Week 3- HEALTH ASSESSMENT LECTURE + LAB

Match the graded pulse with the appropriate description. 0, 1+ , 2+ , 3+ A) absent B) easily palpable C) weak, barely palpable D) increased, full, bounding

3+, increased, full, bounding 2+, easily palpable 1+, weak, barely palpable 0, absent

The nurse notices that a patient has ascites, which indicates the presence of: A) Fluid B) This is a normal finding C) Whoosing sound of the heart D) Regular bowel movement sounds

A) Fluid

What conditions normally skew the normal capillary refill times? Select all that apply A) a cool room B) decreased body temperature C) cigarette smoking D) peripheral edema E) anemia F) angina

A) a cool room B) decreased body temperature C) cigarette smoking D) peripheral edema E) anemia

Arteries are: A) high pressure, tough, strong elastic, unoxygenated B) have large diameters, low pressure, capacitance vessel (high volume, intraluminal valves. Moves due to muscles and respiratory system, oxygenated. A) high pressure, tough, strong elastic, oxygenated. B) have large diameters, low pressure, capacitance vessel (high volume, intraluminal valves. Moves due to muscles and respiratory system, unoxygenated.

A) high pressure, tough, strong elastic, oxygenated.

Which explanation should be given to the patient for crossing the arms on the chest during the transfer? A. "Crossing your arms on your chest helps prevent injury to the arms." B. "Crossing your arms on your chest helps prevent the IV catheter from pulling out." C. "Crossing your arms on your chest helps to monitor blood pressure during the transfer." D. "Crossing your arms on your chest helps to identify your arm band."

A. "Crossing your arms on your chest helps prevent injury to the arms." Rationale: During the transfer, having the patient cross the arms on the chest helps prevent injury to the arms during transfer. Having the patient cross the arms may or may not prevent an IV catheter from pulling out. The arms do not need to be crossed to assess the patient's blood pressure. Verifying the correct patient should be done before the transfer.

The patient's family is being taught how the patient will be moved from the bed to a wheelchair at home. The patient has normal weight-bearing capacity and normal upper-body strength. Which response is the most appropriate safety advice? A. "Help your family member to the side of the bed, maintain that position for a moment, and determine if there is any dizziness or pain." B. "When your family member is sitting on the side of the bed, bring the wheelchair to a 45-degree angle and move your family member into the chair." C. "A transfer belt is not needed because your family member has good strength and mobility." D. "When moving to the wheelchair, stay behind your family member at all times. You may need to hold your family member under the arms to ease into the chair."

A. "Help your family member to the side of the bed, maintain that position for a moment, and determine if there is any dizziness or pain." Rationale: When moving a patient to a chair, the family should allow the patient to sit on the side of the bed to stabilize blood pressure, reducing the risk of dizziness. A transfer belt enhances patient safety. A family member should remain in front of the patient to use good body mechanics during the transfer. A family member should never count on being able to hold the patient and get the patient into position without assistance. The patient should not be lifted from under the axilla.

Which statement by the patient's assigned nurse would not be appropriate before moving a patient up in bed. A. "You can remain still; please do not try to help push up in the bed." B. "I am going to get assistance to help pull you up in the bed." C. "Tell me about your level of pain before we move you up in the bed." D. "I am going to be careful with these tubes and IV lines when moving you."

A. "You can remain still; please do not try to help push up in the bed." Rationale: The patient should be allowed to assist as much as possible during interventions. The patient should not be cautioned against helping unless doing so would cause complications or difficulties. Obtaining assistance makes repositioning easier. Assessing pain before repositioning allows the nurse to decrease painful movements. The nurse should ensure that tubes and lines are secured while moving the patient.

The health care team member is evaluating an older adult patient who is obese for transfer and recognizes that the patient has limited mobility. Which transfer method should the health care team member use? A. A ceiling lift B. A slider board C. A transfer belt D. Three or four additional health care team members to help

A. A ceiling lift Rationale: The ceiling lift is the safest method to use for preventing health care team member injury and providing patient safety. Lifts are designed to allow patient transfers with a minimum of physical effort, resulting in a decreased potential for injuries to the patient and health care team members. A transfer belt can only be used if the patient is able to stand to transfer. A slider board requires additional help and is not the best option if the patient is obese. Additional health care team members may be used but not without a transfer aid to prevent injury.

When the number of health care team members is limited and the patient cannot assist, which device is the safest for transferring the patient from bed to chair? A. A hydraulic lift B. A slider board C. A transfer belt D. Nonskid shoes

A. A hydraulic lift Rationale: A hydraulic lift may be used safely by one health care team member. A slider board requires three health care team members. A transfer belt and nonskid shoes can be used if the patient is able to stand to transfer. At least two health care team members are required for a patient who is unable to assist.

When using a hydraulic lift, the health care team member should select the hammock style sling for which patient? A. A patient who is weak and flaccid B. A patient who has normal muscle tone C. A patient who has a spinal injury at T12 or below D. A patient who does not want to transfer independently

A. A patient who is weak and flaccid Rationale: Of the two types of slings that are supplied with a mechanical or hydraulic lift, hammock style and canvas strips, the hammock style is better for patients who are flaccid and weak. These patients need the support of the hammock, which covers more of the patient's body surface area and thereby lifts more of the body. The canvas strips can be used for patients with normal muscle tone. The seat selection is based on a patient's muscle tone, not necessarily on spinal injury or the patient's motivation to transfer.

When transferring a patient with a head trauma from the bed to a stretcher, the health care team member should perform which action? A. Assess the patient for cognitive deficits and simplify instructions as appropriate. B. Ensure that the patient's arms are kept at the patient's sides. C. Monitor the patient's intracranial pressure before and after the transfer. D. Explain to the family that the transfer cannot occur until the patient is awake and alert.

A. Assess the patient for cognitive deficits and simplify instructions as appropriate. Rationale: Patients with head trauma or stroke may have perceptual cognitive deficits that create safety risks. If the patient has difficulty with comprehension, the health care team member should simplify instructions and maintain consistency. Keeping the patient's arms at the sides risks injury to the arms. Placing the arms on the patient's chest helps prevent injury to the arms during transfer. Monitoring intracranial pressure before and after a transfer from the bed to a stretcher is not necessary. Families should be taught about necessary precautions for transferring the patient safely.

When the patient is able to assist and two nurses are working together to move the patient up in bed, one nurse should instruct the patient to perform which action? A. Assist by pushing down with the feet on the bed surface. B. Lift the feet while being shifted. C. Take a deep breath while being moved. D. Roll to a side-lying position immediately before being moved.

A. Assist by pushing down with the feet on the bed surface. Rationale: When the patient is able to assist, the patient should push down with the heels and elevate the trunk during the move. Lifting the feet increases the workload during a move. The patient should be instructed to breathe out, not take a large breath in, during the move, thereby avoiding the Valsalva maneuver. The patient should lie supine while being moved up in bed.

An older female adult is being educated about preventing bone demineralization. Which instruction should be included in the patient's education plan? A. Begin a proper weight-bearing exercise program. B. Avoid exercise that requires weight bearing of the lower extremities. C. Postmenopausal patients who are not taking estrogen require low doses of calcium. D. Avoid vitamin D supplements if taking calcium.

A. Begin a proper weight-bearing exercise program. Rationale: To reduce bone demineralization, the health care team member should instruct older adult patients to begin a proper weight-bearing exercise program that includes activity three or more times a week. Increased vitamin D aids in calcium absorption. Postmenopausal patients who are not taking estrogen should consume increased doses of calcium daily.

