Exam 2 quizlet 220
After completing the focused assessment of Lourdes' pedal pulses, the wound on the bottom of her foot, and Lourdes' subjective report of numbness, the nurse begins to obtain the client's history, focusing on data related to her peripheral vascular system. To learn about any history of intermittent claudication, what question should the nurse ask? -"When you first stand up, do you feel dizzy or light-headed?" -"Can you feel your pulse pounding after vigorous activity?" -"Have you experienced any leg cramping or pain in your legs?" -"Do you have an urge to move your legs a lot during the night?"
"Have you experienced any leg cramping or pain in your legs?"
A client reports that she often experiences leg cramps, usually after walking around the park. What follow-up question by the RN provides the best information about the client's claudication distance? -"when did you first notice you were having leg cramps? "-"How long have you been walking this same distance? "-"How far do you walk before the leg cramps begin? "-"On a 10-point scale, how would you rank your pain?"
"How far do you walk before the leg cramps begin?"
The RN has already observed that both of Lourdes' feet are cool and pale. What questions should the RN ask Lourdes to obtain additional supporting data? (select all that apply) -"Are any of your veins bulging or crooked?" -"Do you feel tingling, numbness, or burning sensation in your legs and feet?" -"Have you ever had a blood clot?" -"Do your toes or toenails ever look blue?" -"After a bump, do you bruise easily?"
-"Do you feel tingling, numbness, or burning sensation in your legs and feet?" -"Do your toes or toenails ever look blue?"
Which rationale explains why a patient with a recent myocardial infarction would have a basic metabolic panel drawn to monitor serum electrolytes? Elevated levels increase the risk for atherosclerosis. Abnormal levels can cause cardiac arrhythmias. Reduced levels can result in decreased oxygen levels. Normal levels suggest healing of muscle tissue.
-Abnormal levels can cause cardiac arrhythmias. *Increased or decreased electrolytes, such as potassium and magnesium, can cause cardiac arrhythmias.
When reporting to the supervisor, the RN tells the supervisor that the client's pressure sore developed because the client had a stone in her shoe that she couldn't feel. How should the RN summarized the initial report by the client? -Discomfort in both feet -Foot paralysis bilaterally -Bilateral parasethesia in the feet -numbing pain in her feet.
-Bilateral paraesthesia in the feet *Paresthesia refers to abnormal sensation, such as numbness or tingling, so this is the best terminology to describe the client's report of numbness and lack of feeling in her feet.
The RN next plans to determine the client's ankle brachial index. 15. What equipment should the RN obtain prior to completing this measurement? -Measuring tape -Blood pressure cuff -Tourniquet -Pulse oximeter
-Blood pressure cuff *A blood pressure cuff along with a Doppler probe is used to obtain the systolic blood pressure in the lower extremity. To calculate the ankle brachial index (ABI), this value is compared with the systolic blood pressure in the upper extremity.
Although there is no visible swelling, Lourdes' legs are large, so the RN gently depresses the tissue over the tibia for one second, noting that the tissue bounces back immediately. What action should the RN take next? -Ask the client to elevate her legs and repeat -Compress the tissue more firmly for 5 seconds -Note that there is currently no edema present -Document the presence of non-pitting edema
-Compress the tissue more firmly for 5 seconds
The wound Lourdes mentioned is located on the plantar surface of her right foot, on the ball of the foot. The RN observes the wound bed is red and the tissue immediately surrounding the wound is inflamed. The RN plans to document the stage of the wound. -Observe the tissue to determine the phase of wound healing -Determine the depth of the wound and underlying tissue damage -Note the amount, color and character of the wound drainage -Measure the width of the wound from front to back and side to side
-Determine the depth of the wound and underlying tissue damage
To palpate the epitrochlear node, the RN palpates the area above and behind the medial condyle of the humerus but is unable to palpate the node. 18. What action should the RN take next? -Document that the node is not palpable -Palpate the area below the medial condyle -Ask the client to slowly flex her elbow -Apply pressure over the antecubital fossa
-Document that the node is not palpable
The RN's assessment reveals that the valves are competent, and the RN continues the assessment. While Lourdes is standing, the RN notes the absence of any dependent rubor. 14. What action should the RN take in response to this finding? -Document this finding on the physical assessment form -Immediately help the client sit down and elevate her legs -Lightly palpate the calves for warmth or tenderness -Assess for range of motion in the lower legs and feet
-Document this finding on the physical assessment form *Dependent rubor, a deep blue-red color when the legs are in a dependent position, occurs with severe arterial insufficiency. The absence of dependent rubor is a normal assessment finding, and should be documented in the physical assessment but requires no further intervention.
