) Nothing---this finding is normal. 2) Refer this patient to a specialist. 3) Immediately check the patient's dorsalis pedis pulse. 4) Refer the patient for immediate management of a life-threatening condition.
1) Nothing---this finding is normal.
When assessing the radial pulse of a patient, the nurse should count the: 1) Pulse for 1 minute if the rhythm is irregular. 2) Pulse for 15 seconds and multiply by four, if the rhythm is regular. 3) Initial pulse for a full 2 minutes to detect any variation in amplitude. 4) Pulse for 10 seconds and multiply by six, if the patient has no history of cardiac abnormalities.
1) Pulse for 1 minute if the rhythm is irregular.
Which tests are performed to test coordination and upper extremity cerebellar function? 1) Rapid Alternating Movements (RAM) 2) The Romberg Test 3) Graphesthesia 4) All of the above
1) Rapid Alternating Movements (RAM)
A nurse is interviewing a patient who uses an expression with which the nurse is unfamiliar. What is the most appropriate expression for the nurse to use to clarify expression's meaning from the patient? 1) Tell me what you mean by _________? 2) I think that expression means ____________. 3) That expression is unclear to me. 4) Where did you hear that expression?
1) Tell me what you mean by _________?
An elderly patient comes to the clinic for evaluation. During the skin assessment, the nurse notes considerable skin tenting. Why does this finding require further assessment? 1) Tenting indicates dehydration 2) Tenting indicates malnutrition 3) Tenting indicates dramatic weight loss 4) Tenting indicates vitamin B12 deficiency
1) Tenting indicates dehydration
A patient presents at the clinic with scrotal pain. What is the presumptive diagnosis? 1) Testicular torsion 2) Priapism 3) Hydrocele 4) Varicocele
1) Testicular torsion
A 60 year-old man is having his skin assessed. The patient tells the nurse he has been a heavy smoker for the last 40 years. He has clubbing of the fingernails. What does this finding tell the nurse? 1) The patient has chronic hypoxia. 2) The patient has melanoma. 3) The patient has COPD. 4) The patient has asthma.
1) The patient has chronic hypoxia.
A patient is found to have a smooth, glossy tongue. What might this indicate? 1) Vitamin B12 deficiency 2) Vitamin D deficiency 3) Vitamin C deficiency 4) Vitamin B1 deficiency
1) Vitamin B12 deficiency
To test cranial nerve VIII, which of the following tests should be performed: 1) Whispered Voice test 2) Corneal Reflex 3) Finger-to-Finger test 4) Confrontation test
1) Whispered Voice test
Examining the male breast is: 1) a relatively brief, but important part of the exam. 2) not necessary in a screening exam. 3) a relatively brief, though unimportant part of the exam. 4) not necessary because men do not have breast tissue.
1) a relatively brief, but important part of the exam.
Examination of the lymphatic system is performed to gain information about: 1) an infectious process or possible malignant growth in that region. 2) chronic subclinical infections. 3) possible malignant growth in that region and past Infections. 4) thyroid malfunction.
1) an infectious process or possible malignant growth in that region.
Using the Snellen Chart, 20/30 vision means the client is able to read: 1) at 20 feet what a normal eye can read at 30 feet. 2) at 30 feet what a normal eye can read at 20 feet. 3) the 20/20 line at a distance of 30 feet. 4) 20 mm sized letters at a distance of 30 feet.
1) at 20 feet what a normal eye can read at 30 feet.
The goals of Healthy People related to the neurological system include all of the following except: 1) decrease in adults who engage in physical activity 2) reduce stroke deaths 3) reduce tobacco use by adults 4) Increase in adults of early warning signs and symptoms of stroke
1) decrease in adults who engage in physical activity
Gynecomastia is: 1) enlargement of the flat disk of undeveloped breast tissue beneath the nipple in the male breast. 2) presence of "mast" cells in the male breast. 3) cancer of the male breast. 4) presence of supernumerary breast on the male chest.
1) enlargement of the flat disk of undeveloped breast tissue beneath the nipple in the male breast.
The Glasgow Coma Scale assesses: 1) eye opening, motor response, and verbal response. 2) orientation, alertness, and eye opening. 3) orientation, motor response, and verbal response. 4) alertness, motor response, and verbal response.
1) eye opening, motor response, and verbal response.
Hypospadias is when the urinary meatus opens: 1) on the ventral side of the glans. 2) on the dorsal side of the glans. 3) about centrally on the glans. 4) at the base of the penis.
1) on the ventral side of the glans.
