N309 Exam 1 Quickie Quizzes
Mrs. Williams is an 89-year-old independent woman who lives alone and has severe arthritis in her hands. Over the last few months the arthritis has gotten worse and she is concerned because she can no longer clean her apartment. What question by the nurse would gain the most usable information to assist with this concern?
"Do you have family who visit you regularly?"
Considering the acronym OLD CART, the nurse is asking a newly admitted patient questions during the assessment process. The patient is a 35-year-old man who presents with pain in the upper arm since lifting weights 3 days ago. What question would be appropriate to ask that would give information for the "D" in the acronym?
"Does the pain come and go or is it constant?"
When trying to explore a patient's perspective on his or her illness, the question that would best determine the patient's thoughts on the cause of the problem would be:
"Why do you think you have (name the specific symptom)?"
When the nurse is performing a physical examination on admission of a patient to the medical unit, the patient says the doctor already did an exam. The best response by the nurse would be:
"the doctor focuses on the treatment of the disease process and the nursing assessment focuses more on the body's response to the disease."
A patient has a moderate risk for developing pressure ulcers. The nurse would expect the Braden score to be
13-14
The nurse is performing a Braden assessment on a 62-year old retired man. The nurse documents no impairment in sensory perception, skin usually dry, sitting in a chair most of the day with ambulation short distances outside the room three times a day, and making frequent changes in position. The nurse would record those portions of the Braden score as
15
When answering questions about health during a presentation at a women's club luncheon, the nurse emphasizes that prevention of disease is multifaceted but is connected directly to:
A healthy lifestyle
Which of the following patients would be classified as having chronic pain?
A patient with rheumatoid arthritis
A new RN tells her preceptor that she has always had trouble remembering all the steps of the nursing process. The preceptor tells the new grad that an easy way is to think about the anagram:
ADPIE
Acute shortness of breath is a medical emergency. Immediate assessments are necessary. What is the priority assessment the nurse would make with a patient who has acute shortness of breath?
Auscultate the lungs
Which of the following are considered an anthropometric measurement?
BMI, triceps skin fold, midarm muscle circumference
The nurse has completed an assessment on a new patient. After gathering the data, formulating a nursing diagnosis, and developing a plan of care, it is important for the nurse, before finalizing the plan, to:
Discuss the plan with the patient
The nurse percusses the lungs of a patient with pneumonia. What percussion note would the nurse expect to document?
Dullness
If the nurse who is conducting the interview feels uncomfortable asking about certain subjects, then it is okay to ignore those questions.
False
OLD CART is a mnemonic that will help the nurse remember the steps in the nursing process.
False
Smoking is a habit that only affect the individual who smokes.
False
To help with management of the patient's pain, a nurse should focus on the four A's to monitor a patient's outcome: analgesia, ADLs, adverse effects, and acceptable drug related behaviors.
False
The nurse is grouping subjective and objective data. Which data would the nurse list as subjective?
Headaches began 3 days ago
Staff are talking to the hospital educator and ask about "a government project that is meant to improve the health of people in the United States." The educator bases her response on the knowledge of:
Healthy People 2020
The nurse collects vital signs on a client with pain. Which of the following would indicate to the nurse that the client is experiencing pain?
Heart rate of 110 BPM
The nurse gathers the follow data: complaint of headache and sore throat, redness noted on pharynx with white exudates on tonsils, minimal cough, temperature 100.6%F orally. It was noted that the patient had another sore throat 2 weeks ago. The most appropriate nursing diagnosis for this data would be:
Impaired comfort related to headache and sore throat pain
The first technique in your physical assessment is
Inspection
When auscultating the lungs, the nurse listens over symmetrical lung fields for which of the following?
One deep inspiration and expiration through an open mouth.
A good tool to use to assess alcohol and drug use is the:
PAGE questionnaire
Which statement would demonstrate the correct method for writing an evaluation of patient progress after implementing the nursing process?
Patient ambulated 3/3 times during a planned 8-hour period
The nurse is developing goals after completing the assessment of a newly admitted medical patient. The nurse would document the goals under which part of the nursing process?
Planning
During a health class, the nurse is emphasizing exercise and healthy eating. The level of prevention being utilized by the nurse is:
Primary prevention
A patient in the Emergency Department is diagnosed with myocardial infarction (heart attack). The patient describes pain in his left arm and shoulder. What name is given to this type of pain?
Referred pain
The nurse discusses ear plugs for a patient with low tone deafness when working in a noisy environment. The nurse is utilizing:
Tertiary prevention
Which of the following would the nurse use as the primary assessment for a client's pain?
