Nokea
Which lobe(s) of the lungs is(are) accessible for auscultation both anteriorly and 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: A,C
Rationale: The left and right upper lobes can be auscultated anteriorly and posteriorly due to their position in the chest.
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Score the patient responses on the Glasgow Coma Scale. Calculate the patient's total score. Would you consider this patient as having a significant neurological impairment?
- A. Eye opening to pain: 2, Withdraws from pain: 4, Incomprehensible sounds: 2, Total: 8, Significant impairment
- B. Eye opening to pain: 2, Withdraws from pain: 5, Incomprehensible sounds: 2, Total: 9, Moderate impairment
- C. Eye opening to pain: 3, Withdraws from pain: 4, Incomprehensible sounds: 3, Total: 10, Moderate impairment
- D. Eye opening to pain: 2, Withdraws from pain: 4, Incomprehensible sounds: 3, Total: 9, Moderate impairment
Correct Answer: A
Rationale: Glasgow Coma Scale: Eye opening to pain (2), withdraws from pain (4), incomprehensible sounds (2), total = 8, indicating significant neurological impairment (score ?¤8 is severe).
During palpation of the patient's abdomen, he flinches and tightens the abdominal muscles where you are palpating. This tightening of abdominal muscles is known as
- A. Guarding
- B. Rigidity
- C. Rebound tenderness
- D. Distension
Correct Answer: A
Rationale: Guarding refers to the involuntary tightening of abdominal muscles in response to pain or palpation, often indicating discomfort or pathology.
Which of the following assessment findings is not within the textbook normal range?
- A. 23 bowel sounds per minute in each quadrant
- B. Capillary refill of 5 seconds in a 41-year-old male patient
- C. Respiratory rate of 24 per minute
- D. Systolic pressure of 86 mm Hg
- E. Diastolic pressure of 62 mm Hg
Correct Answer: B,D
Rationale: Capillary refill of 5 seconds (normal is <2-3 seconds) and systolic pressure of 86 mm Hg (normal is 90-120 mm Hg) are outside normal ranges.
Which of the following assessment findings may provide you with neurological status data?
- A. Thick, dirty hair
- B. Lethargy
- C. Color of the lower extremities
- D. Edema of the left hand and arm
- E. Pulse rate of 44 bpm
Correct Answer: B
Rationale: Lethargy is a neurological finding indicating altered mental status, while other options relate to physical appearance or circulatory issues.
Describe the assessments that you will perform to establish the status of his renal system and ensure that he is not getting into fluid overload problems.
- A. Urine output, weight, edema, breath sounds
- B. Blood pressure, serum creatinine, BUN
- C. Fluid intake, electrolyte levels, lung auscultation
- D. All of the above
Correct Answer: D
Rationale: Renal system assessment includes urine output, weight, edema, breath sounds, blood pressure, serum creatinine, BUN, fluid intake, and electrolyte levels to monitor for fluid overload.