Nokea
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.
You may also like to solve these questions
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.
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 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.
A nurse is caring for a patient with exacerbation of COPD and pneumonia. When auscultating the lungs, coarse expiratory, low-pitched, and continuous sounds that clear with coughing are present. How will the nurse document this breath sound in the electronic health record?
- A. Rhonchi
- B. Bronchovesicular breath sounds
- C. Stridor
- D. Bronchial breath sounds
Correct Answer: A
Rationale: Rhonchi are abnormal low-pitched, continuous breath sounds auscultated during inspiration and occasionally expiration, indicating that air is passing through or around secretions. Bronchovesicular breath sounds are normal sounds heard on inspiration and expiration. Stridor is a harsh, loud, high-pitched sound auscultated on inspiration indicating narrowing of the upper airway or presence of a foreign body. Bronchial sounds are normal blowing, hollow sounds, auscultated over the larynx and trachea.
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.