When assessing consciousness, the order of stimulation is: 1) spontaneous, normal voice, loud voice, tactile, noxious 2) normal voice, loud voice, spontaneous, noxious, tactile 3) tactile, normal voice, loud voice, noxious, spontaneous 4) none of the above
1) spontaneous, normal voice, loud voice, tactile, noxious
When performing perineal care on a bed-ridden patient, the patient is in ______________. 1) supine position with knees flexed and the nurse washes from clean to dirty. 2) prone position with knees extended, and the nurse washes from clean to dirty. 3) prone position with knees flexed and the nurse washes from clean to dirty. 4) supine position with knees extended and the nurse washes from clean to dirty.
1) supine position with knees flexed and the nurse washes from clean to dirty.
The S1 heart sound is produced by _________ 1) the closure of the mitral and tricuspid valves. 2) blood filling the ventricles. 3) blood moving through the semilunar valves. 4) the closure of the aortic and pulmonic valves.
1) the closure of the mitral and tricuspid valves.
A patient presents at the neurology clinic for an initial visit. The nurse notes that the patient has irregular, uncoordinated movements. How would the nurse note this in the patient's record? 1) "Patient exhibits spasticity." 2) "Patient is ataxic." 3) "Patient is atonic." 4) "Patient is hypotonic."
2) "Patient is ataxic."
A nurse is assessing a patient who has been diagnosed with a neuromuscular disorder. The nurse notes the patient cannot lift the right leg off of the bed when the nurse applies resistance. The nurse would document the muscle strength in the right leg as 1) Fair 2) 2/5 3) 50% 4) within normal limits
2) 2/5
A 62 year-old woman comes to the clinic with a history of COPD. Which assessment finding would you be most likely to observe? 1) Scoliosis 2) Barrel chest 3) Kyphosis 4) Pectus Excavatum
2) Barrel chest
Mr. Brown was playing soccer and hurt his right knee. It appears swollen. What is the first assessment the nurse should make? 1) Palpate for crepitus in the knee 2) Compare the swollen knee to the other knee 3) Assess active ROM in the knee 4) Feel the knee for warmth
2) Compare the swollen knee to the other knee
Which cranial nerve is not routinely tested? 1) Cranial Nerve III 2) Cranial Nerve I 3) Cranial Nerve VIII 4) Cranial Nerve XI
2) Cranial Nerve I
A patient comes to the clinic complaining of waking during the night with sudden shortness of breath. She is diagnosed with paroxysmal nocturnal dyspnea (PND). Before leaving the clinic, the patient asks you what causes PND. What would be your response? 1) Chronic heart failure. 2) Fluid overload from elevation of the legs. 3) Cardiac decompression. 4) Fluid overload related to renal failure.
2) Fluid overload from elevation of the legs.
When doing an acute assessment of the Central Nervous System, the nurse would be concerned with the following findings: 1) Vital signs within parameters 2) Glasgow Coma Scale of 3 3) Alert and Oriented X4 4) Normal pupillary reaction
2) Glasgow Coma Scale of 3
What is the greatest risk factor for cervical cancer? 1) HIV 2) HPV 3) Genetics 4) Age
2) HPV
All of the following statements are true of dementia except: 1) Dementia cannot be cured. 2) Onset of dementia occurs suddenly. 3) Dementia symptoms are not usually reversible. 4) Patients with dementia have difficulty thinking abstractly.
2) Onset of dementia occurs suddenly.
When assessing a client's skin you note one growth is different from the others. It is asymmetrical, brown with a white area, and has irregular borders. This may indicate_____________ 1) Nothing. It is normal. 2) Possible skin cancer. 3) Seborrheic keratosis 4) Acne.
2) Possible skin cancer.
All except the following can trigger delirium in a hospitalized patient age 65 or older: 1) Urinary tract infection 2) Recent loss 3) Renal failure 4) Cellulitis
2) Recent loss
A patient presents with a throbbing, right lower extremity ulcer. The shallow ulcer is around the ankle with an irregular border. Because of the presence of mild edema, the right dorsalis pedis pulse is difficult to palpate. What is the probable etiology of this ulcer? 1) Arterial insufficiency 2) Venous insufficiency 3) Diabetes Mellitus 4) Coronary artery disease
2) Venous insufficiency
During passive ROM exercises, the nurse abducts the client's arm when the arm is moved 1) above the client's head. 2) away from the midline of the body. 3) below the level of the client's body. 4) toward the midline of the body.
2) away from the midline of the body.