The nurse performing a physical examination notices that the skin of the patient's lower extremities is pale, cool, thin, and shiny. The patient's nails are thickened, and there is little hair growth on the extremities. The nurse should consider that the patient may have which problem? A. Chronic arterial insufficiency B. Hypotension C. Heart murmur D. DVT

A. Chronic arterial insufficiency Rationale: Classic signs of chronic arterial insufficiency in the lower extremities include pale, cool, thin, and shiny skin with reduced hair growth. Nail beds on the feet are thickened. Symptoms of DVT include leg pain and warm, firm, and swollen legs. Hypotension may result in dizziness, lightheadedness, and faintness. Murmurs may cause fainting but do not affect the lower extremities.

Which assessment tool is used to measure a patient's LOC? A. Glasgow Coma Scale B. Snellen chart C. Rosenbaum chart D. Six cardinal positions of gaze examination

A. Glasgow Coma Scale Rationale: The Glasgow Coma Scale is used to assess a patient's LOC. The Snellen chart is used to assess the patient's distance vision and the Rosenbaum chart is used to assess the patient's near vision. The six cardinal positions of gaze examination are used to assess extraocular eye movement.

A patient complaining of palpitations is admitted to the unit. The nurse auscultates the patient's heart sounds and notes a murmur. The nurse should assess which characteristics of the murmur? A. Intensity and pitch B. Location and depth C. Pitch and depth D. Location and pitch

A. Intensity and pitch Rationale: Characteristics of murmurs, such as intensity and pitch, help identify contributing factors. Intensity of a murmur is related to blood flow through the heart or the amount of blood regurgitated. Pitch depends on the velocity of blood flow through the valves. Location and depth are not characteristics that are helpful in identifying contributing factors.

When assessing a patient's LOC, the health care team member observes that the previously alert patient cannot provide a name or current location. What should the health care team member do next? A. Notify the practitioner immediately. B. Report this change in response at the change of shift. C. Reassess the patient in 4 hours. D. Document the patient's unwillingness to cooperate.

A. Notify the practitioner immediately. Rationale: The practitioner should be notified immediately of this change. A fully conscious patient is oriented to name, time, and current location. As consciousness diminishes, the patient may show an unwillingness to cooperate. The deterioration in LOC should not be disregarded for any period because the patient may deteriorate further in that time. Documenting unwillingness to cooperate does not result in interventions to treat the underlying problem.

Which potential complication can occur during the transfer of a patient who has been immobile for several days? A. Orthostatic hypotension B. Cardiac arrhythmia C. Chest pain D. Nausea

A. Orthostatic hypotension Rationale: A patient who has been immobile for several days or longer may develop orthostatic hypotension or become dizzy during a transfer. Transferring a patient is unlikely to cause an arrhythmia or chest pain unless there is an underlying cardiac history. Nausea may be a result of orthostatic hypotension but not because of the transfer.

Which patient activity has the highest risk for falling? A. Patient toileting B. Walking in the hallway C. Moving from bed to chair D. Sitting on the side of the bed

A. Patient toileting Rationale: Patient toileting is a high-risk activity. If the patient is at risk for falling, a health care team member should stay with the patient while toileting. Patients can fall while walking in the hallway, moving from bed to chair, and sitting on the side of the bed, but the risk is higher when the patient is toileting.

A patient arrives in the emergency department reporting nausea, flu-like symptoms, indigestion, back pain, and exhaustion. Initially, the nurse should perform which action? A. Perform only portions of the cardiovascular examination that are absolutely necessary B. Perform a thorough cardiovascular assessment of the patient, including risk factors, family history, and smoking behaviors C. Perform a thorough gastrointestinal assessment of the patient D. Perform only portions of the gastrointestinal examination that are necessary

A. Perform only portions of the cardiovascular examination that are absolutely necessary Rationale: The patient has atypical signs of chest pain. A patient who presents with signs or symptoms of heart problems, such as chest pain, may be suffering a life-threatening condition requiring immediate attention. The nurse should act quickly and perform the portions of the examination that are absolutely necessary. Later, when a patient's condition is stable, a more thorough assessment can reveal baseline heart function and risks for heart disease. Although these symptoms may suggest a gastrointestinal illness, they are also atypical signs of chest pain, a life-threatening condition that takes priority over gastrointestinal illness.

A patient, who is receiving peritoneal dialysis, suddenly develops abdominal pain, nausea and vomiting, and positive Blumberg, Markle, and Balance signs. Which is the most likely cause of these symptoms? A. Peritonitis B. Appendicitis C. Cholecystitis D. Pancreatitis

A. Peritonitis Rationale: Peritonitis is associated with sudden or gradual onset of pain generalized or localized, dull or severe and unrelenting. The patient may have shallow respirations; positive Blumberg, Markle, and Balance signs; reduced or absent bowel sounds; nausea and vomiting; and positive obturator and iliopsoas signs. Appendicitis pain is initially periumbilical or epigastric and colicky. The patient may have guarding; tenderness; and positive Aaron, Rovsing, Markle, and McBurney signs. Cholecystitis presents with severe, unrelenting right upper quadrant or epigastric pain; epigastric tenderness and rigidity; and A positive Murphy sign. Pancreatitis presents with dramatic, sudden, excruciating left upper quadrant pain; epigastric tenderness; vomiting; fever, shock; a positive Grey Turner sign; and a positive Cullen sign.

Which evidence-based intervention is effective in reducing falls in a nursing unit? A. Purposeful rounding by health care team members B. Reduction of noise C. Place patient at risk for falls closer to the nurses' station D. Use of raised bed rails

A. Purposeful rounding by health care team members Rationale: Purposeful rounding by health care team members that addresses patient needs, such as toileting, pain, and positioning, can greatly reduce patient falls. The use of raised bed rails should be based on the individual patient needs and reviewed regularly. Greater injury can result from falling while climbing over a raised bed rail. Reducing noise on the unit addresses patient comfort and sleep needs but is not a factor in patient falls. Placing a patient closer to the nurses' station may be effective if the patient requires increased visual monitoring.

The health care team member preparing to transfer and position the patient in a chair should plan to implement which intervention? A. Remain in front of the patient until the patient regains balance. B. Delay the transfer if the patient is very weak. C. Withhold the transfer if the patient is cognitively impaired. D. Provide the patient with a call button before resuming duties.

A. Remain in front of the patient until the patient regains balance. Rationale: After transferring the patient, the health care team member should remain in front of the patient until the patient regains balance and continue to provide physical support if the patient is weak or cognitively impaired. Withholding the transfer because the patient is weak or cognitively impaired is not appropriate. Mobility is an important intervention in the healing process. The health care team member should provide the patient with a call button but should not walk away until the patient regains balance.

A nurse observes that a patient with obesity has slipped down in bed. Which statement describes how the nurse and an additional health care team member should move the patient up in bed if the patient can assist? A. Standing next to the bed near the patient's upper body, positioning one arm under the patient's head and the opposite shoulder, positioning the arm under the patient's closer shoulder and arm, and asking an additional health care team member to assume the proper position at the patient's lower torso. B. Standing next to the bed near the patient's upper body, positioning one arm under the patient's head and shoulder, positioning the other arm under the patient's torso, and asking an additional health care team member to assume the proper position at the patient's feet. C. Pulling the patient up in bed with the hands placed under the patient's head and shoulders while the patient pushes up with both legs and asking an additional health care team member to assume the same position. D. Having the patient pull up using the bed rails while the health care team members assume a position at the patient's lower torso with arms under the patient's lower back and torso and push up on the patient's legs.

A. Standing next to the bed near the patient's upper body, positioning one arm under the patient's head and the opposite shoulder, positioning the arm under the patient's closer shoulder and arm, and asking an additional health care team member to assume the proper position at the patient's lower torso. Rationale: If the patient can assist, one of the health care team members should be positioned at the patient's upper body, with the arm nearer the head of the bed under the patient's head and opposite shoulder and the other arm under the patient's closer arm and shoulder. An additional health care team member should be positioned at the patient's lower torso to provide support for the even distribution of the patient's weight. The patient should be moved up in bed with at least two additional health care team members to avoid injuring the nurse. Having the nurse or health care team member push up on the patient's leg is not proper technique and may cause harm to the team member or the patient.

