RLE

15

A 75-year-old male rubs his chest and tells you it really hurts. He tells you he wants to go to the hospital, and you help him walk to the stretcher. What is his Glasgow Coma score?

anthropometric measurements

A comprehensive nutritional assessment always includes:

eye opening response

A neurological examination is systematic method of assessing the integration of brain function and motor response. Abnormalities often reflect impairment to the brain of spinal cord. What aspect of Glasgow Coma Scale assesses the function of the reticular activating system (RAS) extending from brainstem through the thalamus to the cerebral cortex?

Phase 5 is the first tapping sound heard during deflation of the cuff and is the systolic blood pressure.

A nurse is evaluating a nursing student's understanding of Korotkoffs sounds. Which of the following statements demonstrates a need for further teaching?

hypothermia

A patient has been brought to the Emergency Room after being rescued from an accident in a ski resort. She has been exposed to the freezing temperaturesfor hours already and is in a stuporous state. The patient has been suffering which of the following alterations in body thermoregulation?

constant fever

A patient has sought consultation due to fever episodes. She describes her fever as episodes that fluctuate minimally but always remains above 37.7 degreesCelcius for about 5 days already. The OPD nurse documents this as:

heatstroke

A patient reports that she has been exercising in hot weather; she feels warm, is flushed, and is not sweating. Her temperature is 41 degrees Celcius andshe just experienced a seizure. What condition is the patient most likely experiencing?

Heatstroke

A patient reports that she has been exercising in hot weather; she feels warm, is flushed, and is not sweating. Her temperature is 41°C and she just experienced a seizure. What condition is the patient most likely experiencing?

Unequal pupil size

A patient was admitted into the ward is at risk for Increased Intracranial Pressure (ICP). Which of the following is a priority of the Nurse on Duty to monitor?

I'll stay with you" (gets a tissue).

The patient is crying after being given a diagnosis with a poor prognosis. The best response from the nurse is which of the following?

positive Romberg sign.

The patient sways and starts to fall when asked to stand with feet together and arms at sides with the eyes closed. This finding would be documented as a:

check what the client's temperature was the last time it was taken.

The patient's temperature at 8 am using an oral electronic thermometer is 36.1 degrees Celsius. If the respiration, pulse, and blood pressure were withinnormal range, what would the nurse do next?

erroneously low

The student nurse had positioned the arm of the patient above the level of the patient's hand. The nurse on duty expects that the reading of the bloodpressure will be:

between fourth and fifth intercostal space at the left midclavicular line.

The student nurse was tasked to get the apical pulse of the patient who has episodes of arrhythmia. She is correct when she places the stethoscope on whichof the following site?

"How would you describe yourself?"

To assess self-perception, the nurse asks which of the following?

interphalangeal joint pressure

Which is an example of peripheral painful stimuli?

Pulling the pinna straight back and upward

Which of the following actions by a nurse would be incorrect when taking an adult's temperature using a tympanic thermometer?

Arm above the level of the heart

Which of the following can cause an erroneously low blood pressure result?

Essential Fats

Which of the following is known as the amount of fat necessary for maintenance of life and reproductive functions?

History Taking

Which of the following is known to be the most important part of Patient Assessment?

36

Which of the following is the BMI of someone who is obese?

Both Height and Weight

Which of the following parameter is used to calculate for Body mass Index of a patient?

Obesity

Which of the following refers specifically to adults with a BMI of 30 or higher.

Oxygen saturation of 89%

Which of the following values for vital signs would the nurse address first

general appearance

Which of the following will the nurse assess first when doing a head to toe examination?

Carotid Pulse

Which of the pulse points is located along the anterior border of the sternocleidomastoid muscle?

Palpation

Which of these techniques uses the sense of touch to assess texture, temperature, moisture, and swelling when the nurse is assessing a patient?

4 am to 6 am

Which time of day would we have the lowest temperature reading?

dysrhythmia

The patient has reported having random, irregular beats 30 minutes after she took her heart medications. The nurse documents this as:

Prehypertension

An adult blood pressure reading of 120/80 mm Hg is:

Resting Metabolic Rate (RMR)

Another factor contributing to Overweight and Obesity includes the BMR plus any additional energy expended through daily sedentary activities. This is known as?

supra-orbital pressure is to be used with orbital, skull, facial fractures, or frontal craniotomies.