When assessing a patient with low hemoglobin, the nurse looks for symptoms of fluid retention, understanding that the patient may have which condition? Hemodilution Hypoxia Infection Hyperlipidemia
-Hemodilution *Hemodilution occurs in cardiac failure patients when excess fluid is retained.
The complete blood count results for a patient with chronic obstructive pulmonary disease (COPD) show an elevated red blood cell count. Which clinical manifestation would the nurse associate with this finding? Hyperlipidemia Hypoxia Infection Hemodilution
-Hypoxia *Long-term hypoxia results in stimulation of red blood cell production for increased oxygen-carrying capacity.
The nurse notes that the wound is round and 0.5 cm in diameter. To assess for the presence of any undermining tracts, what action should the nurse implement? -Note the amount and appearance of any drainage to help determine the depth. -Gently irrigate the wound with sterile saline to help determine the depth. -Insert a sterile, cotton-tipped applicator to measure the depth. -Use sterile forceps to apply sterile packing to help determine the depth.
-Insert a sterile, cotton-tipped applicator to measure the depth
Which findings would prompt the nurse to perform a focused cardiopulmonary assessment? -Medical history of a cardiovascular problem -Medical history of a respiratory problem -Signs and symptoms of decreased oxygenation -Signs and symptoms of activity intolerance -Signs and symptoms of increased peripheral perfusion
-Medical history of a cardiovascular problem -Medical history of a respiratory problem -Signs and symptoms of decreased oxygenation -Signs and symptoms of activity intolerance
After assessing the femoral artery, the nurse palpates the inguinal lymph nodes. What technique should be used? -Lightly press the palmar surface of one hand over the inguinal area. -Move the finger pads over the area using a gentle circular motion. -Firmly compress the area until blanching occurs and then release. -Gently press downward with the fingertips until the node is felt.
-Move the finger pads over the area using a gentle circular motion.
During the health history, Lourdes reported that her feet and ankles swell occasionally. To assess for edema, what action the RN take first? -Ask the client to lie down and elevate her feet and legs -Ask the client to gently dorsiflex each of her feet -Observe and compare the client's lower extremities -Gently compress the tissue on the top of the client's feet
-Observe and compare the client's lower extremities
The nurse palpates the dorsalis pedis pulses bilaterally and determines that both pulses are weak and thready. What additional assessment information will validate this finding? -Pale, cool skin. -Flushed, moist skin -Inflamed, hot skin. -Dry, inelastic skin.
-Pale, cool skin.
The RN begins the assessment at the client's inguinal area, assessing the femoral artery and the inguinal lymph nodes. The RN palpates the femoral artery and notes that it is weak. The RN decides to assess for the presence of a bruit. What action should the RN take? -Position a stethoscope over the artery -Observe the site for bulges or swelling -Firmly compress the artery with the fingertips -Feel the inguinal area with the back of the hand.
-Position a stethoscope over the artery
Which data would be obtained by the nurse preparing to perform a cough assessment on a patient with a respiratory disorder? Sputum characteristics Pulse oximetry Capillary refill Respiratory rate
-Sputum characteristics *Obtaining information about the amount and characteristics (e.g., color, odor, consistency) of sputum is an important part of a cough assessment.
