Nokea
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.
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A yellow tinge to the skin that may indicate obstruction in the flow of bile from the liver is known as ____.
Correct Answer: jaundice
Rationale: Jaundice is a yellow tinge to the skin; it may indicate obstruction in the flow of bile from the liver.
When admitting a patient to the hospital the nurse notes the patient has mild sunburn. How should the nurse document this finding?
- A. Dyspnea
- B. Cyanosis
- C. Erythema
- D. Ecchymosis
Correct Answer: C
Rationale: Erythema is redness or inflammation of the skin or mucous membranes that is the result of dilation and congestion of superficial capillaries; erythema is seen in mild sunburn.
Listening for bowel sounds should be done over all four quadrants of the abdomen using the diaphragm of the stethoscope. What is the normal rate of bowel sounds per minute?
- A. 2 to 10
- B. 3 to 20
- C. 4 to 32
- D. 5 to 40
Correct Answer: C
Rationale: The normal rate of bowel sounds per minute is 4 to 32.
The nurse is performing auscultation of breath sounds on a respiratory patient. The sounds heard on inspiration and expiration are low-pitched coarse gurgling and have a snoring sound. What best identifies these sounds?
- A. Crackles
- B. Plural friction rub
- C. Rhonchi
- D. Sonorous wheezes
Correct Answer: D
Rationale: Sonorous wheezes have a low-pitched, coarse, gurgling, snoring quality and usually indicate the presence of mucus in the trachea and large airways.
An abnormal condition in which a person must sit or stand to breathe deeply or comfortably is known as ____.
Correct Answer: orthopnea
Rationale: Orthopnea is an abnormal condition in which a person must sit or stand to breathe deeply or comfortably.