Which information should the health care team member know regarding safe patient transfer and positioning? A. The equilibrium of an object is maintained as long as the line of gravity passes through its base of support. B. Alternating balanced activity between arms and legs reduces the risk of back injury. C. When friction is added between the object to be moved and the surface on which it is moved, less force is required to move it. D. Facing away from the direction of movement prevents abnormal twisting of the spine.

A. The equilibrium of an object is maintained as long as the line of gravity passes through its base of support. Rationale: The principles of safe patient transfer and positioning include: The equilibrium of an object is maintained as long as the line of gravity passes through its base of support; dividing balanced activity between arms and legs reduces the risk of back injury; when friction is reduced between the object to be moved and the surface on which it is moved, less force is required to move it; and facing the direction of movement prevents abnormal twisting of the spine.

The health care team member and an orientee are transferring a patient from the bed to a stretcher. Which action by the orientee indicates the need for further education? A. The orientee does not lock the stretcher. B. The orientee lowers the head of the bed as much as the patient can tolerate. C. The orientee has the patient cross the arms for transfer. D. The orientee places the slide board under the drawsheet.

A. The orientee does not lock the stretcher. Rationale: The orientee should lock the stretcher brakes so the stretcher does not move during the transfer. If the stretcher is not locked, it could move and place the patient at risk for injury. The orientee should lower the head of the bed as much as the patient can tolerate for the transfer. The patient should cross the arms on the chest to help prevent injury. The slide board should go under the drawsheet when the patient is ready to transfer.

When assessing jugular venous pressure, the nurse has the patient assume a supine position and raises the head of the bed slowly. The nurse notices the patient continuing to have pulsation as the head of the bed is raised past 45 degrees. What is the nurse's assessment of the patient's fluid status? A. The patient's fluid status may be overload. B. The patient's fluid status is normal. C. The patient's fluid status is dry. D. The patient's fluid status is variable, as indicated by the change of position.

A. The patient's fluid status may be overload. Rationale: Increased pulsation height may indicate fluid overload or right-side heart failure and is not a normal finding. Normally, veins are flat when the patient is sitting, and pulsations become evident as the patient's head is lowered. The patient's fluid status is not normal, and the patient is not dry. The change in pulsation does not indicate a variable status. It would be normal for pulsation to decrease as the patient sits up.

To transfer a patient from the bed to a stretcher, the health care team member uses a slide board for which reason? A. To decrease physical stress on team members performing the transfer B. To decrease the number of team members needed C. To allow the patient to transfer independently D. To decrease the patient's risk of falling during the transfer

A. To decrease physical stress on team members performing the transfer Rationale: Physical stress can be decreased significantly by the use of a slide board or friction-reducing board positioned under a drawsheet beneath the patient. The slide board is used to decrease physical stress but does not necessarily reduce the number of health care team members needed to assist with the transfer. The patient is dependent on health care team members when using the slide board. The fall risk does not decrease with a slide board compared with other transfer methods, but patient comfort is increased.

When teaching a student nurse how to auscultate the heart, the nurse correctly explains that the base of the heart is located in which area? A. Upper left portion of the heart B. Bottom tip of the heart C. Middle range of the heart D. Proximal side of the heart

A. Upper left portion of the heart Rationale: The base of the heart is in the upper left portion of the heart; the bottom tip of the heart is the apex. The base of the heart is not located in the middle range or proximal side of the heart. The student nurse must know this because visualization improves the ability to assess findings accurately and helps to determine the possible source of abnormalities.

Which finding would necessitate immediate notification of the practitioner? A. Vascular sounds over the epigastric region B. Faint hypoactive bowel sounds in a patient after surgery C. An easily palpable liver in a 70-year-old patient D. A hard mass in the right lower quadrant of a pediatric patient's abdomen

A. Vascular sounds over the epigastric region Rationale: If vascular sounds over the epigastric region (an aortic bruit) are auscultated, the nurse should stop the assessment and notify the practitioner immediately. An aortic bruit may indicate the presence of an aneurysm. The nurse should not percuss or palpate an area where a suspected bruit is heard. Faint bowel sounds are expected in a postoperative patient. Abdominal organs are more easily palpated in older adults. The most common mass palpated in children is feces; an immediate call to the practitioner is not warranted.

When inspecting the abdomen, what findings would cue the nurse of the need for action? (SATA) A) The presence of striae on the right and left lower quadrants. B) A protruberant shaped abdomen. C) A midline, inverted umbilicus. D) A large amount of pigmented nevi scattered accross the abdomen. E) Marked visible peristalsis.

B) A protruberant shaped abdomen. A protruberant shaped abdomen indicates abdominal distention. E) Marked visible peristalsis. Visible peristalsis may be seen in very thin people. Especially in the presence of a protruberant abdomen may indicate a bowl obstruction and would require the nurse to follow up. Striae= strech marks. Not alarming, happens when elastic fibers on reticular layer of skin are broken after rapid weight gain/ pregnancy. Midline, inverted umbilicus= normal finding Pigmented Nevi= moles, which are common finding

What should the nurse expect to hear over the liver while percussing? A) Chirps reminiscent of a bird, chirping. B) Dullness C) Resonance D) A strong beating heart

B) Dullness

The sac that surrounds and protects the heart is called the: A) Myocardium B) Pericardium C) Exploritorium D) Endocardium

B) Pericardium

Veins are: Arteries are: A) high pressure, tough, strong elastic, unoxygenated B) have large diameters, low pressure, capacitance vessel (high volume, intraluminal valves. Moves due to muscles and respiratory system, oxygenated. A) high pressure, tough, strong elastic, oxygenated. B) have large diameters, low pressure, capacitance vessel (high volume, intraluminal valves. Moves due to muscles and respiratory system, unoxygenated.

B) have large diameters, low pressure, capacitance vessel (high volume, intraluminal valves. Moves due to muscles and respiratory system, unoxygenated.

The nurse is preparing to auscultate the patient's heart sounds. Which instruction should the nurse give the patient? A. "Say your name repeatedly." B. "Breathe comfortably and refrain from speaking." C. "Walk in place and take deep breaths." D. "Bend the knees and hold your breath."

B. "Breathe comfortably and refrain from speaking." Rationale: Auscultation requires the examiner to isolate each heart sound at all sites without interference from background noise such as talking. The patient should be in a restful position. Taking deep breaths or holding respirations interferes with the nurse's ability to auscultate heart sounds.

The health care team member is teaching the family how the patient will need to be moved from the bed to a wheelchair using a lift at home. Which response is the most appropriate safety advice? A. "Ensure that the sling extends from the head to the waist." B. "Place the hammock sling under the patient's center of gravity." C. "Place the lift's horseshoe bar under the side of the bed opposite the side of the chair." D. "Ensure that the wheelchair brakes are off."

B. "Place the hammock sling under the patient's center of gravity." Rationale: The hammock sling should be placed under the patient's center of gravity, where the greatest portion of body weight is located. The sling should extend from the shoulders to the knees to support the patient's body weight equally. The lift's horseshoe bar is placed under the same side of the bed as the chair to promote efficient lifting and a smooth transfer. Locking the wheelchair brakes prevents the chair from moving while placing the patient in the chair.

