Nokea
A health care provider documents that a patient has a scleral icterus. What is the cause of this coloring?
- A. Bilirubin
- B. Hemoglobin
- C. Serum potassium
- D. Serum magnesium
Correct Answer: A
Rationale: Scleral icterus means the color of the sclera is yellow. The jaundice is due to coloring of the sclera with bilirubin that infiltrates all tissues of the body.
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The nurse is preparing to perform a physical assessment. What essential supplies should this nurse gather?
- A. Flashlight
- B. Gloves
- C. Red pen
- D. Thermometer
- E. Scissors
Correct Answer: A,B,D,E
Rationale: Items essential to the nurse's assessment are a penlight or flashlight, a stethoscope, a blood pressure cuff, a thermometer, gloves, gait belt, watch with second hand, scissors, black pen, and a tongue blade.
During a neurologic assessment the nurse notes a patient has a unilateral dilated and nonreactive pupil. This is a sign that the patient is experiencing pressure on which cranial nerve?
- A. I
- B. II
- C. III
- D. IV
Correct Answer: C
Rationale: The third cranial nerve runs parallel to the brainstem. The function of the oculomotor nerve is essential for eye movements. A traumatic brain injury can result in increased intracranial pressure, edema to the brainstem with pressure on cranial nerve III, causing the ominous sign of a unilateral, dilated, and nonreactive pupil.
A condition in which there is a lack of appetite resulting in the inability to eat is known as ____.
Correct Answer: anorexia
Rationale: Anorexia is a lack of appetite resulting in the inability to eat. It can occur in many disease conditions.
A nursing assessment is a process of collecting data to establish a database. The information contained in the database is a basis for:
- A. a complete physical examination.
- B. a medical assessment.
- C. an individualized plan of care.
- D. writing nursing orders.
Correct Answer: C
Rationale: The information contained in the database is the basis for an individualized plan of care.
When assessing a patient the nurse notes that the patient is unable to lie flat to breathe. When the nurse assists the patient into a sitting position the patient is able to breathe more easily. What should the nurse document that the patient is experiencing?
- A. Dyspnea
- B. Cyanosis
- C. Jaundice
- D. Orthopnea
Correct Answer: D
Rationale: Orthopnea is an abnormal condition in which a person must sit or stand to breathe deeply or comfortably. It occurs in many disorders of the respiratory and cardiac systems.