Central Painful Stimuli is used to elicit s motor response done by stimulating a cranial nerve, thus avoiding the possibility of eliciting a spinal reflex. What is NOT TRUE for eliciting central painful stimuli?

pain

Considered the 5th vital sign:

Fever

Constant, remittent and intermittent are classifications of:

adial pulse

During a return demonstration, the instructor has asked the student nurse to identify which of the following sites is the usual site and less invasivefor assessing a patient's pulse rate?

30-45 seconds

For a client with a previous blood pressure of 138/74 mmHg and pulse of 64 beats/min, approximately how long should the nurse take to release the blood pressure cuff in order to obtain an accurate reading?

Hypothalamus

Regulator of body temperature:

Character and Onset

In assessing using the COLDSPA Structure, C and O Stands for?

Morbid Obesity

It is known as having a body weight 100 percent or more above healthy recommended levels; in an adult, having a BMI of 40 or more considered to be which of the following?

Basal Metabolic Rate

It is known as the rate of energy utilization in the body required to maintain essential activities such as breathing?

Radiation

It is known as the transfer of heat from the surface of one object to the surface of another without contact?

Body temperature

It is the degree of body heat maintained by a person's body.

Pulse rate

It is the result of the rhythmical beating and throbbing of blood in the arterial blood vessel that results from a wave of blood passing through the artery as the ventricles of the heart contracts:

A client being prepared for elective facial surgery with a history of stable hypertension

It would be appropriate to delegate the taking of vital signs of which client to unlicensed assistive personnel?

left upper arm and is measured at the mid-point between the tips of the shoulder and elbow

Mid Uppper Arm Circumference is the circumference of which of the following?

level of consciousness

Nurse Ann has her patient come in and proceeds to ask him his name, his date of birth, if he knows where he is, and what day of the week it is. In doing this Nurse Ann is testing her patient's what?

Complaints of pain associated with numbness and tingling in both feet

Nurse Biden is volunteering with an outreach program to provide basic health care for homeless people. Which finding, if noted, should be addressed first?

"I will be sure to cue in to any indicators that the client may be exaggerating their pain."

Nurse Grace is precepting a new graduate nurse who is assigned to care for a client with chronic pain. Which statement made by the graduate nurse, indicates the need for further teaching regarding pain management?

Heatstroke

Patient reports that she has been exercising in hot weather; she feels warm, is flushed, and is not sweating. Her temperature is 41°C and she just experienced a seizure. What condition is the patient most likely experiencing?

Tachycardia

Pulse rate faster than 100 beats per minute:

the transfer of heat from one molecule to a molecule of lower temperature.

Student Nurse Anne is discussing with the patient the principles of Heat Loss. She is correct when she defined CONDUCTION as:

intermittent

Student Nurse Lovely is having a discussion regarding hyperthermia with her classmates. She is asked which type of fever is a patient experiencingwhen the body temperature alternates at regular intervals between periods of fever and periods of normal or subnormal temperatures. She is correct whenshe answers which of the following?

weight-related health risk

The BMI score is a screening tool which helps in the assessment of which of the following?

Decrease in the level of consciousness

The Nurse on Duty is assessing a patient admitted in the ward with an increasing intracranial pressure. The Nurse on Duty should notify the physician about which early change in their patient's condition?

hypothalamus

The class is discussing how the body regulates heat. Student Nurse Mary is correct if she answers which following statements when asked what is the organthat acts as a thermostat that regulates the core temperature of the body?

Clients who wear dentures.

The following are the contraindications in obtaining oral temperature EXCEPT:

To treat abnormal findings

The following are the purposes of Vital signs EXCEPT:

Measure mid-upper arm circumference (MUAC)

The measurement evaluates the skeletal muscle mass and fat stores is refers to which of the following?

An indication of basic body functioning

The most appropriate definition of Vital Signs:

Sim's

The most appropriate position in obtaining a rectal temperature for an adult would be?

