Nokea
Auscultating the heart sounds should result in a "lub-dup" sound when using the bell and the diaphragm of the stethoscope. What causes the "lub" sound?
- A. Opening of the AV valves
- B. Opening of the semilunar valves
- C. Closing of the AV valves
- D. Closing of the semilunar valves
Correct Answer: C
Rationale: The 'lub-dup' sound of the heart is caused by the closing of the AV and semilunar valves, respectively.
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What should the nurse begin by assessing when performing a head-to-toe assessment?
- A. Support system
- B. Skin integrity
- C. Pain level
- D. Neurologic status
Correct Answer: D
Rationale: When performing a head-to-toe assessment, the nurse begins with a neurologic assessment, then assesses the skin, hair, head, and neck, including the eyes, ears, nose, and mouth. The chest, back, arms, abdomen, perineal area, legs, and feet are examined in that order.
When assessing a patient the nurse notes a yellow tinge to the patient's skin. How should the nurse document this finding?
- A. Dyspnea
- B. Cyanosis
- C. Jaundice
- D. Ecchymosis
Correct Answer: C
Rationale: Jaundice is a yellow tinge to the skin; it may indicate obstruction in the flow of bile from the liver.
What does the nurse recognize as the initial step in conducting an assessment of a patient?
- A. A body systems review
- B. The nursing health history
- C. Biographic data
- D. The present illness
Correct Answer: B
Rationale: The nursing health history is the initial step in the assessment process.
What is the third assessment technique in a standard physical examination?
- A. Auscultation
- B. Percussion
- C. Inspection
- D. Palpation
Correct Answer: A
Rationale: The usual sequence of assessment is inspection, palpation, auscultation, and lastly percussion.
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.