A charge nurse is teaching a new nurse about proper body alignment. The charge nurse asks the new nurse which parts of the patient's body should be aligned. Which response indicates that the new nurse understands the information being given? A. "The head, neck, shoulders, and legs" B. "The joints, tendons, ligaments, and muscles" C. "The head, buttocks, legs, and feet" D. "The joints, spine, cartilage, and feet"

B. "The joints, tendons, ligaments, and muscles" Rationale: The term body alignment refers to the condition of the joints, tendons, ligaments, and muscles in various body positions. When the body is aligned, whether standing, sitting, or lying, no excessive strain is placed on these structures. When the joints, tendons, ligaments, and muscles are aligned, the head, neck, spine, shoulders, buttocks, legs, and feet are aligned as a result.

The health care team member assessing a patient's muscle strength finds full ROM against gravity with full resistance. What grade should the health care team member assign to this finding? A. 1 B. 5 C. 2 D. 4

B. 5 Rationale: Muscle strength is graded on a scale of 0 to 5, with 5 being full ROM against gravity and full resistance. A grade of 4 indicates full ROM against gravity with some resistance. A grade of 2 indicates full ROM and passive resistance. A grade of 1 indicates slight contractility and no movement.

A patient is being evaluated for transfer to a chair. The patient has limited mobility, diminished weight-bearing capacity, and normal upper-body strength. Which action should the health care team member take next? A. Apply a transfer belt around the patient's waist and teach the patient the correct position for transfer. B. Bring the transfer aid to the room and ensure that enough health care team members are available to move the patient. C. Obtain three or four additional health care team members to help with the transfer. D. Abort the transfer and instead allow the patient's feet to dangle for 20 minutes because transfer at this time is too difficult.

B. Bring the transfer aid to the room and ensure that enough health care team members are available to move the patient. Rationale: The health care team member should bring the transfer aid to the room and ensure that enough health care team members are available to move the patient. A patient who has diminished weight-bearing capacity is at higher risk of a fall and needs more support through the process than a routine transfer belt can provide. The transfer aid or other appropriate device gives the most appropriate support. Additional health care team members may be needed, but the number and activity are based on the patient's needs. Allowing the patient to sit on the side of the bed for a few minutes is part of the process, but unless unexpected complications occur, a full transfer is most beneficial.

The health care team member has evaluated an older adult patient for fall risk. The patient, frail and slightly unsteady when walking, has recently arrived from a long-term care facility. Which of these orders places the patient at the greatest risk of falling? A. A broken hip from 5 years earlier B. Daily furosemide and metoprolol tartrate C. Daily aspirin and potassium D. Diabetes mellitus (type 2)

B. Daily furosemide and metoprolol tartrate Rationale: Medications that may cause physical or cognitive impairment and lead to falls include diuretics, antihypertensives, and psychotropics; furosemide is a diuretic and metoprolol tartrate is an antihypertensive, which are both medications that may lead to patient falls. A history of a broken hip, by itself, does not make the patient a current fall risk. Aspirin and potassium are not known to cause hypotensive syncope or other fall risks associated with their side effects. Diabetes can cause many complications, but it has not been linked directly as a cause of patient falls.

The nurse is educating a patient on the importance of monitoring cholesterol levels and knowing the numbers. What information is appropriate to give to the patient? A. Normal cholesterol levels are less than 300 mg/dl. B. LDL cholesterol causes atherosclerotic plaques. C. LDL levels should be less than 200 mg/dl for adults. D. HDL levels should be more than 100 mg/dl.

B. LDL cholesterol causes atherosclerotic plaques. Rationale: LDL particles deliver fat molecules to cells, and in high concentrations, they can drive the progression of atherosclerosis. Desirable cholesterol levels are less than 200 mg/dl. LDL levels should be less than 130 mg/dl for adults and less than 110 mg/dl for children. HDL levels should be more than 45 mg/dl for male patients and more than 55 mg/dl for female patients.

Knowing that a patient has a high risk of falls, the health care team member reviews the preferred method of fall prevention. Which is the preferred method? A. Have a family member stay with the patient through the night. B. Maintain the patient's known daily routine as much as possible. C. Place the patient in a chair at the nurses' station to prevent getting up alone. D. Put all side rails up at bedtime to prevent the patient from getting up at night.

B. Maintain the patient's known daily routine as much as possible. Rationale: Patients who follow a consistent routine feel more secure, are less confused, and can better recognize safety hazards. It may be helpful to have family members stay with the patient through the night if the patient is confused, but it is not necessary for most patients who are at risk of falling. Placing the patient at the nurses' station may be done in extreme situations only per the organization's practice. If all side rails are up, this is considered a restraint, and patients may suffer life-threatening injuries climbing over them or off the foot of the bed.

The nurse concludes that the patient's abdomen is distended. In order to determine if fluid or air is causing distention, the nurse palpates for a fluid wave knowing what? A. Presence of a fluid wave indicates that air is causing the distention. B. Presence of a fluid wave can be detected by using the nondominant hand. C. Jaundice, pruritus, dependent edema, and enlarged superficial abdominal veins accompany ascites from kidney obstruction. D. Absence of a fluid wave indicates ascites.

B. Presence of a fluid wave can be detected by using the nondominant hand. Rationale: Palpation for a fluid wave should be made with the nondominant hand. If a fluid wave is felt, air is not causing the distention. Presence of a fluid wave indicates ascites, found in cirrhosis, peritonitis, metastatic carcinoma, ovarian carcinoma, and pancreatitis. In many cases, jaundice, pruritus, dependent edema, and enlarged superficial abdominal veins accompany ascites from liver congestion, not kidney obstruction.

A patient with hepatitis could be expected to have an enlarged liver. Which quadrant would the nurse palpate to confirm this finding? A. Left upper quadrant B. Right upper quadrant C. Right lower quadrant D. Left lower quadrant

B. Right upper quadrant Rationale: The liver is located in the right upper quadrant of the abdomen. The spleen and stomach are in the left upper quadrant. The large intestines are in the lower quadrants, with the appendix in the right lower quadrant.

Where should the stethoscope be placed to auscultate the aortic valve? A. Second intercostal space to the left of the patient's sternum B. Second intercostal space to the right of the patient's sternum C. Fourth intercostal space to the left of the patient's sternum D. Fifth intercostal space at the patient's left midclavicular line

B. Second intercostal space to the right of the patient's sternum Rationale: The aortic valve is assessed by placing the stethoscope at the second intercostal space to the right of the sternum. The pulmonary valve is assessed by placing the stethoscope at the second intercostal space to the left of the sternum. The tricuspid valve is assessed by placing the stethoscope at the fourth intercostal space to the left of the sternum. The mitral valve is assessed by placing the stethoscope at the fifth intercostal space at the left midclavicular line.

The health care team member is evaluating an older adult patient for fall risk. The patient is given instructions to sit in a chair and get up without using the arms, walk a few feet, and then sit back down in the chair without using the arms. What is the name of this test? A. Orthostatic Hypotension test B. The TUG test C. DAME test D. Homans sign

B. The TUG test Rationale: The TUG test assesses mobility, balance, walking ability, and fall risk in older adults. To measure a patient for orthostatic hypotension, the patient should lie down for 5 minutes and have blood pressure and pulse rate measured; then the patient is asked to stand upright, and a repeat blood pressure and pulse rate are measured. The Homans sign is a test for venous thrombosis. DAME is an acronym used to help determine whether a patient has a history of falls or other injuries at home.

An older adult patient has a history of falling and comes in with bruises on the arms and legs. The new health care team member is reviewing the patient's history for lifestyle behaviors and risk factors for musculoskeletal complications. Which action indicates that further practice and study is needed? A. The health care team member does not ask if the patient has anemia. B. The health care team member does not ask if the patient has recently fallen. C. The health care team member does not ask the patient about use of caffeine D. The health care team member does not ask who the patient lives with. Rationale: It is important to review the patient's history for lifestyle behaviors and risk factors for musculoskeletal injuries; this patient has a history of falling and came in with injuries suggesting a possible fall. Asking if the patient has anemia, uses caffeine, or who the patient lives with may be important; however, the patient came in with bruising and a history of falling at home.