The clinic supervisor enters Lourdes' room, and the RN gives the supervisor a brief report, based on the assessment completed up to this point. 16. It is most important to report which finding to the supervisor? (select all the apply) -Ankle brachial index of .94 -Lack of dependent rubor -Stage 2 pressure ulcer -Bilateral cyanosis in both legs -Location varicose veins
-Stage 2 pressure ulcer -Bilateral cyanosis in both legs
Which area of the body will have motor and sensory deficits in a right-sided cerebrovascular accident (CVA)? Right side Left side Both sides Neither side
Left side
Match the condition to its cause. 1. Amyloid plaques and neurofibrillary tangles 2. Smoking 3.Excess inner-ear fluid 4.Age-related hearing loss
1. Alzheimer disease 2. Decreased olfaction 3.Ménière disease 4.Presbycusis
Match the reflex to it's responce 1. Flex arm 2. Plantarflex foot 3. Flex and supinate forearm 4. Extend leg
1. Biceps 2. Achilles 3. Brachioradialis 4. Patellar
Match the cranial nerve(s) to the expected finding associated with its function. 1. Identifies salty taste 2. Detects the smell of orange 3. Hears a whispered word 4. Reads the Snellen chart
1. Cranial nerve V 2. Cranial nerves X and XII 3. Cranial nerves VII and IX 4. Cranial nerve I
Match each visual condition to its description. 1. Distance vision is clear, but near vision is blurred. 2. High intraocular pressure causes damage to the optic nerve. 3. Retina deterioration causes central vision loss. 4. Damage occurs to retinal blood vessels from hyperglycemia.
1. Myopia 2. Cataracts 3. Hyperopia 4. Glaucoma
Match the pulmonary function test (PFT) with the measured element. -Air volume expelled with lungs maximally inflated -Air volume expelled in 1 second from start of FVC -Air volume left in lungs after forced expiration -Air volume left in lungs after normal expiration -Maximal flow rate in the middle of FVC maneuver 1.Forced expiratory volume in 1 second (FEV1) 2.Forced vital capacity (FVC) 3.Forced expiratory flow (FEF) 4.Residual volume (RV) 5.Functional residual capacity (FRC)
2.Forced vital capacity (FVC) 1.Forced expiratory volume in 1 second (FEV1) 4.Residual volume (RV) 5.Functional residual capacity (FRC) 3.Forced expiratory flow (FEF)
Which rating would the nurse assign to a patient who has a slightly hyperactive response to the patellar reflex? 1+ 2+ 3+ 4+
3+
The Rinne and Weber tests measure which of the following? A. Air and bone conduction B. Movement of the tympanic membrane C. Tenderness of the mastoid area D. Nodules in the auricles
A. Air and bone conduction
What does full movement of the eyes in the six cardinal fields of gaze reflect? A. Both B and C B. Proper functioning of the oculomotor, trochlear, and abducens nerves C. Proper functioning of the extraocular muscles D. Proper functioning of the olfactory and optic nerves
A. Both B and C Proper functioning of the oculomotor, trochlear, and abducens nerves Proper functioning of the extraocular muscles
What are the Snellen and Rosenbaum charts used to assess? A. Optic nerve B. Trigeminal nerve C. Abducens nerve D. Facial nerve
A. Optic nerve
What is the correct way to palpate the frontal sinuses? A. Press the thumbs against the brow bones. B. Press the thumbs along the sides of the nose. C. Press the bridge of the nose between the thumb and first finger. D. Press the tip of the nose between the thumb and first finger.
A. Press the thumbs against the brow bones.
Which information would the nurse expect to obtain from a chest x-ray prescribed for a patient with a cough and shortness of breath? Select all that apply. Hypoxia from diminished lung function Areas of increased lung tissue density Impaired electrical activity in the heart Size of the heart Atherosclerosis in heart blood vessels
Areas of increased lung tissue density? Size of the heart
Which objective data would the nurse focus on obtaining in a patient with signs of cardiac muscle hypoxia? Select all that apply. Chest pain Dyspnea Abnormal cardiac enzymes levels Irregular heartbeat Decreased breath sounds
Abnormal cardiac enzymes levels Irregular heartbeat
Which sensory alteration would the nurse describe when an 82-year-old patient reports an inability to smell anything for years? Myopia Anosmia Presbycusis Ménière disease
Anosmia
The nurse understands that peripheral neuropathy occurs from damage to sensory fibers at which location? Near the base of the brain Close to the body's midline Lower part of the spinal cord Away from the body's center
Away from the body's center
Which questions would the nurse include during the patient interview of a focused cardiovascular health assessment? Select all that apply. Are you having chest pain? Have you had recent weight gain? What type of work do you do? How many pillows do you sleep with? Do you ever experience dizziness?
