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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.
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What is the medical terminology for each of the 'lubb dupp' heart sounds?
- A. S1 and S2
- B. S1 and S3
- C. S2 and S4
- D. Murmur and bruit
Correct Answer: A
Rationale: The 'lubb' is S1 (closure of mitral and tricuspid valves), and 'dupp' is S2 (closure of aortic and pulmonic valves).
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.
What type of assessment is performed on admission?
- A. A focused assessment
- B. An initial head-to-toe shift assessment
- C. A comprehensive health assessment
- D. A brief admission systems assessment
- E. Disease and injury assessment
Correct Answer: B,C
Rationale: A comprehensive health assessment (C) is typically performed on admission to gather baseline data, often including an initial head-to-toe shift assessment (B) to evaluate all body systems.
You are caring for a patient with mitral valve stenosis. You plan to assess the mitral valve during your initial assessment. Where will you be best able to auscultate the mitral valve?
- A. The right base of the heart
- B. The left base of the heart
- C. The apex of the left ventricle
- D. The left lateral sternal border
Correct Answer: C
Rationale: The mitral valve is best heard at the apex of the left ventricle, typically in the 5th intercostal space, midclavicular line.
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.