Benign conditions of the breast include 1) ductal carcinoma 2) fibrocystic changes 3) Paget's disease 4) precancerous lesions
2) fibrocystic changes
The most common musculoskeletal concerns that prompt an individual to seek care are: 1) muscle cramps and weakness. 2) joint pain and loss of function. 3) bone fractures and sprains. 4) joint stiffness and swelling.
2) joint pain and loss of function.
When you ask your 68 year-old patient to stand with feet together and arms at his side with his eyes closed, he starts to sway and moves his feet further apart. You would document this as a: 1) negative Romberg's sign. 2) positive Romberg's sign. 3) positive Homan's sign. 4) lack of coordination.
2) positive Romberg's sign.
Absorption of nutrients takes place primarily in the: 1) liver. 2) small intestine. 3) colon. 4) stomach.
2) small intestine.
A nurse is performing an admission assessment on a patient new to the unit. What would be the best way to phrase a question about the patient's marital status? 1) "Is your spouse living with you?" 2) "Are you living with your spouse?" 3) "Do you live alone or with someone?" 4) "Are you married, divorced, or widowed?"
3) "Do you live alone or with someone?"
A patient comes to the clinic, reporting that he woke up this morning with a painful right eye. What would be the most appropriate response from the nurse? 1) "It is probably just allergies. If it still hurts in the morning call me." 2) "A painful eye happens sometimes with allergies. Do you have allergies?" 3) "You will need to see the doctor to have your eye checked." 4) "Did you do anything different yesterday? You may have eye strain."
3) "You will need to see the doctor to have your eye checked."
The examiner is going to inspect and palpate for a hernia. During this examination, the man is instructed to: 1) Hold his breath during palpation. 2) Cough after the examiner has gently inserted the exam finger into the rectum. 3) Bear down when the examiner's finger is at the inguinal canal. 4) Relax in a supine position while the examination finger is inserted into the canal.
3) Bear down when the examiner's finger is at the inguinal canal.
Determining an individual's intellect and language will test the functioning of which of the following structures? 1) Cerebellum 2) Medulla oblongata 3) Cerebrum 4) Cranial nerves
3) Cerebrum
Studies have shown that a stethoscope can transmit bacteria among patients. How can you prevent your stethoscope from becoming a "staphoscope"? 1) Use a different stethoscope with each patient 2) Wipe stethoscope on uniform before use 3) Clean stethoscope with alcohol swab before each use 4) Have patient shower before bringing stethoscope into contact with patient
3) Clean stethoscope with alcohol swab before each use
Assessing how the patient says "light, tight, dynamite" tests the motor function of which cranial nerve? 1) Oculomotor Nerve 2) Cranial Nerve VII 3) Cranial Nerve XII 4) Cranial Nerve IV
3) Cranial Nerve XII
The six muscles that control eye movement are innervated by cranial nerves: 1) II, III, and V. 2) IV, VI, and VII. 3) III, IV, and VI. 4) II, III, and VI
3) III, IV, and VI.
During history taking, a patient reports cramping in his calf when walking a few blocks. He states that it goes away when he sits down for a few minutes. How would the nurse document this symptom? 1) Rest pain 2) Poikilothermia 3) Intermittent claudication 4) Venous stasis
3) Intermittent claudication
Decreased tissue perfusion of an extremity would cause which of the following signs? 1) Increased redness, swelling and heat of the affected area 2) Lack of ability to move the extremity 3) Pallor, thin skin, possible pain, and coolness of the extremity 4) Throbbing, aching discomfort in the affected area
3) Pallor, thin skin, possible pain, and coolness of the extremity
Which of the following statements represent subjective data obtained from the patient regarding his skin? 1) Skin appears dry. 2) No obvious lesions. 3) They deny color change. 4) Lesion noted lateral aspect of right arm.
3) They deny color change.
Cerebellar function is assessed by testing which of the following? 1) muscle size and strength 2) cranial nerve examination 3) coordination 4) spinothalamic test
3) coordination
The Weber and Rinne tests examine: 1) reflexes. 2) visual acuity. 3) hearing. 4) cerebellar function
3) hearing.
A 70 year-old woman comes to the clinic for a health examination. Which of the following is a common age-related change in the curvature of the spinal column? 1) lordosis 2) scoliosis 3) kyphosis 4) lateral scoliosis
3) kyphosis
Of all of the following principles related to physical exams, which principle for performing a physical exam is the most important? 1) begin with general and go to specifics. 2) examine symmetrical areas. 3) maintain safety of client and nurse. 4) move from head to toe.
