Nokea
Score the patient responses on the Glasgow Coma Scale. Calculate the patient's total score. Would you consider this patient as having a significant neurological impairment?
- A. Eye opening to pain: 2, Withdraws from pain: 4, Incomprehensible sounds: 2, Total: 8, Significant impairment
- B. Eye opening to pain: 2, Withdraws from pain: 5, Incomprehensible sounds: 2, Total: 9, Moderate impairment
- C. Eye opening to pain: 3, Withdraws from pain: 4, Incomprehensible sounds: 3, Total: 10, Moderate impairment
- D. Eye opening to pain: 2, Withdraws from pain: 4, Incomprehensible sounds: 3, Total: 9, Moderate impairment
Correct Answer: A
Rationale: Glasgow Coma Scale: Eye opening to pain (2), withdraws from pain (4), incomprehensible sounds (2), total = 8, indicating significant neurological impairment (score ?¤8 is severe).
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Body temperature can provide you with information regarding which of the following?
- A. Central nervous system
- B. Immune system
- C. Hydration level
- D. Infection
- E. Respiratory system
- F. Cardiovascular system
Correct Answer: B,D
Rationale: Body temperature is influenced by the immune system (B) in response to pathogens and indicates infection (D) when elevated.
The bottom of the lower lobes of the lungs extends down to which of the following?
- A. 8th intercostal space midclavicular line anteriorly
- B. 6th intercostal space laterally
- C. 10th intercostal space anteriorly
- D. 6th intercostal space midclavicular line anteriorly
- E. 8th intercostal space posteriorly
- F. 10th intercostal space laterally
Correct Answer: E,F
Rationale: The lower lobes extend to the 8th intercostal space posteriorly and 10th intercostal space laterally.
Explain the importance of performing an initial shift assessment within the first hour of your shift.
- A. Ensures early detection of changes in patient condition
- B. Establishes a baseline for comparison
- C. Guides care planning and interventions
- D. All of the above
Correct Answer: D
Rationale: An initial shift assessment within the first hour establishes a baseline, detects changes, and guides care planning.
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.
Which of the two heart sounds is the loudest?
- A. S1
- B. S2
- C. S3
- D. S4
Correct Answer: A
Rationale: S1 is typically louder than S2 because it involves the closure of the mitral and tricuspid valves, which produce a stronger sound.