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A nurse admitting a patient to a long-term care facility performs a functional assessment. Which questions will the nurse include as part of the assessment? Select all that apply.
- A. Are you able to dress yourself?
- B. Do you have a history of smoking?
- C. What is the problem for which you are seeking care?
- D. Do you prepare your own meals?
- E. Do you manage your own finances?
- F. Whom do you rely on for support?
Correct Answer: A,D,E
Rationale: A functional health assessment including strengths and areas needing improvement focuses on the effects of health or illness on a patient's quality of life. Questions about the patient's ability to perform ADLs and IADLs such as dressing, grooming, preparing meals, and managing finances are included. A history of smoking is a lifestyle factor, and the chief complaint is the reason for seeking health care; both are assessed during the health history. Social networks and support psychosocial factors are also assessed during the health history.
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A nurse on a medical-surgical unit is caring for a group of patients. For which patient will the nurse perform a focused assessment?
- A. Newly admitted
- B. Recent application of a wrist cast
- C. Signs of acute respiratory distress
- D. Post-abdominal surgery without complications
Correct Answer: B
Rationale: After application of a cast, the nurse performs a focused neurovascular assessment, to assess circulation, sensation, and motor ability. A newly admitted patient requires a comprehensive assessment. The nurse performs an emergency assessment on a patient who presents with signs of acute respiratory difficulty. A postoperative patient without complications will receive ongoing assessments at regular intervals to evaluate the effectiveness of care and to assess for new problems.
When inspecting the skin of a patient who has cirrhosis of the liver, the nurse notes the skin has a yellow tint. What term will the nurse use to document the skin assessment in the electronic health record?
- A. Jaundice
- B. Cyanosis
- C. Erythema
- D. Pallor
Correct Answer: A
Rationale: Jaundice refers to a yellowish skin color caused by liver, gallbladder, or pancreatic diseases. Cyanosis is a bluish skin color caused by a cold environment or decreased oxygenation. Erythema is a reddish color caused by blushing, alcohol intake, fever, injury trauma, or infection. Pallor is a paleness caused by anemia or shock.
A school nurse assesses adolescents' visual acuity using a Snellen eye chart. Which explanation does the nurse provide to the student whose vision is 20/40 in both eyes?
- A. They see better than 50% of people.
- B. Double vision is present.
- C. Vision is less than normal.
- D. They have normal vision.
Correct Answer: C
Rationale: Normal vision is 20/20. The higher the denominator indicates increasingly worse vision; 20/40 vision indicates less than normal vision.
A nurse in the emergency department is using the Glasgow coma scale to assess a patient who was struck in the head and upper body with a baseball bat. Based on the information in the neurologic assessment, what numerical value will the nurse assign?
- A. 3
- B. 7
- C. 11
- D. 15
Correct Answer: B
Rationale: Eye opening to painful stimulus = 2 points, no speech = 1 point; and withdrawal to painful stimulus = 4 points, for a total score of 7. A score of 8 or less is associated with coma.
A nurse is assessing a patient's eyes for accommodation. Place the steps of this assessment in the order they are performed.
- A. Document the results in the electronic health record.
- B. Ask the patient to look at a distant object, then back to the object held.
- C. Hold a straight object 10 to 15 cm (4 to 6 inches) from the bridge of the patient's nose.
- D. Observe for pupillary constriction when looking at the near object and for pupillary dilation when looking at the distant object.
- E. Ask the patient to look at the object.
Correct Answer: C,E,B,D,A
Rationale: To test accommodation the nurse holds the forefinger, a pencil, or other straight object about 10 to 15 cm (4 to 6 inches) from the bridge of the patient's nose. The patient is asked to look at the object, then at a distant object, then back to the object being held. The pupil normally constricts when looking at a near object and dilates when looking at a distant object. The patient must be cooperative to complete this assessment. The results are documented last.