3) maintain safety of client and nurse.
When examining the ear with an otoscope, the nurse remembers the tympanic membrane should appear: 1) light pink with a slight bulge. 2) pulled in at the base of the cone of light. 3) pearly gray and slightly concave. 4) whitish with a small fleck of light in the superior portion.
3) pearly gray and slightly concave.
Which technique offers little useful information in cardiac assessment? 1) auscultation 2) palpation 3) percussion 4) inspection
3) percussion
Which of the following may be noted through inspection of the abdomen? 1) fluid waves and abdominal contour. 2) umbilical eversion and Murphy's sign. 3) pulsation or movement, distention, and abdominal contour. 4) peritoneal irritation, general tympany, and peristaltic waves.
3) pulsation or movement, distention, and abdominal contour.
The area of the nervous system that is responsible for mediating reflexes is the: 1) cerebellum. 2) medulla. 3) spinal cord. 4) cerebral cortex.
3) spinal cord.
For an abdominal examination, the client should be: 1) in a comfortable prone position. 2) seated with back supported. 3) supine with arms at side. 4) supine with legs straight and hands behind head.
3) supine with arms at side.
Normal findings of strength testing include: 1) greater upper extremity strength of client than examiner. 2) non-dominant extremity slightly stronger than dominant. 3) symmetric strength of muscle pairs. 4) visible atrophy of a muscle or muscle group.
3) symmetric strength of muscle pairs.
The following cranial nerves are mixed (having both motor and sensory function): 1) optic (II) and acoustic (VIII) 2) olfactory (III) and spinal (XI) 3) trigeminal (V) and vagus (X) 4) trochlear (IV) and abducens (VI)
3) trigeminal (V) and vagus (X)
Each glandular lobe in the breast has lobules with milk-producing cells. What cells in these lobules produce milk? 1) Montgomery's cells 2) Lactiferous cells 3) Milk cells 4) Acini cells
4) Acini cells
When assessing a headache, what subjective data needs to be requested? 1) Onset and location of headache 2) Character, duration, and precipitating factors 3) Pattern of headache and coping strategies 4) All of the above
4) All of the above
Subjective data that needs to be collected when interviewing a female and male about their genitourinary (GU) system includes: 1) urinary symptoms. 2) sexual activity, contraceptive use, and STI contact. 3) past GU history. 4) All of the above.
4) All of the above.
An older adult is being treated for depression. You would first: 1) Evaluate the significance of the loss causing the depression. 2) Assess the level of family/social support. 3) Obtain a current list of medications the patient is taking. 4) Assess the patient's suicide risk.
4) Assess the patient's suicide risk.
When assessing the foot and ankle of a clinic patient, the nurse notes that the patient complains of pain along the Achilles' tendon. What might this patient have? 1) Strain 2) Plantar fasciitis 3) Sprain 4) Bursitis
4) Bursitis
When reading a medical record you see the following notation: Patient states, "I have had a cold for about a week and now am having difficulty breathing." Which word would you use to describe this patient's respiratory status? 1) Orthopnea 2) Tachypnea 3) Hypoxia 4) Dyspnea
4) Dyspnea
Nursing students are doing a class presentation on stroke. What is the term they would use for deficits in articulation? 1) Aphasia 2) Nystagmus 3) Dysarthria 4) Dystonia
4) Dystonia
A 44 year-old female comes into the clinic having recently been discharged from the hospital with pneumonia. What type of assessment will the health care provider do to gather data from the patient? 1) Comprehensive 2) Emergency 3) Intuitive 4) Focused
4) Focused
Changes of aging occur in the gastrointestinal system. Which symptom would cause concern and require intervention? 1) Decreased sense of taste 2) Dry mouth 3) Gallstones (cholelithiasis) without symptoms 4) No bowel movement in four days
4) No bowel movement in four days
Which of the following techniques would not be necessary in order to document "Full ROM of neck"? 1) Put your chin to your chest. 2) Put your ear to your shoulder. 3) Raise your chin as far as you are able. 4) Turn your head to the left against my hand.
4) Turn your head to the left against my hand.
The chart states that a 62-year old woman has a stroke in the right parietal area of the brain. The nurse expects to note which of the following? 1) Tremors on the left side of the face 2) Tremors on the right side of the face 3) Weakness in the right arm 4) Weakness in the left arm
4) Weakness in the left arm
The functional assessment (ADLs) during the evaluation of the musculoskeletal system screens for : 1) quality of life. 2) the need for home health services. 3) the safety of independent living. 4) all of the above
4) all of the above
Heart murmurs may be attributed to: 1) the mitral valve closing before the tricuspid valve. 2) resistance to atrial ejection due to hypertension. 3) sudden opening of the aortic valve. 4) backward movement of blood flow through an incompetent valve.
