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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.
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The acronym CTA stands for what? Which means what?
- A. Clear to auscultation, lungs are clear
- B. Chest tube assessment, tube patency
- C. Cardiac tone auscultation, heart sounds normal
- D. Clear thoracic assessment, no abnormalities
Correct Answer: A
Rationale: CTA stands for 'clear to auscultation,' indicating normal lung sounds with no abnormalities.
The off-going nurse reported to you that one of your patients had been having an irregular pulse for several hours. You plan to assess this patient's heart rate carefully during your initial patient rounds at the beginning of your shift. Which of the following would be the most accurate way to do this?
- A. Palpate a radial pulse in both wrists for 30 seconds
- B. Auscultate the apical pulse for 60 seconds
- C. Take a second nurse with you to palpate the radial pulse at the same time that you auscultate the apical pulse for 60 seconds
- D. Palpate the PMI for a full minute
Correct Answer: B
Rationale: Auscultating the apical pulse for 60 seconds provides the most accurate heart rate, especially for irregular rhythms.
Which lobe(s) of the lungs is(are) not accessible for auscultation posteriorly?
- A. The left upper lobe
- B. The left lower lobe
- C. The right upper lobe
- D. The right middle lobe
- E. The right lower lobe
Correct Answer: D
Rationale: The right middle lobe is located anteriorly and laterally, not accessible posteriorly.
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).
List all the assessments that are part of a neurological examination.
- A. Level of consciousness, pupil response, motor function, sensory function, reflexes
- B. Cranial nerve testing, muscle strength, coordination, gait, sensation
- C. Mental status, reflexes, motor function, sensory function, pupil response
- D. All of the above
Correct Answer: D
Rationale: A neurological examination includes level of consciousness, pupil response, motor function, sensory function, reflexes, cranial nerve testing, coordination, and gait.