The client's report of the pain
Your patient has multiple sclerosis (MS). Neuromuscular disorders such as MS may lead to decreased vital capacity. What does vital capacity measure?
The maximum volume of air exhaled from the point of maximum inspiration.
You are teaching a physiology class for pre-nursing students. A student asks what the purpose of the upper airway is in regard to the lower airway. What would be your best answer?
To warm inspired air
The patient is positioned in a recumbent position. Which approach should the nurse take to assess the patient's lung fields for a patient in this position?
Turn the patient to assess all lung fields so the dependent areas can be assessed for breath sounds.
A patient hospitalized 3 days ago has a normal albumin level. The patient is most likely to be
Well nourished 1 month ago, but prealbumin is a more current indicator
A young toddler is brought to the emergency room by his parents. The mother states that the child was playing on the floor with toys and suddenly began to wheeze. The mother reports no recent illnesses. The nurse suspects that the most likely cause of the wheezing is
a foreign body obstruction
When a nurse assesses a 78 y/o client with pneumonia, which finding should be evaluated first?
airway patency
If your patient has a skin rash, you should ask specific questions to determine whether either of the patient's parents a history of
allergies
The nurse caring for a patient diagnosed with a 2nd rib fracture should know the location of the sternal angle also called what?
angle of Louis
When listening to heart sounds, you can hear S1 best at the
apex of the heart
You are caring for a patient with COPD. During your shift assessment you find your patient is experiencing a change in his respiratory and mental status. You are aware the most accurate measurement of the concentration of O2 in the blood is what?
arterial blood gas
Skin temperature is best assessed with the
back of the hand
A 65y/o client comes in for a follow-up after having a basal cell lesion removed from his face. When teaching the client how to inspect his skin for signs of melanoma, the nurse should tell the client to look for
black or purple irregularly shaped nodules
False low blood pressure can occur with
cuff too large, pressing stethoscope too tightly against pulse, repeating assessment too quickly
What characteristic nail color should the nurse recognize as an indication of hypoxia?
cyanotic (blue)
During your physical examination of the patient, you gently pinch the back of her hand. The skin remain in a "tent" shape and slowly returns to its normal position. This is a sign of:
dehydration
Dyspnea is a general symptom of several different disease processes. Some factors that may aggravate it are:
exertion, lying down, inhaled irritants
When auscultating the anterior chest on a large-breasted women, the nurse should:
gently move the breast tissue to the side.
Vesicles in a unilateral dermatomal pattern are typical of
herpes zoster
As you assess your patient, you note clubbed fingers. This is a sign of
hypoxia
During a nutritional assessment, a patient's serum transferrin level helps you assess the patient for
liver damage
Asymmetric borders on a lesion suggest a
malignant lesion
During percussion, you hear a flat sound. The most likely source of this sound is:
muscle
The patient with psoriasis is admitted to a medical unit for unrelated reasons. When documenting the type of lesion represented by psoriasis, the nurse should document a
plaque
The serum albumin test assesses
protein levels in the body
When patients are unconscious, the most appropriate route for taking a temperature is:
rectal
Which of the following indicators would be most likely to signify to the nurse that the patient is having pain?
rubbing a body part
The nurse documents vesicular lung sounds upon auscultation. The nurse heard what type of sound?
sound heard throughout inspiration and two thirds expiration
A 76 y/o client is diagnosed with iron deficiency anemia. Which finding should the nurse expect when assessing this client's nails
spoon shape
A patient undergoes a biopsy to confirm a diagnosis of skin cancer. Immediately following the procedure, the nurse should observe the site for
swelling
An adult patient is assesses as having an apical pulse of 140. How would a nurse document this finding?
tachycardia
The nurse tells a newly admitted patient that she is going to do a health assessment to help in planning care and educational needs during the patient's hospital stay. Before the physical examination, the nurse should first:
take a complete health history
The nurse is going to take a blood pressure on a patient who has had a previous left mastectomy with lymph node dissection. What would be an appropriate action by the nurse?
take the blood pressure in the right arm
Functions of the skin include
temperature control, provides protection, sensory perception
What is the phrase that defines the volume of air inspired and expired with a normal breath?
tidal volume
The fingernails can provide important clues to the patient's respiratory system
true
A patient appears in the clinic with a cough that began 24 hours prior to coming to this visit. The nurse evaluates the patient based on the most common cause of an acute cough, which is
viral respiratory infection
The nurse is caring for a patient with malignant melanoma. She explains that the first and most important treatment for malignant melanoma is
wide excision