Are you having chest pain? Have you had recent weight gain? How many pillows do you sleep with? Do you ever experience dizziness?
Which technique would the nurse use to assess a patient's judgment? Ask the patient to follow a set of instructions. Have the patient add 6 + 3. Have the patient repeat three objects at a later time Ask the patient what to do if the house was on fire
Ask the patient what to do if the house was on fire
Which condition would the nurse suspect in a postsurgical patient who is experiencing dyspnea with decreased breath sounds? Chronic obstructive pulmonary disease (COPD) Asthma Atelectasis Heart failure
Atelectasis
Which postoperative complication can be prevented by regularly performing deep-breathing exercises? Thrombus formation Bronchospasm Alveolar enlargement Atelectasis
Atelectasis *Patients who have had abdominal or chest surgery are especially at risk for atelectasis because postsurgical pain causes them to breathe more shallowly, limiting the flow of air required to clear the airways.
Which health problem risk would be evaluated by obtaining a lipid panel? Cardiac injury Atherosclerosis Fluid around heart Blood electrolyte imbalances
Atherosclerosis
What questions can you ask a patient to assess his or her state of consciousness? A. Ask the patient about his or her thoughts, feelings, and emotions. B. Ask for the date, his or her name, and the location. C. Ask the patient to repeat a series of five numbers. D. Ask the patient to write his or her name and address.
B. Ask for the date, his or her name, and the location.
What should the nurse do if a patient displays staggering or loss of balance during the Romberg test? A. Give the patient a gentle push to further assess balance. B. Delay other balance tests. C. Have the patient stand on one foot with the eyes closed. D. Have the patient hop on one foot.
B. Delay other balance tests.
When examining the eyes, which of the following is an expected finding? A. Reddened conjunctivae B. Equal pupils C. Crusted eyelashes D. Periorbital edema
B. Equal pupils
Which of the following tips will assist with eliciting the patellar and Achilles deep tendon reflexes? A. Have the patient sit with his or her feet flat on the floor. B. Have the patient focus on pulling his or her clasped hands apart. C. Have the patient flex his or her knees at a 45-degree angle. D. Strike the knee above the patella.
B. Have the patient focus on pulling his or her clasped hands apart.
A nurse is assessing a patient's neck. Which of the following is considered an expected finding? A. Jugular vein distention B. Midline trachea C. Carotid artery prominence D. Thyroid enlargement
B. Midline trachea
Which of the following is the correct way to assess a patient's nose for patency? A. Have the patient breathe rapidly through both nares. B. Occlude one naris, and have the patient breathe through the open naris. C. Occlude both nares, and have the patient breathe through the mouth. D. Have the patient blow out through both nares.
B. Occlude one naris, and have the patient breathe through the open naris.
During vocalization, the soft palate: A. Lowers symmetrically B. Raises symmetrically C. Vibrates D. Has a gag reflex
B. Raises symmetrically
Which patient situations are of immediate concern? Has myopia Becomes restless Has motion sickness Begins to slur words Begins to act confused Suddenly has drooping on left side of face
Becomes restless Begins to slur words Begins to act confused Suddenly has drooping on left side of face
What eye condition would cause the patient to have blurry vision?