B. The health care team member does not ask if the patient has recently fallen. Rationale: It is important to review the patient's history for lifestyle behaviors and risk factors for musculoskeletal injuries; this patient has a history of falling and came in with injuries suggesting a possible fall. Asking if the patient has anemia, uses caffeine, or who the patient lives with may be important; however, the patient came in with bruising and a history of falling at home.

Preventive health screenings for adolescents and young adults include female and male external genitalia for which reason? A. This area of the body is associated with many health complaints. B. The incidence of STIs is increasing. C. It may explain why they have pain. D. The external genitalia may show sexual abuse.

B. The incidence of STIs is increasing. Rationale: Examination of female and male external genitalia is part of preventive health screenings for adolescents and young adults because of the growing incidence of STIs. Fifty percent of all new STIs are diagnosed in people 15 to 24 years old. This area of the body is not necessarily associated with many health complaints unless the patient has an STI. The assessment of the external genitalia may or may not explain the patient's pain or show sexual abuse.

The health care team member observes several nursing assistants transferring an unconscious patient from the bed to a stretcher. Which observation indicates the need for further education? A. One nursing assistant supports the patient's head. B. The nursing assistants are using the three-person lift technique. C. The brakes are locked on the bed and stretcher. D. The patient's arms are crossed over the chest.

B. The nursing assistants are using the three-person lift technique. Rationale: The three-person lift technique is physically stressful to the health care team member and uncomfortable for the patient. The head and neck of an unconscious patient should be supported, and the arms should be crossed over the chest to prevent injury. The brakes must be locked to prevent the bed or stretcher from rolling away while the patient is transferred.

When a slide board is used for transfer, where is it placed? A. Directly under the patient B. Under the drawsheet C. Under the mattress D. Under the incontinence pad

B. Under the drawsheet Rationale: The slide board is placed under the drawsheet to prevent friction from skin contact with the board. For this reason, the board is not placed directly under the patient or under the incontinence pad. The slide board will not work if placed under the mattress.

You find normal vital sounds in your patient except for a capillary refill time of 5 seconds. What are your next steps? A) Ask the patient about a history of frostbite B) Suspect jaundice C) Consider this a delayed capillary refill time, and investigate further D) This is a normal capillary refill time that requires no further assessment.

C) Consider this a delayed capillary refill time, and investigate further

The nurse is preparing to auscultate for heart sounds. Which technique is correct? A) Listening to wear the apical pulse is felt the strongest. B) Listening for all possible sounds at a time for each specified area C) Z pattern ---> base of the heart ----> across -----> down -----> over the apex D) Radial ---> brachial ---> across ---> down ----> circumflex

C) Z pattern ---> base of the heart ----> across -----> down -----> over the apex

A patient is being assisted to a standing position and is asked to rock back and forth. Which explanation best describes the benefits of using a rocking motion? A. "A rocking motion gives the patient the motivation to stand." B. "A rocking motion reduces the chance of the patient having postural hypotension." C. "A rocking motion gives the body momentum to stand." D. "A rocking motion provides stimulation to the body to stand."

C. "A rocking motion gives the body momentum to stand." Rationale: A rocking motion gives the patient's body momentum, reducing the muscular effort required to lift the patient. Rocking does not prevent postural hypotension; having the patient dangle the legs at the edge of the bed may prevent postural hypotension. Rocking may help motivate the patient and provide stimulation to stand, but that is not its main purpose.

A patient with a decreased range of motion and weakness in the upper and lower extremities is scheduled for discharge from the hospital. The nurse should recognize the need for further teaching if the patient makes which statement? A. "Redness on my elbows is a sign of skin injury." B. "I should change my position at least every 2 hours." C. "Discomfort is expected and I should find a comfortable position and remain in it." D. "I should call the practitioner if moving my arms becomes more difficult."

C. "Discomfort is expected and I should find a comfortable position and remain in it." Rationale: Discomfort can be a symptom of tissue injury or decreased mobility, and a single position should not be maintained. The patient's statements on changing position, notifying the practitioner about worsening symptoms, and recognizing signs of skin injury are appropriate.

A patient is complaining of swelling in both feet. The nurse palpates the feet, and the imprint of the nurse's finger remains visible on the foot for 15 seconds. What grade of edema would the nurse document? A. 3+ edema B. 1+ edema C. 2+ edema D. 4+ edema

C. 2+ edema Rationale: An imprint that remains visible on the foot for 15 seconds is defined as grade 2+ edema. Grade 1+ edema disappears rapidly. Grade 3+ edema may last more than 1 minute, and grade 4+ edema lasts 2 to 5 minutes.

During an assessment of the carotid arteries, the nurse places the bell of a stethoscope over the left carotid artery and hears a blowing or swishing sound. The nurse should suspect that this sound is caused by which phenomena? A. Breath sounds from the patient B. Artifact noise heard from the environment C. A bruit in the carotid artery D. A completely occluded carotid artery

C. A bruit in the carotid artery Rationale: Narrowing of the carotid artery lumen by arteriosclerotic plaques causes disturbances in blood flow. Blood passing through the narrowed section creates turbulence and emits a blowing or swishing sound, called a bruit. The patient should be asked to hold the breath for a few heartbeats during the carotid artery assessment so that respiratory sounds do not interfere with auscultation; the nurse should not hear breath sounds. Noise from the environment does not cause a blowing or swishing sound from the artery. An artery that is completely occluded does not have fluid movement sounds.

In which patient is the use of a sling transfer with a mechanical lift contraindicated? A. A patient with a recent stroke B. An obese patient with limited mobility C. A patient with a recent total hip replacement D. A 40 kg (88.2 lb) pediatric patient with a musculoskeletal disorder

C. A patient with a recent total hip replacement Rationale: A mechanical lift should not be used for a patient with a recent total hip replacement. The sling should be used on a patient with a recent stroke or an obese patient with limited mobility. Health care team members should not lift any patient weighing greater than 15.9 kg (35 lb); instead, the sling should be used.

For which pediatric patient should the health care team member use a hydraulic lift to make a transfer to a chair from a bed? A. A pediatric patient who has no underlying musculoskeletal disorder but is weak and has pain after abdominal surgery B. A pediatric patient who weighs less than 14 kg (31 lb) but cannot self-transfer because of a developmental disability C. A pediatric patient who weighs over 15.9 kg (35 lb) and cannot self-transfer because of a developmental disability D. A pediatric patient who weighs over 14 kg (31 lb) and is able to transfer with the health care team member's assistance but refuses to get out of bed

C. A pediatric patient who weighs over 15.9 kg (35 lb) and cannot self-transfer because of a developmental disability Rationale: The health care team member should use transfer equipment for a pediatric patient who weighs more than 15.9 kg (35 lb) and cannot transfer independently or a pediatric patient who has a musculoskeletal disorder. A pediatric patient weighing less than 15.9 kg may be transferred safely without a hydraulic lift. Using a lift to force a reluctant pediatric patient out of bed would not be appropriate.

Which of these action should be taken to assess a patient's CN V (trigeminal)? A. Apply a light sensation with a cotton ball to one side of the face. B. Have the patient frown, smile, puff out the cheeks, and raise the eyebrows. C. Apply a light sensation with a cotton ball to symmetric areas of the face. D. Ask the patient to speak and swallow.

C. Apply a light sensation with a cotton ball to symmetric areas of the face. Rationale: CN V (trigeminal) is assessed by applying light sensation with a cotton ball to symmetric areas of the face. To check CN V, assess if the sensations are symmetric; thus, both sides of the face must be evaluated. CN VII (facial) is evaluated by having the patient frown, smile, puff out the cheeks, and raise the eyebrows. CN IX (glossopharyngeal) and CN X (vagus) are assessed by having the patient speak and swallow.