4) backward movement of blood flow through an incompetent valve.
A patient has a normal pupillary light reflex. The nurse recognizes this indicates that: 1) the eyes converge to focus on the light. 2) light is reflected at the same spot in both eyes. 3) the eye focuses the image in the center of the pupil. 4) constriction of both pupils occurs in response to bright light.
4) constriction of both pupils occurs in response to bright light.
The root of the spinal nerve that provides a general idea of where the nerve innervates is called a: 1) macule 2) vesicle 3) fissure 4) dermatone
4) dermatone
The usual order of examination techniques used to examine the abdomen is: 1) auscultation, inspection, percussion, deep palpation. 2) auscultation, percussion, inspection, palpation. 3) inspection, auscultation, percussion, deep palpation, light palpation. 4) inspection, auscultation, percussion, light palpation, deep palpation.
4) inspection, auscultation, percussion, light palpation, deep palpation.
When documenting findings of the eyes, PERRLA means: 1) pupils even react regularly to light and accommodation 2) pupils equal react round to light and air 3) pupils even react round to light and air 4) pupils equal round reactive to light and accommodation
4) pupils equal round reactive to light and accommodation
When teaching a client about the use of a cane, the nurse will advise the client to hold the cane with 1) either hand. 2) the hand that is dominant (right or left). 3) the hand of the body's weaker side. 4) the hand of the body's stronger side.
4) the hand of the body's stronger side.
Select the best description of an accurate assessment of a patient's respirations. 1) Count for a full minute before taking the pulse. 2) Count for 15 seconds and multiply by 4. 3) Count after informing the patient that you are going to count respirations. 4) Count for 30 seconds following pulse assessment and multiply by 2.
Count for 30 seconds following pulse assessment and multiply by 2.
Which statement describes the lung sound "crackles" (formerly called rales)? 1) It occurs as air moves through a narrowed bronchiole. 2) It occurs as air moves through fluid. 3) It is the result of thick secretions in large airways. 4) It is a result of inflamed pleural surfaces.
It occurs as air moves through fluid.
A 72-year-old teacher comes to a skilled nursing facility for rehabilitation after being in the hospital for 6 weeks. She has been confined to bed for the majority of her hospitalization. The nurse is completing an initial assessment and evaluating the client's skin condition. On her sacrum there is full-thickness skin loss that is 5 cm in diameter with damage to the subcutaneous tissue. The underlying muscle is not affected. What is the stage of this pressure ulcer? 1) Stage 1 2) Stage 2 3) Stage 3 4) Stage 4
Stage 3
During the integument health history, the nurse asks the patient about prescription medications, immunizations, and diagnosed illnesses. What will this information provide to the nurse? 1) History of physical abuse 2) Patient's risk for skin cancer 3) Patient's risk for pressure ulcer formation 4) Systemic diseases that have skin manifestations
Systemic diseases that have skin manifestations
The nurse notices a colleague is preparing to check the blood pressure of an obese patient by using a standard-sized blood pressure cuff. The nurse should expect the reading to: 1) Yield a falsely low blood pressure. 2) Yield a falsely high blood pressure. 3) Be the same regardless of cuff size. 4) Vary as a result of the technique of the person performing the assessment.
Yield a falsely high blood pressure.
When documenting, you should avoid writing down: 1) Your patient's medical diagnosis. 2) Your patient's previous assessment and any anticipated or unanticipated changes. 3) What the next caregiver will need to know better to understand and care for the patient. 4) Your complaints about the patient.
Your complaints about the patient.
The four (4) areas to consider during the general survey of a patient are: 1) Ethnicity, speech, and socioeconomic status. 2) Sex, vital signs, and hemoglobin levels. 3) Pain, pulse pressure, and range of motion. 4) Behavior, dress, mobility, and physical appearance.
aBehavior, dress, mobility, and physical appearance.
When auscultating for bowel sounds: 1) listen in upper quadrants for 20 seconds before determining that bowel sounds are absent. 2) listen in all four quadrants for 5 minutes before determining that bowel sounds are absent. 3) listen in all four quadrants for 20 seconds before determining that bowel sounds are absent. 4) use the bell of the stethoscope and listen for lower pitched bowel sounds.
listen in all four quadrants for 5 minutes before determining that bowel sounds are absent.