Cataract
A deep tendon reflex with a normal response is scored as: A. 0 B. 1+ C. 2+ D. 3+
C. 2+
What term refers to the constriction of the pupils when a patient focuses on an object held about 10 centimeters from the nose? A. Ptosis B. Glaucoma C. Accommodation D. Peripheral vision
C. Accommodation
Which symptom found when examining the head would be a cause for concern? A. Symmetrical features at rest B. Even distribution of hair C. Bruits in the temporal arteries D. Symmetrical features with movement
C. Bruits in the temporal arteries
Which lymph nodes are located in the depression above and posterior to the medial condyle of the humerus? A. Axillary lymph nodes B. Inguinal lymph nodes C. Epitrochlear lymph nodes D. Parotid lymph nodes
C. Epitrochlear lymph nodes
Which of the following cranial nerves is assessed by holding a scented object under the patient's nose? A. Facial nerve B. Oculomotor nerve C. Olfactory nerve D. Acoustic nerve
C. Olfactory nerve
A nurse is inspecting the patient's ears with an otoscope. Which of the following findings would be considered abnormal? A. Visible cone of light B. Pearly gray tympanic membrane C. Perforation of the tympanic membrane D. Small amount of cerumen
C. Perforation of the tympanic membrane
Which parameters are assessed during the Mini-Mental State Examination (MMSE)? Judgment Reasoning Calculation Spatial orientation Cognitive orientation
Calculation Spatial orientation Cognitive orientation
Which set of values would the nurse review to determine whether heart muscle injury has occurred? Complete blood count (CBC) with differential Lipid panel Basic metabolic panel Cardiac enzymes
Cardiac enzymes *Elevated cardiac enzyme levels are indicative of cardiac muscle injury. Cardiac enzymes and proteins are released when myocardial necrosis (death of heart muscle cells) occurs.
What information should be included when entering documentation of an enlarged lymph node? A. Location, size, and shape B. Consistency and tenderness C. Discreteness and movability D. All of the above
D. All of the above
Which of the following are risk factors for glaucoma? A. Age over 40 years B. Diabetes C. High blood pressure D. All of the above
D. All of the above
Which structures are included in a complete assessment of the mouth? A. Lips, mucosa, teeth, and gums B. Tongue and floor of the mouth C. Hard and soft palates D. All of the above
D. All of the above
Assessment of the ears includes which of the following? A. Inspection B. Palpation C. Examination with an otoscope D. All of the above
D. All of the above Inspection Palpation Examination with an otoscope
Which test or tests assess accuracy of movement? A. Finger-to-finger test B. Finger-to-nose test C. Heel-to-shin test D. All of the above
D. All of the above Finger-to-finger test Finger-to-nose test Heel-to-shin test
Which of the following are included in the assessment of mental status? A. Speech and language B. Emotional stability C. Physical appearance and behavior D. All of the above
D. All of the above: Speech and language Emotional stability Physical appearance and behavior
The gag reflex should be: A. Tested with a tongue blade on each side of the oropharynx B. Present on both sides C. Tested in the midline of the oropharynx only D. Both A and B
D. Both A and B
Which of the following actions are part of the assessment of the glossopharyngeal and vagus nerves? A. Testing the gag reflex B. Having the patient swallow C. Touching the patient's face with dull and sharp objects D. Both A and B
D. Both A and B Testing the gag reflex Having the patient swallow
A whispered voice test includes which of the following? A. Having the patient wiggle a finger in the opposite ear. B. Whispering while standing 1 to 2 feet from the patient's ear. C. Playing soothing music in the examination room. D. Both A and B.
D. Both A and B. Having the patient wiggle a finger in the opposite ear. Whispering while standing 1 to 2 feet from the patient's ear
When using the Snellen chart, what does a vision evaluation of 20/50 mean? A. The patient has difficulty seeing far objects clearly. B. The patient can read at 20 feet what most people can read at 50 feet. C. The patient can read at 50 feet what most people can read at 20 feet. D. Both A and B.
D. Both A and B. The patient has difficulty seeing far objects clearly. The patient can read at 20 feet what most people can read at 50
Which of the following methods is correct for examining the ear of an adult patient with an otoscope? A. Gently pull the auricle up and back. B. Gently pull the auricle down and back. C. Use the largest speculum that will fit comfortably in the patient's ear. D. Both A and C.
D. Both A and C.
How would you assess sensitivity to superficial pain? A. Touch the patient with the sharp side of a broken tongue blade. B. Have the patient keep his or her eyes open. C. Allow 2 seconds between stimuli. D. Both A and C.
