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A nurse is performing a breast assessment using the circular technique for palpation, gently compressing the breast tissue against the chest wall. How does the nurse proceed with the examination?
- A. Begins at the tail of Spence and moves in increasing smaller circles
- B. Starts at the outer edge of the breast and palpates up and down the breast
- C. Works in a counterclockwise direction and palpates from the periphery toward the areola
- D. Proceeds from the inner edge of the breast and palpates up and down the breast
Correct Answer: A
Rationale: During breast assessment, the nurse palpates each quadrant of the breasts in a systematic method using the pads of the first three fingers to gently compress the breast tissue against the chest wall. In the circular method, the nurse begins at the tail of Spence and moves in increasingly smaller circles. In the wedge method, the nurse works in a clockwise direction and palpates from the periphery toward the areola. In the vertical strip method, the nurse begins at the outer edge of the breast, palpating up and down the breast.
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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.
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 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.
The nurse places a patient in the dorsal recumbent position during a physical assessment. Which nursing assessments can the nurse perform with the patient in this position? Select all that apply.
- A. Assessing the abdomen
- B. Taking peripheral pulses
- C. Performing a breast examination
- D. Auscultating the heart
- E. Assessing vital signs
- F. Assessing balance and gait
Correct Answer: B,C,D
Rationale: In the dorsal recumbent position, the patient lies on the back with legs separated, knees flexed, and soles of the feet on the bed. It is used to assess the head, neck, anterior thorax, lungs, heart, breasts, extremities, and peripheral pulses. It should not be used for abdominal assessment because it causes contraction of the abdominal muscles. Vital sign assessment should be done in the sitting position, and evaluating balance and gait is done with the patient in the standing position.
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.