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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.
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A nurse is performing a breast assessment using the circular technique for palpation, gently compressing the breast tissue against the chest wall. How does the nurse proceed with the examination?
- A. Begins at the tail of Spence and moves in increasing smaller circles
- B. Starts at the outer edge of the breast and palpates up and down the breast
- C. Works in a counterclockwise direction and palpates from the periphery toward the areola
- D. Proceeds from the inner edge of the breast and palpates up and down the breast
Correct Answer: A
Rationale: During breast assessment, the nurse palpates each quadrant of the breasts in a systematic method using the pads of the first three fingers to gently compress the breast tissue against the chest wall. In the circular method, the nurse begins at the tail of Spence and moves in increasingly smaller circles. In the wedge method, the nurse works in a clockwise direction and palpates from the periphery toward the areola. In the vertical strip method, the nurse begins at the outer edge of the breast, palpating up and down the breast.
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 in the emergency department is using the Glasgow coma scale to assess a patient who was struck in the head and upper body with a baseball bat. Based on the information in the neurologic assessment, what numerical value will the nurse assign?
- A. 3
- B. 7
- C. 11
- D. 15
Correct Answer: B
Rationale: Eye opening to painful stimulus = 2 points, no speech = 1 point; and withdrawal to painful stimulus = 4 points, for a total score of 7. A score of 8 or less is associated with coma.
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.
During physical assessment, a nurse inspects a patient's abdomen. What assessment technique does the nurse perform next?
- A. Percussion
- B. Palpation
- C. Auscultation
- D. Whichever provides patient comfort
Correct Answer: C
Rationale: When assessing the abdomen, the sequence for assessment is: inspection, auscultation, percussion, and palpation. Auscultation follows inspection to avoid stimulating bowel sounds during percussion.