You seem worried, but I need to ask a few questions."

The mother of an infant with severe asthma is extremely anxious. The nurse is treating the client in the Emergency Room. When collecting the history, the best response of the nurse is which of the following?

75 to 120 bpm

The normal pulse rate foe 6 years old is:

60-100 bpm

The normal pulse rate for an adult is:

30 to 40 respirations/minute

The normal respiratory of an infant is:

Values

The nurse asks, "What are the most important things to you in life?" to assess the functional pattern related to:

sensory deficits, illness history, and lifestyle factors.

The nurse assessing an older adult focuses the health history on which of the following?

Underweight

The nurse calculates a body mass index (BMI) of 18 for a young adult woman who comes to the physician's office for a college physical. This patient is considered:

Dorsal surface of the hand

The nurse is assessing a patient's skin during an office visit. What part of the hand and technique should be used to best assess the patients skin temperature?

a systematic approach to obtaining subjective information.

The nurse is completing a Review of Systems during a health assessment. The nurse knows that the ROS is considered:

working phase.

The nurse is gathering the health history data before performing the physical assessment. This phase of the interview process belongs to which of the following?

Observing the patient's body stature and nutritional status

The nurse is performing a general survey. Which action is a component of the general survey?

Do you accidentally urinate when you sneeze, laugh, cough, or bear down?"

The nurse is preparing a questionnaire to assess stress incontinence in a patient. Which is the most important question that should be asked by the nurse?

Organizes the assessment to ensure that the patient does not change positions too often.

The nurse is preparing to perform a physical assessment. The correct action by the nurse is reflected by which statement? The nurse:

Examiner to build rapport and to increase the patient's confidence in him or her.

The nurse keeps in mind that the most important reason to share information and to offer brief teaching while performing the physical examination is to help the:

expressive aphasia.

The nurse on duty notices that a patient is able to understand what is said but has trouble formulating a response. The nurse suspects:

uses subjective data to analyze findings and intervene.

The nurse performs patient teaching after assessing that the nutritional history reveals that the patient generally consumes a high-fat, high-calorie diet. This critical thinking:

ADLs.

The nurse who asks about feeding, bathing, toileting, dressing, grooming, mobility, home maintenance, shopping, and cooking is assessing which of the following?

Palpation

The nurse will use which technique of assessment to determine the presence of crepitus, swelling, and pulsations?

Palpating the kidneys and uterus

The nurse would use bimanual palpation technique in which situation?

hyperpyrexia

What is another term for a very high fever which its medical criterion is someone is running a body temperature of more than 106.7 degrees Fahrenheit or41.5 degrees Celcius?

Bradycardia

What is known as a slower than normal heart rate?

3

What is the Glasgow Coma Sore for a patient who is pulseless and apneic?

Weight and Height

What two pieces of information do you need to know about yourself to figure out your BMI?

How would you rate your pain on a scale of 0 to 10?"

When assessing pain intensity, which question should the nurse ask as part of a history of present illness?

inserting lines between parents to show marriage.

When gathering the family history, the nurse draws a genogram in which of the following?

Inspection.

When performing a physical assessment, the first technique the nurse will always use is:

The client will ambulate to the end of the hallway within 2 days.

When planning nursing care for a client, objectives should be SMART. Specific, measurable, action-oriented, realistic, and timely. Which example best describes an outcome that is measurable??

the presence of abnormalities

When temperatures with baseline and normal temperature ranges are compared, what is normally revealed?

Since there is no evidence of distress or urgency, postpone the measurement until later.

When the nurse enters a client's room to measure routine vital signs, the client is on the phone. What technique should the nurse use to determine the respiratory rate?

Conduction

Which among the heat transfer is the transfer of heat from one molecule to a molecule of lower temperature?

Convection

Which among the transfer of heat where there is a dispersion of heat by air current?

Head-to-toe approach

Which approach to a complete physical assessment should be used for an adolescent?

A client with an arrhythmia

Which client meets the criteria for selection of the apical site for assessment of the pulse rather than a radial pulse?

"Stand with feet together and eyes open then closed."

Which instruction would the nurse give to a patient while performing the Romberg test?