Nokea
During assessment of your patient, you notice that the patient has numbness of the left side of her face. You would use the medical term to document this finding.
- A. Paresthesia
- B. Hypoesthesia
- C. Anesthesia
- D. Dysesthesia
Correct Answer: B
Rationale: Hypoesthesia is the medical term for reduced sensation or numbness in a specific area, such as the face.
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You have just completed an initial shift assessment of a male in his 30s with a history of elevated hypertension and elevated cholesterol. Which of the following assessment findings provides information about his circulatory system?
- A. Skin is pale, warm, and dry
- B. BP is 164/98
- C. R is 27 regular and even
- D. AP is 94 regular and 2+, RP is 90 irregular and 2+, and pulse deficit is 4
- E. Pedal pulses are weak and equal bilaterally
- F. He has 2+ edema of both ankles
- G. He is awake, alert, and oriented to four spheres
Correct Answer: B,D,E,F
Rationale: BP, pulse deficit, pedal pulses, and edema are direct indicators of circulatory status, reflecting vascular pressure, perfusion, and fluid dynamics.
The correct sequence to assess the abdomen is
- A. Auscultation, olfaction, observation, palpation, and percussion
- B. Observation, auscultation, palpation, percussion, and olfaction
- C. Observation, palpation, percussion, auscultation, and olfaction
- D. Olfaction, auscultation, observation, palpation, and percussion
- E. Olfaction, observation, auscultation, percussion, and palpation
Correct Answer: B
Rationale: Abdominal assessment starts with observation, then auscultation (before palpation/percussion to avoid altering bowel sounds), followed by palpation, percussion, and olfaction.
A patient was admitted yesterday with pneumonia. When auscultating his breath sounds you detect rales in the right lower lobe. How quickly should you reassess this abnormal finding?
- A. Within 15 minutes
- B. Within 60 minutes
- C. In less than 2 hours
- D. In 4 hours or less
- E. When the patient complains of dyspnea
Correct Answer: C
Rationale: Rales (crackles) indicate fluid in the lungs, requiring reassessment within 2 hours to monitor for worsening pneumonia or respiratory distress.
You are preparing to perform an initial shift assessment. You know that the correct order in which you should perform the five techniques for objective assessment (except for the abdomen) is
- A. Auscultation, olfaction, observation, palpation, and percussion
- B. Observation, auscultation, palpation, percussion, and olfaction
- C. Observation, palpation, percussion, auscultation, and olfaction
- D. Olfaction, auscultation, observation, palpation, and percussion
- E. Olfaction, observation, auscultation, percussion, and palpation
Correct Answer: B
Rationale: The correct order for assessment (except abdomen) is observation, auscultation, palpation, percussion, and olfaction to avoid altering findings.
During palpation of the patient's abdomen, he flinches and tightens the abdominal muscles where you are palpating. This tightening of abdominal muscles is known as
- A. Guarding
- B. Rigidity
- C. Rebound tenderness
- D. Distension
Correct Answer: A
Rationale: Guarding refers to the involuntary tightening of abdominal muscles in response to pain or palpation, often indicating discomfort or pathology.