Nokea
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.
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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.
You have just completed an initial shift assessment of your 72-year-old female patient who has congestive heart failure. Which of the following assessment findings causes you the most concern?
- A. Fine papular rash under both breasts
- B. Reports her last BM was 2 days ago
- C. AP 78 regular and distant
- D. Has not voided in 12 hours
- E. Complaints of fatigue
Correct Answer: D
Rationale: Not voiding in 12 hours is concerning in a patient with congestive heart failure, as it may indicate worsening renal perfusion or fluid retention.
Blood pressure can provide you with information regarding which of the following?
- A. Central nervous system
- B. Cardiovascular system
- C. Integumentary system
- D. Renal system
- E. Fluid status
- F. Infection
Correct Answer: B,D,E
Rationale: Blood pressure reflects cardiovascular function (B), renal function (D) through regulation of blood volume, and fluid status (E) as it affects vascular volume.
What medical term would be appropriate to use when reporting that your patient is drowsy or mentally sluggish?
- A. Lethargy
- B. Somnolence
- C. Obtundation
- D. Stupor
Correct Answer: A
Rationale: Lethargy is the appropriate term for a state of drowsiness or mental sluggishness.
The acronym PMI stands for what? Which means what?
- A. Point of maximum impulse, strongest heart beat
- B. Pulse measurement index, pulse strength
- C. Primary medical inspection, initial assessment
- D. Point of mitral intensity, mitral valve sound
Correct Answer: A
Rationale: PMI stands for 'point of maximum impulse,' the location where the heart's apex beat is strongest, typically at the 5th intercostal space.