D. Both A and C. Touch the patient with the sharp side of a broken tongue blade. Allow 2 seconds between stimuli.
When assessing lymph nodes, it is important to do which of the following? A. Compare lymph nodes bilaterally. B. Use the thumbs to palpate. C. Provide privacy for the patient. D. Both comparing the lymph nodes bilaterally and providing privacy for the patient.
D. Both comparing the lymph nodes bilaterally and providing privacy for the patient.
Which cognitive alteration would the nurse suspect when an older adult patient receiving pain medication following a hip replacement stays awake all night and is confused? Delirium Dementia Depression Sensory deprivation
Delirium
Lourdes' feet are pale and cool to the touch, consistent with the weak, thready pedal pulses palpated by the nurse. The nurse uses a Doppler ultrasound stethoscope to confirm the presence of the dorsalis pedis pulses. After applying gel to the transducer and placing the transducer over the middle of the dorsal surface of the foot, the nurse hears a regular swooshing sound. What action should the nurse take? -Notify the healthcare provider (HCP) immediately of the lack of a pulse. -Move the end of the transducer closer to the toes and listen again. -Remove the excess gel, apply pressure more gently, and try again. -Document the presence of the pulse heard by Doppler ultrasound.
Document the presence of the pulse heard by Doppler ultrasound.
Which major subjective symptom is associated with both chronic obstructive pulmonary disease (COPD) and pneumonia? Dyspnea Elevated arterial carbon dioxide level Irregular heart rhythm Chest pain
Dyspnea *Dyspnea is the subjective feeling of difficulty breathing and is common to many respiratory problems including COPD and pneumonia.
Which cues would the nurse expect in a patient with hypoxic myocardial tissue? Select all that apply. Fever Dyspnea Vomiting Chest pain Diaphoresis
Dyspnea Vomiting Chest pain Diaphoresis
Which cues would the nurse expect to find in a patient with an inability to effectively pump blood to the tissues? Select all that apply. Dyspnea with exertion Fatigue Lower extremity edema Crushing chest pain Nausea and vomiting
Dyspnea with exertion Fatigue Lower extremity edema
Which laboratory data would the nurse monitor in an older adult patient who is confused and may have suffered a cerebrovascular accident (CVA)? select all that apply Electrolytes CA-125 Blood glucose Cholesterol level Urinalysis
Electrolytes Blood glucose Cholesterol level Urinalysis
Which vital sign results are correctly correlated to their unexpected cognitive findings? Elevated temperature—confusion, disorientation Hypertension—headache Orthostatic hypotension—dizziness Low pulse oximetry—restlessness Low blood pressure—stroke
Elevated temperature—confusion, disorientation Hypertension—headache Orthostatic hypotension—dizziness Low pulse oximetry—restlessness
Which cues would the nurse likely observe in a patient with a cerebrovascular accident (CVA)? Select all that apply. Elevated triglycerides Aphasia Motor deficits Brain infarct indicated on CT scan Reduced cholesterol levels in laboratory results
Elevated triglycerides Aphasia Motor deficits Brain infarct indicated on CT scan
Which impairment is a patient with a recent cerebrovascular accident (CVA) experiencing when able to follow commands but has difficulty responding verbally? Delirium Dementia Expressive aphasia Receptive aphasia
Expressive aphasia
Which eye condition is caused by an increase in intraocular pressure? Hyperopia Glaucoma Diabetic retinopathy Macular degeneration
Glaucoma
Which patient conditions can lead to conductive hearing loss? Select all that apply. Works around loud noises Takes an ototoxic drug Injures head in a car accident Has excess cerumen buildup in ear Is diagnosed with otitis media
Has excess cerumen buildup in ear Is diagnosed with otitis media
Which questions would the nurse include as part of a focused respiratory health assessment? Have you ever been exposed to hazardous materials at work? Have you had recent weight gain? Have you ever lost consciousness? Do you take medications to prevent blood clots?
Have you ever been exposed to hazardous materials at work?
Which questions would the nurse include during the patient interview of a focused respiratory health assessment? Select all that apply. Have you ever smoked? Have you had recent weight gain? Do you use oxygen at home? Do you have difficulty clearing secretions? Do you have a cough? For how long?
