Nokea
The nurse is completing a neurological assessment on an adult patient. Which of the following assessments should the nurse include when assessing the patient's coordination?
- A. Toe walk
- B. Finger to nose
- C. Drift
- D. Romberg
- E. Heel to opposite shin
Correct Answer: B,D,E
Rationale: A neurological assessment is completed to observe motor status by assessing gait, toe and heel walk, and drift, whereas when assessing coordination, the nurse observes finger to nose, Romberg sign, and heel to opposite shin.
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Immediate surgery is planned for a patient with acute abdominal pain. Which of the following questions will elicit the most complete information about the patient's coping-stress tolerance pattern?
- A. Can you tell me how intense your pain is now?
- B. What do you think caused this abdominal pain?
- C. How do you feel about yourself and your hospitalization?
- D. Are there other major problems that are a concern right now?
Correct Answer: D
Rationale: The coping-stress tolerance pattern includes information about other major stressors confronting the patient. The health perception-health management pattern includes information about the patient's ideas about risk factors. Feelings about self and the hospitalization are assessed in the self-perception-self-concept pattern. Intensity of pain is part of the cognitive-perceptual pattern.
A patient is seen in the emergency department with chest pain and hypotension. Which type of assessment should the nurse do at this time?
- A. Focused
- B. Subjective
- C. Emergency
- D. Comprehensive
Correct Answer: C
Rationale: Since the patient is hemodynamically unstable, an emergency assessment is needed. Comprehensive and focused assessments may be needed after the patient is stabilized. Subjective information is needed, but objective data such as vital signs also are essential for the unstable patient.
When the nurse is planning for the physical examination of an alert older-adult patient, which of the following adaptations to the examination technique should be considered?
- A. Speaking slowly when directing the patient
- B. Avoiding the use of touch as much as possible.
- C. Using slightly more pressure for palpation of the liver.
- D. Organizing the sequence to minimize position changes.
Correct Answer: D
Rationale: Older patients may have age-related changes in mobility that make it more difficult to change position. There is no need to avoid the use of touch when examining older patients. Less pressure should be used over the liver. Since the patient is alert, there is no indication that there is any age-related difficulty in understanding directions from the nurse.
When assessing the circulation to the lower leg of a patient who has had knee surgery, which action should the nurse take first?
- A. Feel for the temperature of the foot.
- B. Visually inspect the colour of the foot.
- C. Check the patient's pedal pulses using the fingertips.
- D. Compress the nail beds to determine capillary refill time.
Correct Answer: B
Rationale: Inspection is the first of the major techniques used in the physical examination. Palpation and auscultation are used later in the examination.
The nurse is preparing to perform a focused abdominal assessment for a patient who has high-pitched bowel sounds. Which equipment will be needed?
- A. Flashlight
- B. Stethoscope
- C. Tongue blades
- D. Percussion hammer
Correct Answer: B
Rationale: A stethoscope is used to auscultate bowel sounds. The other equipment may be used for a comprehensive assessment, but will not be needed for a focused abdominal assessment.