Nokea
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.
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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.
During physical assessment, a nurse inspects a patient's abdomen. What assessment technique does the nurse perform next?
- A. Percussion
- B. Palpation
- C. Auscultation
- D. Whichever provides patient comfort
Correct Answer: C
Rationale: When assessing the abdomen, the sequence for assessment is: inspection, auscultation, percussion, and palpation. Auscultation follows inspection to avoid stimulating bowel sounds during percussion.
A nurse and AP are caring for a patient who just returned from the operating room after a femoral-popliteal arterial bypass graft. The nurse is getting another admission. What activity can the nurse safely delegate to the AP?
- A. Determining if pedal pulses are present
- B. Evaluating the patient's pain
- C. Reinforcing the sterile dressing
- D. Ordering dressing supplies
Correct Answer: D
Rationale: The nurse can delegate noncomplex activities to the AP such as obtaining (dressing) supplies, bedmaking, bathing, I & O, toileting, and ambulation. The nurse must perform assessments, provide teaching, perform sterile procedures, and develop the care plan.
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.
A patient has come to the emergency department with symptoms of a stroke. During the assessment, the nurse asks the patient to raise their eyebrows, smile, and show their teeth to evaluate which cranial nerve?
- A. Olfactory
- B. Optic
- C. Facial
- D. Vagus
Correct Answer: C
Rationale: Motor function of the facial nerve (cranial nerve VII) is assessed by asking the patient to raise their eyebrow, smile, and show their teeth. The olfactory nerve (cranial nerve I) is tested by testing the sense of smell using various familiar substances. The nurse tests the optic nerve (cranial nerve II) for acuity and visual fields and the vagus nerve (cranial nerve X) by asking the patient to swallow and speak, noting hoarseness.