When assessing a patient's abdomen, the nurse should perform what action? A. Palpate masses or organ enlargement deeply and firmly. B. Position the patient in a supine position with the arms behind or over the head. C. Auscultate over each quadrant. D. Assess painful quadrant areas first.

C. Auscultate over each quadrant. Rationale: To auscultate bowel sounds, the nurse should place the diaphragm of the stethoscope lightly over each abdominal quadrant and listen over each one before deciding that bowel sounds are absent. Placing the patient's arms under the head or keeping the patient's knees fully extended may cause the abdominal muscles to tighten. Muscle tightening prevents adequate palpation. Manipulation of body parts, including masses, may increase the patient's pain and anxiety and make it difficult to complete the assessment. Painful areas should be assessed last.

The most pronounced change in GI function in an older adult is constipation. What factor contributes to this problem? A. High fiber intake B. Increased fluid intake C. Decreased peristalsis D. Decreased abdominal tone

C. Decreased peristalsis Rationale: Decreased peristalsis results in constipation for many older adults. Consumption of high-fiber foods and increased fluid intake are measures used to reduce constipation. Decreased abdominal tone is a normal finding in older adult patients but is not the main cause of constipation.

When transferring a patient using a hydraulic lift, the health care team member notices that the patient seems more flaccid and weaker than on the previous day. Which action should the health care team member take? A. Check the patient's status the next day and, if weakness continues, share this information verbally at the change of shift. B. Document this change and, if the patient continues to get worse for several days in a row, notify the practitioner. C. Document this change and report it to the primary care practitioner and the rehabilitation staff. D. Encourage the patient to try harder.

C. Document this change and report it to the primary care practitioner and the rehabilitation staff. Rationale: The health care team member should record pertinent observations such as weakness, transfer ability, and assistance needed to the next shift and report progress or remission to the rehabilitation staff. The health care team member should not wait for weakness to progress before notifying the practitioner; the practitioner and rehabilitation staff must be notified immediately so the patient's condition can be assessed and interventions implemented as necessary. The patient's status should be reported at change of shift each day. Weakness does not indicate that the patient is not trying to transfer. All changes should be documented in the patient's record.

A new nurse is helping move a patient up in bed. A health care team member injury prevention technique is followed when the new nurse performs which action during the patient move? A. Faces the side of the bed B. Raises the bed to a more comfortable position C. Faces the direction in which the patient is to be moved D. Places own feet close together

C. Faces the direction in which the patient is to be moved Rationale: The health care team member should face the direction of the patient's movement. Facing the side of the bed requires twisting the back while moving the patient. Flattening the bed provides easier access to the patient and allows the health care team member to reposition the patient to most positions without working against gravity. The health care team member's feet should be placed apart with the foot nearer the head of the bed in front of the other foot. A wide base of support improves balance and enables the mover to shift body weight while moving the patient up in bed, thereby reducing the force needed.

Which of these is a key component in the success of any fall reduction plan? A. Extensive use of bedside staff sitters B. Central video monitoring in real-time C. Health care team member education D. Enhanced patient and team member relationship

C. Health care team member education Rationale: Health care team member education is a key component to the success of any fall reduction plan and must cover all aspects of care for the appropriate population. Extensive team member education can contribute to a decrease in falls and must emphasize the team member's role in preventing patient falls. Other strategies to prevent patient falls include the use of bedside staff sitters to conduct one-on-one observation. Although effective, the use of a sitter is a costly strategy. Central video monitoring is a relatively new fall prevention strategy that has helped to decrease the number of patient falls and is done in real time with no recordings. Purposeful rounding uses a patient-centered approach, enhances the patient and team member relationship, and reduces the risk of modifiable contributors to patient falls; however, the key component is health care team member education.

A nurse is helping move a patient up toward the head of the bed. Which of these positions should the nurse avoid? A. Facing the head of the bed (the direction of movement) B. Placing own foot near the head of the bed in front of the other foot C. Keeping own knees and hips locked D. Shifting own weight from the front leg to the back leg to lift the patient

C. Keeping own knees and hips locked Rationale: While moving a patient in bed, the nurse or other health care team member's knees and hips should be flexed. The health care team member should face the head of the bed, position a foot near the head of the bed in front of the other foot, flex knees and hips, and then shift weight from the front leg to the back leg to lift the patient.

Which of these positions does not help the patient maintain proper body alignment? A. Lying prone with pillows under the arms and legs B. Lying on the right side with a pillow between the knees C. Lying supine with the neck flexed and the chin to the chest D. Lying supine with a small pillow under the head and the legs extended

C. Lying supine with the neck flexed and the chin to the chest Rationale: Having the neck flexed and the chin to the chest is a position used while moving the patient in bed; it does not help the patient maintain proper body alignment. Lying prone with pillows under the arms and legs, lying on the right side with a pillow between the knees, and lying supine with a small pillow under the head and the legs extended all help the patient maintain proper body alignment.

A family is being instructed on how to get a patient with left-sided paralysis out of bed. The family should be instructed to place the chair in which position? A. In front of the patient B. On the patient's left side C. On the patient's right side D. At any comfortable angle to the bed

C. On the patient's right side Rationale: If the patient demonstrates weakness or paralysis on one side of the body, the chair should be placed on the patient's strong side, which in this case is the right side. The chair should not go on the left side, which is this patient's weak side, or in front of the patient. The chair should be at a comfortable angle to the bed but on the patient's strong side.

A patient's elbow has full ROM but the patient does not have the strength to move it. Which type of ROM is this? A. Active ROM B. Active assisted ROM C. Passive ROM D. Full ROM

C. Passive ROM Rationale: Passive motion is when the joint has full ROM, but the patient does not have the strength to move it independently. Active motion is when the patient needs no support or assistance and is able to move the joint independently. Active assisted ROM is when the patient uses the muscles surrounding the joint to perform the exercise but requires some help with a piece of equipment such as a strap. In full ROM, the joint has full movement potential.

Which intervention will reduce the risk of falling in a patient who needs to go to the bathroom at night? A. Place all four bed rails in the up position B. Place a bed alarm on the bed C. Place a commode at the bedside D. Round on the patient every 4 hours

C. Place a commode at the bedside Rationale: Placing a commode at the bedside on the exit side of the bed eliminates the patient's need to walk to the bathroom, providing added safety and support when the patient is transferring out of the bed. Placing all four side rails up is a restraint and places the patient at risk for a fall if the patient tries to climb over the siderails. The bed alarm may prevent a fall, but if the patient knows to call for assistance or is able to use the bedside commode, the alarm is not necessary. Patient rounding should be more frequent than every four hours.

When transferring a patient to a chair, the health care team member should take which action to prevent complications? A. Delay the transfer if the patient is weak. B. Withhold the transfer if the patient is cognitively impaired. C. Remain in front of the patient until the patient regains balance. D. Place the commode next to the chair so the patient can use it independently.

C. Remain in front of the patient until the patient regains balance. Rationale: After transferring the patient, the health care team member should remain in front of the patient until the patient regains balance and should continue to provide physical support if the patient is weak or cognitively impaired. Withholding the transfer because the patient is weak or cognitively impaired is not appropriate. Promoting mobility is an important intervention in the healing process. The patient who needs assistance to get out of bed to the chair should not use the commode independently.

When assessing a 12-year-old patient, asymmetry of the shoulder and hips is noted. The patient has no complaints of pain. What could this finding be indicative of for this patient? A. Kyphosis B. Lordosis C. Scoliosis D. Slipped disk

C. Scoliosis Rationale: Scoliosis, lateral curvature of the spine, is often revealed by asymmetry of the shoulders and hips. Lordosis is evidenced by an increased lumbar curvature. Kyphosis presents as an exaggerated posterior curvature of the thoracic spine. A patient with a slipped disk usually has numbness, tingling, and pain.

