Nokea
The nurse places a patient in the dorsal recumbent position during a physical assessment. Which nursing assessments can the nurse perform with the patient in this position? Select all that apply.
- A. Assessing the abdomen
- B. Taking peripheral pulses
- C. Performing a breast examination
- D. Auscultating the heart
- E. Assessing vital signs
- F. Assessing balance and gait
Correct Answer: B,C,D
Rationale: In the dorsal recumbent position, the patient lies on the back with legs separated, knees flexed, and soles of the feet on the bed. It is used to assess the head, neck, anterior thorax, lungs, heart, breasts, extremities, and peripheral pulses. It should not be used for abdominal assessment because it causes contraction of the abdominal muscles. Vital sign assessment should be done in the sitting position, and evaluating balance and gait is done with the patient in the standing position.
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A nurse in the neurology clinic is assessing a patient's eyes for extraocular movements. Which correctly describes the procedure for this test?
- A. Ask the patient to sit about 3 ft away, facing the nurse.
- B. Have the patient follow a penlight held 1 ft from their face slowly through the cardinal positions.
- C. Move a penlight in concentric circular motion in front of the patient's eyes.
- D. Ask the patient to cover one eye with a hand or index card.
Correct Answer: B
Rationale: The steps in testing for extraocular movement are: (1) Ask the patient to sit or stand about 2 ft away, facing the nurse, who is sitting or standing at eye level with the patient; (2) ask the patient to hold the head still and follow the movement of a forefinger or a penlight with the eyes; (3) keeping the finger or light about 1 foot from the patient's face, move it slowly through the cardinal positions of gaze-up and down, left and right, diagonally up and down to the left, diagonally up and down to the right. Option B most accurately describes this procedure.
A nurse admitting a patient to a long-term care facility performs a functional assessment. Which questions will the nurse include as part of the assessment? Select all that apply.
- A. Are you able to dress yourself?
- B. Do you have a history of smoking?
- C. What is the problem for which you are seeking care?
- D. Do you prepare your own meals?
- E. Do you manage your own finances?
- F. Whom do you rely on for support?
Correct Answer: A,D,E
Rationale: A functional health assessment including strengths and areas needing improvement focuses on the effects of health or illness on a patient's quality of life. Questions about the patient's ability to perform ADLs and IADLs such as dressing, grooming, preparing meals, and managing finances are included. A history of smoking is a lifestyle factor, and the chief complaint is the reason for seeking health care; both are assessed during the health history. Social networks and support psychosocial factors are also assessed during the health history.
A patient has come to the emergency department with symptoms of a stroke. During the assessment, the nurse asks the patient to raise their eyebrows, smile, and show their teeth to evaluate which cranial nerve?
- A. Olfactory
- B. Optic
- C. Facial
- D. Vagus
Correct Answer: C
Rationale: Motor function of the facial nerve (cranial nerve VII) is assessed by asking the patient to raise their eyebrow, smile, and show their teeth. The olfactory nerve (cranial nerve I) is tested by testing the sense of smell using various familiar substances. The nurse tests the optic nerve (cranial nerve II) for acuity and visual fields and the vagus nerve (cranial nerve X) by asking the patient to swallow and speak, noting hoarseness.
A nurse on a medical-surgical unit is caring for a group of patients. For which patient will the nurse perform a focused assessment?
- A. Newly admitted
- B. Recent application of a wrist cast
- C. Signs of acute respiratory distress
- D. Post-abdominal surgery without complications
Correct Answer: B
Rationale: After application of a cast, the nurse performs a focused neurovascular assessment, to assess circulation, sensation, and motor ability. A newly admitted patient requires a comprehensive assessment. The nurse performs an emergency assessment on a patient who presents with signs of acute respiratory difficulty. A postoperative patient without complications will receive ongoing assessments at regular intervals to evaluate the effectiveness of care and to assess for new problems.
When inspecting the skin of a patient who has cirrhosis of the liver, the nurse notes the skin has a yellow tint. What term will the nurse use to document the skin assessment in the electronic health record?
- A. Jaundice
- B. Cyanosis
- C. Erythema
- D. Pallor
Correct Answer: A
Rationale: Jaundice refers to a yellowish skin color caused by liver, gallbladder, or pancreatic diseases. Cyanosis is a bluish skin color caused by a cold environment or decreased oxygenation. Erythema is a reddish color caused by blushing, alcohol intake, fever, injury trauma, or infection. Pallor is a paleness caused by anemia or shock.