Have you ever smoked? Do you use oxygen at home? Do you have difficulty clearing secretions? Do you have a cough? For how long?
Which questions would the nurse ask to assess cognition? How is your stress level? What is your occupation? Are you having any problems sleeping? Do you ever feel like the room is spinning? Have there been any changes in your memory?
How is your stress level? Are you having any problems sleeping? Have there been any changes in your memory?
Which cranial nerve is affected if the patient has anosmia? I II VII IX
I Cranial nerve I (olfactory) is affected if the patient has anosmia, which is a decrease or loss of smell.
Which peripheral vascular assessment would the nurse perform when admitting a patient with impaired cardiac function? Auscultating breath sounds Auscultating an apical pulse Inspecting skin color in the extremities Measuring the chest for expansion
Inspecting skin color in the extremities *Inspecting extremities for skin color such as cyanosis, pallor, or pink skin tone is part of a peripheral vascular assessment.
Which assessment techniques would the nurse include when performing a physical assessment on a patient with an oxygenation problem? Select all that apply. Inspection Palpation Auscultation Reflexes Vital signs
Inspection Palpation Auscultation Vital signs
Which interpretation would the nurse make for the chart entry, Oriented × 3? Knows the answers to person, place, and time Adds three simple numbers together Can remember three objects repeated earlier Is able to read, write, and speak
Knows the answers to person, place, and time
The nurse reviews Lourdes' initial complaint that her feet feel numb. Which assessment should the nurse perform first? Locate the inguinal lymph nodes Measure toenail capillary refill. Compare calf circumferences. Palpate the dorsalis pedis pulses.
Palpate the dorsalis pedis pulses.
Which finding is an expected response of the Babinski reflex? Dorsiflexion of the big toe Fanning of all four toes Supination of the big toe Plantarflexion of the toes
Plantarflexion of the toes
Which action would the nurse take when using the Romberg test? Allow the patient to walk in a straight line with eyes open. Determine if the patient can distinguish between dull and sharp touch. Report a positive result when the patient sways. Have the patient stand at least for 30 seconds.
Report a positive result when the patient sways.
The nurse is aware that a patient kept in strict isolation after a bone marrow transplant is at increased risk for developing which alteration? Delirium Dementia Sundowning Sensory deprivation
Sensory deprivation
Which parameter is the nurse primarily assessing by having the patient draw a clock?
Spatial orientation
Which interpretation would the nurse make when a patient loses balance when performing the heel-to-toe walk? The Broca area is injured Touch sensory pathways are inflamed. There is a dysfunction in the cerebellum. The glossopharyngeal nerve has been damaged
There is a dysfunction in the cerebellum.
Which information would the nurse be aware of when using cardiac enzyme measurements for assessment of myocardial infarction? Select all that apply. They are released when death of cardiac cells occurs. Elevated serum levels suggest cardiac damage. There are "good" and "bad" types of cardiac enzymes. Alterations in enzyme types may indicate infection. Abnormally low levels are seen with decreased oxygenation.
They are released when death of cardiac cells occurs. Elevated serum levels suggest cardiac damage.
Which cue would alert the nurse that the patient may have a gustatory alteration? Uses a lot of salt on foods Asks the nurse to repeat questions Experiences tingling and numbness in the feet Has a right cloudy eye lens
Uses a lot of salt on foods Using a lot of salt on foods would alert the nurse that a gustatory (taste) alteration may be occurring.
Which cranial nerve is affected in sensorineural hearing loss? VI VII VIII IX
VIII Cranial nerve VIII (vestibulocochlear) is the nerve affected in sensorineural hearing loss.
Which cues are expected with a patient who has Ménière disease? Vertigo Progressive hearing loss Loss of taste Wernicke aphasia Tinnitus
Vertigo Progressive hearing loss Tinnitus-ringing in ears
Which cues are associated with Alzheimer disease? Wandering Sundowning Memory loss Repetitive behaviors Sudden onset of confusion. Extreme feelings of hopelessness
Wandering Sundowning Memory loss Repetitive behaviors