A patient is being transferred from the bed to a chair by an orientee. Which action by the orientee indicates the need for further education? A. The orientee places a transfer belt on the patient before transfer. B. The orientee places nonskid shoes on the patient before transfer. C. The orientee holds the patient under the axilla for transfer. D. The orientee uses own knee to support the patient's weak leg.

C. The orientee holds the patient under the axilla for transfer. Rationale: The under-axilla technique is uncomfortable for patients. A transfer belt allows the health care team member to move the patient at the center of gravity. Nonskid shoes decrease the risk of slipping during transfer. A patient's weak leg should be supported by the health care team member's knee.

An older adult patient is admitted to an inpatient unit from home. The health care team member observes a small stage 2 pressure injury on the lower aspect of the patient's right buttock. When asked, the patient reports remaining seated all day. The patient reported being afraid to walk since falling last month. After arranging a physical therapy consult, what should the health care team member tell the patient? A. The patient did the right thing because a hip fracture may have occurred. B. The patient should move around from side to side when sitting. C. The patient needs regular exercise, including walking. D. The patient can work with physical therapy for help in getting back in shape.

C. The patient needs regular exercise, including walking. Rationale: Increasing lower body strength and improving balance through regular physical activity may reduce the risk of falling. Sitting for long periods of time may lead to deconditioning, muscle atrophy, and pressure injuries. The health care team member observes a small stage 2 pressure injury on the lower aspect of the patient's right buttock; there is no indication of a hip fracture. Moving from side to side may help prevent pressure injuries but does not prevent muscle atrophy and deconditioning. Physical therapy helps, but the benefits are minimal unless the patient takes part in self-care and begins to exercise and walk.

Which sequence should be used in transferring a patient to the stretcher with a slide board and three health care team members? A. Two team members roll the patient onto the slide board and the third team member pulls the slide board. B. One team member pulls the drawsheet, the second team member holds the drawsheet to guide the patient to the stretcher, and the third team member removes the slide board. C. Two team members pull the drawsheet with the patient onto the stretcher and the third team member holds the drawsheet to guide the patient to the stretcher. D. Two team members roll the drawsheet under the patient and the third team member pulls the drawsheet.

C. Two team members pull the drawsheet with the patient onto the stretcher and the third team member holds the drawsheet to guide the patient to the stretcher. Rationale: Two team members position themselves at the side of the stretcher, while the third team member stands at the side of the bed without the stretcher. Two team members pull the drawsheet with the patient onto the stretcher while the third team member holds the drawsheet to help guide the patient to the stretcher. When the patient is safely on the stretcher, the third team member removes the slide board. There should be two team members who pull the drawsheet to prevent injury.

When assessing a patient, the nurse notes that the left femoral pulse is d diminished, 1+ / 4+. What are the next steps? A) Document it and move on B) Check cap refill in the lateral toes of the left extremity C) Review the chart to decide if this is baseline data for this patient D) Auscultate the site for a bruit.

D) Auscultate the site for a bruit.

What does a blowing and swishing sound with the bell of the stethoscope over the left carotid artery indicate? A) Ventricular hypertrophy B) Fluid volume overload C) Vascular disorder D) Blood flow turbulence

D) Blood flow turbulence

Your patient has a history of heart failure and complains of being woke up from sleep due to shortness of breath. Thoughts? A) The patients medical history reveals allergies paired with asthma B) All patients with heart failure have sleep apnea C) The patient is experiencing orthopnea D) You suspect praroxysmal nocturnal dyspnea

D) You suspect praroxysmal nocturnal dyspnea

The nurse is caring for a patient with an indwelling urinary drainage catheter. The nurse suspects the catheter is obstructed. Which finding would confirm the nurse's suspicions? A. Midline dull epigastric pain B. A fluid wave verified by ultrasound examination C. Tenderness at the costovertebral angle D. A smooth rounded mass at the symphysis pubis

D. A smooth rounded mass at the symphysis pubis Rationale: A full bladder results in a smooth mass above the symphysis pubis. A fluid wave indicates the presence of ascites. Tenderness at the costovertebral angle indicates kidney inflammation. Midline dull epigastric pain is indicative of a gastric ulcer.

An older adult patient is admitted with a urinary tract infection. The patient uses a cane but is still unsteady and answers some questions inappropriately. What action should be taken first? A. Insert an indwelling catheter to reduce the need for toileting. B. Call the practitioner and obtain an order for lorazepam. C. Call the practitioner and obtain an order for restraints. D. Assess the environment and remove hazards.

D. Assess the environment and remove hazards. Rationale: The first action that should be taken is to assess the patient's environment and remove any hazards that may be present. Inserting an indwelling catheter or requesting an order for lorazepam is inappropriate and can lead to an increased risk of falling. Requesting an order for restraints is inappropriate and unnecessary.

Which condition is one of the most common causes of nonspecific abdominal pain leading to emergency department visits for pediatric patients? A. Rectal pain B. Diarrhea C. Urinary tract infection D. Constipation

D. Constipation Rationale: Constipation is the most common cause of nonspecific abdominal pain leading to emergency department visits. Rectal pain, diarrhea and urinary tract infection do occur, but constipation is the most common cause of nonspecific abdominal pain leading to emergency department visits.

When preparing to transfer a patient to the stretcher, the health care team member should take which action first? A. Place the slide board under the patient. B. Place a drawsheet under the patient. C. Turn the patient onto one side. D. Determine the number of people needed to assist with the transfer.

D. Determine the number of people needed to assist with the transfer. Rationale: When preparing to transfer a patient, the health care team member should first determine the number of people needed to assist with the transfer. The transfer should not start until all required health care team members are available. Once all the team members are present, a drawsheet can be placed if not present as well as the slide board. The health care team member should not turn the patient onto one side until all the team members are present.

Family members are being taught how to transfer the patient safely from the bed to a chair. Which action indicates that the family has been adequately prepared for the task? A. Family members verbalize the steps for transferring the patient safely from bed to chair. B. Family members write down the steps in order for transferring the patient from bed to chair. C. Family members watch a video demonstrating proper transfers. D. Family members correctly perform the steps for transferring the patient from bed to chair.

D. Family members correctly perform the steps for transferring the patient from bed to chair. Rationale: A return demonstration is the most effective way to determine if family members are adequately prepared. A video may reinforce understanding of the procedure, but it does not allow for determination of adequate preparation. Having family members state or write the correct steps also does not allow for proper evaluation of preparation.

When educating family and caregivers before the patient returns home, the health care team member should take which action first? A. Assess whether the home is free of safety hazards. B. Ensure that all appropriate aids, such as shower stools and commode elevators, are available in the home. C. Ensure that a chair with arms is available to help facilitate rising and sitting. D. Have family and caregivers practice safe transfer techniques in the organization before discharge.

D. Have family and caregivers practice safe transfer techniques in the organization before discharge. Rationale: The first priority for educating family and caregivers before discharge is to practice appropriate and safe transfer techniques. Making the home environment free of hazards, such as throw rugs, electric cords, and slippery floors, is important, but safe patient transfers should be practiced before the return home. Not all patients need aids, such as shower stools, commode elevators, or chairs with arms.

To perform a Romberg test, what action should the health care team member take? A. Have the patient walk across the room and observe for a limp. B. Stand behind the patient and observe postural alignment (position of hips relative to shoulders). C. Place the patient in a supine position, support the leg while flexing the foot in dorsiflexion, and assess for pain. D. Have the patient stand with feet together and arms at sides, both with eyes open and eyes closed, and observe for swaying.

D. Have the patient stand with feet together and arms at sides, both with eyes open and eyes closed, and observe for swaying. Rationale: The Romberg test, used to evaluate balance, is performed by having the patient stand with feet together, arms at sides, with eyes open and then with eyes closed, while a health care team member observes the patient for swaying. The health care team member checks for scoliosis by observing postural alignment. The team member observes gait as part of the musculoskeletal assessment. The team member tests for Homan sign by supporting the leg while flexing the foot in dorsiflexion.

When assisting a patient from bed to chair, the health care team member should take which action to facilitate the transfer? A. Move the patient quickly from the side of the bed to the chair. B. Keep own knees locked and bend from the waist. C. Stand with own feet together to allow more room to maneuver. D. Place the chair at a comfortable angle to the bed.

D. Place the chair at a comfortable angle to the bed. Rationale: The chair should be placed at a comfortable angle to the bed to avoid twisting motions. Locking the knees and bending from the waist engage the back muscles and increase the risk of injury. The feet should be placed wide apart to improve balance during transfer. The patient should be permitted to dangle the legs at the side of the bed for a few minutes to reduce the risk of dizziness or fainting when standing.

A patient with head trauma has difficulty with comprehension. Which is the best method to instruct the patient on how the transfer from the bed to the chair will take place? A. Give written instructions outlining each step. B. Provide a video demonstrating each step. C. Provide a general overview of the procedure. D. Provide oral instructions one step at a time.

D. Provide oral instructions one step at a time. Rationale: A patient who has difficulty with comprehension should be provided with oral instructions given one step at a time, walking the patient through the process. A patient with head trauma and difficulty with comprehension may not be able to understand written instructions or a video. Describing the procedure provides a good overview, but the patient will still need step-by-step instructions.

The health care team member is transferring a patient with cognitive dysfunction using a sling. Which is the best method to instruct the patient on how to transfer to the chair with the sling? A. Describe the procedure. B. Show the patient a video. C. Give the patient written instructions. D. Provide repeated oral instructions simply and consistently.

D. Provide repeated oral instructions simply and consistently. Rationale: Patients with cognitive dysfunction need instructions repeated simply and consistently. If a patient has difficulty with comprehension, provide oral instructions one step at a time, walking them through the process. A patient with head trauma and difficulty with comprehension may not be able to understand written instructions or a video. Describing the procedure is good overview but the patient will still need step by step instructions.

A patient's family is concerned that the patient might fall after being discharged home. Which of these is an excellent reference for the patient and the family regarding prevention of patient falls? A. The attending practitioner B. The risk management department C. Quality assurance team members D. The CDC's website

D. The CDC's website Rationale: The CDC's website provides many educational information sheets and links related to fall prevention. The attending practitioner may be a good source for information but would likely refer the patient and family to the CDC or a similar organization. The risk management department and quality assurance team members are not usually directly involved with direct patient and family education.

During orientation, a new nurse is performing an abdominal assessment. Which action indicates that further practice and study is needed? A. The abdomen is assessed for distention of the bowel before being palpated. B. The nurse determines any tenderness before touching the patient. C. Inspection is done before percussion. D. The abdomen is palpated before auscultation is done.

D. The abdomen is palpated before auscultation is done. Rationale: The abdomen should be inspected first and then auscultated. Palpation and percussion of the abdomen should occur after inspection and auscultation because they can cause bowel sounds to be heard even when peristalsis is absent. Tenderness is determined by palpating the abdomen; inspection and auscultation should occur before palpation.

When assessing an adult comatose patient, the health care team member noted a positive Babinski reflex. Which response did the patient exhibit? A. The toes flexed inward and downward B. The toes fanned downward C. The great toe plantar flexed D. The great toe dorsiflexed

D. The great toe dorsiflexed Rationale: A positive Babinski reflex in an adult indicates CNS dysfunction; if a Babinski reflex is present, the great toe dorsiflexes and is accompanied by fanning of the other toes. Plantar flexion is the movement of the toes flexing downward toward the sole. The toes flexing inward and downward or fanning downward do not indicate a positive Babinski reflex.

A new nurse is attempting to place a drawsheet under a patient. The preceptor recognizes that the new nurse understands how to place the sheet appropriately when the new nurse takes which action? A. The new nurse asks the patient to sit up. B. The new nurse asks the patient to raise the hips. C. The new nurse attempts to lift the patient using the current drawsheet. D. The new nurse has the patient turn from side to side.

D. The new nurse has the patient turn from side to side. Rationale: Having the patient turn from side to side requires the least effort from the patient and allows the drawsheet to be fully placed under the patient. Asking the patient to sit up or raise the hips does not allow the drawsheet to be placed appropriately and requires extra effort by the patient. If the nurse attempts to lift the patient using the current drawsheet, it cannot be placed fully under the patient and may cause musculoskeletal injury to the patient or nurse.

The health care team member and an orientee are transferring a patient from the bed to a wheelchair using the sling. Which action by the orientee indicates the need for further education? A. The orientee places the wheelchair near the bed. B. The orientee locks the chair brakes. C. The orientee removes the footrests. D. The orientee ensures the sling hooks face toward the patient's skin.

D. The orientee ensures the sling hooks face toward the patient's skin. Rationale: When placing the sling under the patient, the health care team member needs to ensure the hooks face away from the patient's skin to prevent any skin damage. The health care team member should position the wheelchair near the bed to reduce the distance the lift has to travel and to allow adequate space to maneuver the lift. The wheelchair needs to be locked and the footrests removed.

After moving the patient up in bed, the nurse should be concerned by which finding? A. The patient retains ROM. B. The patient's comfort level is increased. C. The patient is able to maintain proper body alignment. D. The patient has a small, reddened area on the heel.

D. The patient has a small, reddened area on the heel. Rationale: A reddened area on the patient's heel is an unexpected outcome. The nurse must minimize the risk by maintaining unrestricted circulation and correct patient body alignment while moving, turning, or positioning the patient. Retained ROM, skin that shows no evidence of breakdown, increased patient comfort, and proper body alignment are expected outcomes.

Define emesis & colors

Emesis= vomiting Green- can be particles of food, but also might indicate bile (found in small intestine) Thick dark brown- can be stool or blood. Abnormal finding has to be investigated & communicated White foamy- presence of stomach acid Yellow- can indicate presence of bile or medical problem. Should have a follow up.

Hearing a swishing sound in the abdomen is heard in what area?

Femoral artery- swishing sound occurs during systole (vascular sounds)

What are abnormal sounds in the abdomen?

Hypoactive Hyperactive Normal

What is the correct assessment techniques of the abdomen IN ORDER.

Inspection Auscultation Percussion Palpation

If a patient has recently vomited, feels nauseous, or losing weight what should the nurse take focus on during the oral assessment?

Observe the condition of the mucus membranes Rationale: Because the client has a recent history of nausea, vomiting, and weight loss, the RN should assess the client for signs of fluid volume deficit, including observing the mucus membranes for excessive dryness.

What order do you auscultate the abdomen?

RLQ- are of ileocecal valve, where bowel sounds are normally present RUQ, LUQ, LLQ

Define pulse bigeminus

a heartbeat marked by two beats close together with a pause following each pair of beats

Define pulse alternans

a pulse pattern in which there is alternating (beat-to-beat) variability of pulse strength

Define pulse paradoxus

an exaggerated fall in a patient's blood pressure during inspiration by greater than 10 mm Hg

What is the endocardium?

inner lining of the heart chambers and valves

What is the cardiac cycle?

rhythmic movement of blood through the heart

What is mediastinum

structure separating the right and left thoracic cavities

What is precordium

the area on the anterior chest directly overlying the heart and great vessels

What is the myocardium?

the muscular tissue of the heart.

What is the pericardium?

tough, fibrous, double-walled sac that surrounds and protects the heart